Clinical trials in Italy: focus on the protocols submitted to Ethics Committees

OBJECTIVE

To describe the main characteristics of clinical research protocols submitted to Italian local ethics committees (LECs).

DESIGN

Prospective survey on all research protocols evaluated during the period from 1 September 1998 to 31 July 1999. Data were prospectively collected for each individual study containing information on: general characteristics of the study; study design; population under study; LEC decision; and study monitoring.

SETTING

Twenty Italian LECs from nine regions in Italy.

MAIN OUTCOME MEASURES

Type of protocols, diseases and drugs under investigation, population under study, methodological characteristics (e.g. sponsorship, multicentricity, presence of a control group).

RESULTS

Data on 449 protocols corresponding to 625 evaluations were received. The majority of protocols (83.1%, n=373) were investigational studies on drugs, sponsored 76.8% (n=345) and multicentre 86.4% (n=388). The majority of the drug protocols were on antineoplastic drugs (27.7%, n=104), cardiovascular agents (15.4%, n=58) and systemic anti-infective agents (13.8%, n=52). A few of the drugs investigated were new entities. A few studies focused on subpopulations, e.g. elderly and children (10 and 16, respectively). Early development phases (I and II) were less likely to be sponsored and multicentre. The most represented drug category in phase I-II trials was the antineoplastic agents.

CONCLUSION

A small portion of research protocols submitted to LECs in Italy relate to innovative research. The new Italian legislation, which decentralizes approval of clinical trials from central to local levels, will lead to shorter approval times and should stimulate more original research. Surveys on LECs activity give important information on active research areas, methodological quality of current studies and outcome of the studies in terms of trial closure and publication of the results. The latter information may be obtained through a follow-up of the cohort of studies included in the present cross-sectional survey.

Formulary management

The hospital formulary is not only a list of drugs, but also a policy that involves several complex processes and activities. Formularies are developed based on cost-effectiveness evaluation, but maintaining cost-effectiveness requires educational strategies. The clinical pharmacist plays an active role in formulary processes. These processes are discussed in this paper. There is a need for studies on the cost-effectiveness of clinical pharmacy services in support of the hospital formulary.

Effectiveness of gabexate mesilate in acute pancreatitis. A metaanalysis

Since the effectiveness of gabexate mesilate in patients with acute pancreatitis is controversial, a metaanalysis of the published literature was conducted to address this problem. Five randomized trials were identified by our literature search. Three end points (mortality, complications, and complications requiring surgery) were evaluated. The results of our metaanalysis indicate that the treatment with gabexate mesilate does not affect mortality at 90 days (P = 0.27), but significantly reduces the incidence of complications requiring surgery (odds ratio = 0.61, 95% CI: 0.41-0.89; P < 0.05) and of complications in general (odds ratio = 0.69, 95% CI: 0.54-0.89; P < 0.05). Because the drug proves to be beneficial only to a low proportion of the treated patients, its clinical impact seems to be small. A pharmacoeconomic evaluation shows that its use in all patients with acute pancreatitis would imply a very high cost for preventing each complication. The administration of the drug to select patients who are at higher risk of complications could have a better cost-effectiveness ratio. However, specific studies on this point are still lacking.

Efficacy of hyperimmune anti-cytomegalovirus immunoglobulins for the prevention of cytomegalovirus infection in recipients of allogeneic bone marrow transplantation: a meta-analysis

We carried out an analysis of the randomized clinical trials published on the effectiveness of hyperimmune immunoglobulins for prevention of cytomegalovirus (CMV) infection or disease in CMV-seronegative recipients of allogeneic bone marrow transplantation (BMT). The clinical trials were identified by searching a number of computerized literature databases, by reviewing bibliographies of the paper examined and by consulting experts. All studies we selected were randomized and were aimed at evaluating the efficacy of hyperimmune immunoglobulins in comparison with a control group receiving no immunoglobulins. The results of this analysis indicate that hyperimmune immunoglobulins reduce the frequency of CMV infection (overall odds ratio = 0.444; 95% confidence interval 0.237-0.832, p = 0.011) and CMV related disease (overall odds ratio = 0.445; 95% confidence interval 0.223-0.887, p = 0.021) in CMV-seronegative recipients of allogeneic BMT.

[Evaluation of the tolerance of a lipid emulsion administrated during total parenteral nutrition in surgical patients]

Tolerance's evaluation of a lipid emulsion given in course of parenteral total nutrition in surgical patient's. The first fat emulsions for intravenous application were thrown on the market in the 1920's years. Authors make a study on a limited sample of surgical patients about type and incidence of both immediate and late adverse reactions versus intravenous administration of Lipofundin S. They also suggest, on the same time, a protocol for the survey of these reactions. The results suggest a good tolerance to Lipofundin S intravenous administration and no influence on haematic biochemical parameters.

Is there still an avoidable fraction of post-operative thromboembolic complications with heparin prophylaxis? The results of a case-control surveillance. Collaborative Group on Heparin Prophylaxis in Surgery (S.E.P.E.C.)

A case-control multicenter study was set up in 68 general and specialistic wards in Italian regional hospitals in order to assess whether underuse of heparin prophylaxis may account for at least a fraction of the thromboembolic events still occurring in surgical patients. 100 cases with clinically relevant thromboembolic or hemorrhagic events occurring during hospitalization for major surgery and 200 controls were identified. Controls were selected among patients not presenting any of the events under study during the same period of observation and were matched with cases for age, sex, and type of surgery. The results of the study suggest that heparin use in routine conditions of care closely reflects the "consensus" knowledge, patients at higher risk (specifically orthopedic surgical patients, those with varicose veins or with preoperative bed rest longer than 3 days) being treated more frequently with heparin. Absence of heparin prophylaxis does not appear to represent a specific risk factor for the occurrence of index events (OR 0.73, 95% CI = 0.42-1.26). Despite the higher rates of heparin exposure, the presence of varicose veins is associated with a statistically significant increase in the risk of postoperative complications (OR 2.23, 95% CI = 1.07-4.65). This study indicates that among known pre- and peri-operative risk factors only varicose veins may be unprotected by the current prophylaxis practice.

[Protein-sparing peripