Landscape of coronavirus disease 2019 clinical trials: New frontiers and challenges

BACKGROUND/AIM

The number of coronavirus disease 2019 deaths and cases continues to increase globally. Novel therapies are urgently needed to treat patients with coronavirus disease 2019. We sought to provide a critical review of trials designed during the coronavirus disease 2019 pandemic. Our primary goal was to provide a critical review of the landscape of clinical trials designed to address the coronavirus disease 2019 pandemic. Specifically, we were interested in assessing the design of phase II/III and phase III interventional trials.

METHODS

We utilized the ClinicalTrials.gov database to include trials registered between 1 December 2019 and 11 April 2021 to survey the current landscape of clinical trials for coronavirus disease 2019. Variables extracted included: National Clinical Trial number, title, location, sponsor, study type, start date, completion date, gender group, age group, primary outcome, secondary outcome, overall status, and associated references.

RESULTS

About 57% of studies were interventional, 14.5% were phase III trials, and the majority of the therapeutic trials included hospitalized patients. There were 52 primary composite outcomes and 285 unique interventions spanning 10 drug classes. The outcomes, disease severity, and comparators varied substantially across trials, and the trials were often too small to be definitive.

CONCLUSION

These findings are relevant as we strongly advocate for global coordination of efforts through the use of common platforms that enable harmonizing of endpoints, collection of common key variables and clear definition of disease severity to have clinically meaningful results from clinical trials.

Predictors of duloxetine response in patients with oxaliplatin-induced painful chemotherapy-induced peripheral neuropathy (CIPN): a secondary analysis of randomised controlled trial - CALGB/alliance 170601

Duloxetine is an effective treatment for oxaliplatin-induced painful chemotherapy-induced peripheral neuropathy (CIPN). However, predictors of duloxetine response have not been adequately explored. The objective of this secondary and exploratory analysis was to identify predictors of duloxetine response in patients with painful oxaliplatin-induced CIPN. Patients (N = 106) with oxaliplatin-induced painful CIPN were randomised to receive duloxetine or placebo. Eligible patients had chronic CIPN pain and an average neuropathic pain score ≥4/10. Duloxetine/placebo dose was 30 mg/day for 7 days, then 60 mg/day for 4 weeks. The Brief Pain Inventory-Short Form and the EORTC QLQ-C30 were used to assess pain and quality of life, respectively. Univariate and multiple logistic regression analyses were performed to identify demographic, physiologic and psychological predictors of duloxetine response. Higher baseline emotional functioning predicted duloxetine response (≥30% reduction in pain; OR 4.036; 95% CI 0.999-16.308; p = 0.050). Based on the results from a multiple logistic regression using patient data from both the duloxetine and placebo treatment arms, duloxetine-treated patients with high emotional functioning are more likely to experience pain reduction (p = 0.026). In patients with painful, oxaliplatin-induced CIPN, emotional functioning may also predict duloxetine response. ClinicalTrials.gov, Identifier NCT00489411.

Analyzing temozolomide medication errors: potentially fatal

The EORTC-NCIC regimen for glioblastoma requires different dosing of temozolomide (TMZ) during radiation and maintenance therapy. This complexity is exacerbated by the availability of multiple TMZ capsule strengths. TMZ is an alkylating agent and the major toxicity of this class is dose-related myelosuppression. Inadvertent overdose can be fatal. The websites of the Institute for Safe Medication Practices (ISMP), and the Food and Drug Administration (FDA) MedWatch database were reviewed. We searched the MedWatch database for adverse events associated with TMZ and obtained all reports including hematologic toxicity submitted from 1st November 1997 to 30th May 2012. The ISMP describes errors with TMZ resulting from the positioning of information on the label of the commercial product. The strength and quantity of capsules on the label were in close proximity to each other, and this has been changed by the manufacturer. MedWatch identified 45 medication errors. Patient errors were the most common, accounting for 21 or 47% of errors, followed by dispensing errors, which accounted for 13 or 29%. Seven reports or 16% were errors in the prescribing of TMZ. Reported outcomes ranged from reversible hematological adverse events (13%), to hospitalization for other adverse events (13%) or death (18%). Four error reports lacked detail and could not be categorized. Although the FDA issued a warning in 2003 regarding fatal medication errors and the product label warns of overdosing, errors in TMZ dosing occur for various reasons and involve both healthcare professionals and patients. Overdosing errors can be fatal.

Bevacizumab and central nervous system (CNS) hemorrhage

BACKGROUND

Bevacizumab is widely used and may cause life-threatening bleeding. We attempted to identify clinical characteristics associated with central nervous system (CNS) hemorrhage in a broad population.

METHODS

We performed a retrospective review of the FDA MedWatch database of adverse events reported with bevacizumab from 11/1997 to 5/2009. Our search used keywords: bleeding, hemorrhage, cerebral, intracranial, subarachnoid, cerebellar, hemorrhagic stroke and brain.

RESULTS

A total of 17,466 reports were included in the database: 154 described CNS hemorrhage in 99 patients, and 1,041 reports described non-CNS bleeds. Median age was 62 years, and the primary cancers were consistent with indications for bevacizumab. Patients received a median of three (1-36) doses of bevacizumab prior to the bleed. Thirty percent had documented history of hypertension. Sixteen patients with CNS hemorrhage were reported to have CNS metastases. Death was reported as a complication of hemorrhage in 48 %. The most common predisposing factor for CNS bleeds was use of medications associated with bleeding, followed by thrombocytopenia.

CONCLUSION

In this database, 154 of 1,195 reports of bleeding associated with bevacizumab described a CNS bleed. Although CNS bleeds were not common, they were the reported cause of death in two-thirds of cases.

Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial

IMPORTANCE

There are no known effective treatments for painful chemotherapy-induced peripheral neuropathy.

OBJECTIVE

To determine the effect of duloxetine, 60 mg daily, on average pain severity.

DESIGN, SETTING, AND PATIENTS

Randomized, double-blind, placebo-controlled crossover trial at 8 National Cancer Institute (NCI)-funded cooperative research networks that enrolled 231 patients who were 25 years or older being treated at community and academic settings between April 2008 and March 2011. Study follow-up was completed July 2012. Stratified by chemotherapeutic drug and comorbid pain risk, patients were randomized to receive either duloxetine followed by placebo or placebo followed by duloxetine. Eligibility required that patients have grade 1 or higher sensory neuropathy according to the NCI Common Terminology Criteria for Adverse Events and at least 4 on a scale of 0 to 10, representing average chemotherapy-induced pain, after paclitaxel, other taxane, or oxaliplatin treatment.

INTERVENTIONS

The initial treatment consisted of taking 1 capsule daily of either 30 mg of duloxetine or placebo for the first week and 2 capsules of either 30 mg of duloxetine or placebo daily for 4 additional weeks.

MAIN OUTCOME MEASURES

The primary hypothesis was that duloxetine would be more effective than placebo in decreasing chemotherapy-induced peripheral neuropathic pain. Pain severity was assessed using the Brief Pain Inventory-Short Form "average pain" item with 0 representing no pain and 10 representing as bad as can be imagined.

RESULTS

Individuals receiving duloxetine as their initial 5-week treatment reported a mean decrease in average pain of 1.06 (95% CI, 0.72-1.40) vs 0.34 (95% CI, 0.01-0.66) among those who received placebo (P = .003; effect size, 0.513). The observed mean difference in the average pain score between duloxetine and placebo was 0.73 (95% CI, 0.26-1.20). Fifty-nine percent of those initially receiving duloxetine vs 38% of those initially receiving placebo reported decreased pain of any amount.

CONCLUSION AND RELEVANCE

Among patients with painful chemotherapy-induced peripheral neuropathy, the use of duloxetine compared with placebo for 5 weeks resulted in a greater reduction in pain.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00489411.

Bevacizumab use and central nervous system (CNS) hemorrhage

2073

Background: Bevacizumab is widely used and may cause life-threatening bleeding, usually at sites of disease involvement such as the CNS. We attempted to identify clinical characteristics associated with CNS hemorrhage in a broad population. Methods: We did a retrospective review of the FDA Medwatch database of adverse events reported with bevacizumab from 11/1997 to 5/2009. Results: We searched the database for keywords bleeding, hemorrhage, cerebral, intracranial, subarachnoid, cerebellar, hemorrhagic stroke, and brain. 17,466 reports were included in the database: 154 described CNS hemorrhage in 99 patients, and 1041 reports described non-CNS bleeds. For CNS bleeds, cerebral hemorrhage was the most frequent event reported (n=39), followed by intracranial hemorrhage (n=20) and subarachnoid hemorrhage (n=18). Median age was 62 years; 54% of patients were female. Primary cancer was colorectal (42%), glioma (13%), and breast cancer (10%). Patients received a median of three (1-36) doses of bevacizumab prior to the bleed. 54% of patients received myelosuppressive chemotherapy, and 30% had documented history of hypertension. Sixteen patients with CNS hemorrhage were reported to have CNS metastases. For 70 patients, information on CNS involvement was not reported. Death was reported as a complication of hemorrhage in 48% of patients. Nine patients with brain metastases died and CNS hemorrhage was the cause of death in seven. Six patients with glioma died, and CNS hemorrhage was the cause in three. One patient with brain metastases, and one patient with glioma also experienced a non-CNS bleed. Five patients in each group had received heparin, warfarin or NSAIDs. Low platelet counts were reported in 3 patients with CNS metastases and 2 patients with glioma. The most common factor associated with CNS hemorrhage was medication predisposing to bleeding, followed by thrombocytopenia. Hypertension, a risk factor for CNS hemorrhage, was reported in 4 patients with brain metastases, and 2 patients with glioma. Conclusions: In this database, 154 of 1195 reports of bleeding associated with bevacizumab described a CNS bleed. Although CNS bleeds were not common, they were the reported cause of death in more than half of the cases.

Understanding and managing the possible adverse effects associated with bevacizumab

PURPOSE

The adverse events associated with bevacizumab therapy are characterized, and the underlying pathophysiology, risk factors, frequency, and management of these events are described.

SUMMARY

The adverse events associated with bevacizumab include hypertension, proteinuria, thromboembolism, impaired wound healing, bleeding, perforation, reversible leukoencephalopathy syndrome, skin rash, and infusion-related hypersensitivity reactions. Patients should be monitored for these events throughout the course of bevacizumab therapy. Hypertension is by far the most common adverse event associated with bevacizumab. Blood pressure should be routinely monitored, and hypertension should be medically managed with antihypertensive drugs as deemed appropriate during bevacizumab therapy. Patients should be monitored for proteinuria every three to four weeks, and bevacizumab should be discontinued with persistent proteinuria of >2+. Thromboembolic events, impaired wound healing, bowel and nasal septum perforation, and bleeding share similar pathophysiology. Thromboembolic events should be managed in accordance with guidelines established by the American College of Chest Physicians, and bevacizumab should be discontinued for new life-threatening venous or arterial thromboembolism. To minimize the risk of bleeding or impaired wound healing, bevacizumab should be started at least four weeks after surgery or discontinued for at least six to eight weeks before elective surgery. The management of other adverse events is more anecdotal, with relatively few reports of their occurrence with bevacizumab.

CONCLUSION

Many of the potential serious complications of bevacizumab can be averted by close monitoring of patient-specific variables, which should be measured at baseline and then at predetermined intervals throughout the course of therapy to maximize patient safety.

Evaluation of the Modified Diet in Renal Disease Equation for Calculation of Carboplatin Dose

Background:

Serum creatinine (SCr)-based formulas are used to estimate glomerular filtration rate (GFR) when calculating a dosage for carboplatin using the Calvert equation, but these formulas often underestimate measured GFR. The Modified Diet in Renal Disease (MDRD) equation appears to be a more accurate estimate of GFR in patients with chronic kidney disease, but this equation has not been studied extensively in patients with cancer.

Objective:

To determine the absolute difference between the dose of carboplatin administered (traditional SCr-based formulas used to estimate GFR) and the dose calculated using the MDRD equation to estimate GFR and compare the frequencies of thrombocytopenia, neutropenia, and dosage modifications between subjects in whom the difference in dose was 20% or more (divergent) or less than 20% (nondivergent).

Methods:

A retrospective analysis was conducted using data from patients who received carboplatin. Inclusion criteria were receipt of at least 2 doses of carboplatin, either as monotherapy or combination therapy, and documentation of desired area under the concentration-time curve (AUC). Patients were excluded if the baseline values needed to estimate GFR using the MDRD equation were not available. The absolute difference between the dose of carboplatin administered and that calculated using the MDRD equation was determined and, from this comparison, the subjects were divided into 2 groups (divergent vs nondivergent).

Results:

The medical records of 186 adults who received more than 2 doses of carboplatin were included in the analysis. The doses were divergent in 89 (48%) patients. The mean target AUC values were 5.3 mg/mUmin and 5.1 mg/mL/min in the divergent and nondivergent groups, respectively, and most patients received cytotoxic regimens with a relatively low risk of febrile neutropenia. The frequencies of neutropenia, thrombocytopenia, and dosage modifications were similar between the 2 groups. Use of the MDRD equation to calculate the carboplatin dosage did not appear to result in a change in the frequency of myelosuppression or the need for dose modifications compared with traditional SCr-based formulas.

Conclusions:

The traditional SCr-based formulas for the calculation of carboplatin dosage should be used to estimate carboplatin dose until more data become available regarding the use of the MDRD equation in this population.

Cancer Pain Management in Ambulatory Patients

Pain, by definition, is a subjective phenomenon. The subjective component in chronic pain due to cancer is very important. Opioid analgesics are the mainstay of treatment for cancer pain. Their use should be optimized to provide adequate pain relief. Optimal use includes understanding the concepts of tolerance, physical dependence, and psychological dependence. None of these should limit or inhibit pain management. Optimal use also includes familiarity with the clinical use of opioids. Regular use is generally preferred over “prn” use. Increased parenteral versus oral effectiveness of opioids, secondary to a high first-pass effect, is an important consideration when routes of administration must be altered. Familiarity with approximate equianalgesic doses allows for conversion from one opioid to another. Such conversion might help increase the convenience, increase the efficacy, or decrease the adverse effects of an opioid regimen. Knowledge of durations of action of opioids helps in the selection of dosing intervals to facilitate continuous pain relief. Morphine is the most common opioid chosen for cancer pain management, but others may be equally effective. Follow-up assessments with subsequent alterations are as important as the initial selection of drug, dose, and dosing interval. Adjuvant analgesics, such as nonsteroidal antiinflammatory drugs, anticonvulsants, or antidepressants, may enhance pain relief, especially in certain pain syndromes (eg, metastatic bone pain, neuropathic pain). These agents are usually used in addition to opioids.

Cyclophosphamide-induced facial discomfort

OBJECTIVE

To report the occurrence of cyclophosphamide-induced facial discomfort in patients at our institution, to review previous literature reports, and to discuss possible methods of prevention.

SETTING

An oncology clinic in a university teaching hospital.

PATIENTS

From January 1990 to March 1993, 14 patients experienced uncomfortable sensations of the skin or mucous membranes associated with cyclophosphamide administration. Details pertaining to each patient are described.

INTERVENTIONS

Initial interventions included changing the duration of infusion or concentration of cyclophosphamide. We postulated that an anticholinergic medication such as ipratropium bromide may prevent cyclophosphamide-induced facial discomfort.

MAIN OUTCOME MEASURES

Changing the infusion duration or cyclophosphamide concentration or administering ipratropium bromide intranasally resulted in variable degrees of improvement.

CONCLUSIONS

The number of cyclophosphamide reactions seen at our institution indicates that facial or scalp burning, oropharyngeal tingling, nasal congestion, rhinorrhea, sneezing, and/or lacrimation may occur more frequently than previously noted. Thus, careful questioning is necessary to determine whether these clinical symptoms are present and bothersome in patients treated with cyclophosphamide. Intranasal ipratropium bromide, as well as other measures to prevent or decrease the intensity of cyclophosphamide-induced facial discomfort should be investigated.

Use of clonidine to treat hot flashes secondary to leuprolide or goserelin

OBJECTIVE

To determine the effects of clonidine, a centrally acting adrenergic agonist, in abating symptoms of hot flashes in men receiving either leuprolide or goserelin for prostate cancer.

DESIGN

Patients were administered transdermal or oral clonidine 0.1-0.2 mg/d. Dosages were increased in increments of 0.1-0.3 mg/d every two to four weeks if symptoms persisted or until adverse effects developed.

SETTING

Medical oncology clinic at the University of Illinois and the hypertension clinic at the Veterans Affairs West Side Medical Center.

PARTICIPANTS

Consenting male patients were eligible for the study if they were receiving leuprolide or goserelin for prostate cancer and were experiencing hot flashes. Exclusion criteria included diastolic blood pressure of 75 mm Hg or below or a history of adverse reactions to clonidine.

MAIN OUTCOME MEASURES

Effectiveness of clonidine was determined by questioning patients about frequency, severity, and duration of hot flashes at baseline and at two- to four-week intervals.

RESULTS

All four patients receiving clonidine experienced a partial response within two weeks of starting treatment. No dose-dependent response was observed. Adverse effects were noted in one patient but did not result in discontinuation.

CONCLUSIONS

Our results document the first report of the use of clonidine to treat hot flashes secondary to leuprolide or goserelin therapy. Symptomatic improvement was noted in all four patients. Further evaluation of clonidine as well as other centrally acting adrenergic agonists is needed.

Misperceptions and inadequate pain management in cancer patients

This article examines misperceptions and barriers to adequate pain relief in cancer patients. Healthcare professionals have gaps in their knowledge of opioid drugs as well as misconceptions concerning tolerance, physical dependence, and addiction that often lead to the underprescribing of these agents. The pervasiveness of the "say no to drugs" message in our society and the fear of addiction on the part of patients and their families creates yet another barrier to the legitimate use of opioids to treat cancer pain. Legal and regulatory documents filled with arbitrary and ill-defined labels meant to promote the legitimate use of these drugs and curtail their misuse may instead intimidate healthcare professionals and negatively influence prescribing habits. Increased educational efforts for pharmacists and other healthcare professionals as well as the development of clinical role models and state cancer pain initiatives are cited as means to break down these barriers in order to achieve adequate pain relief for all cancer patients.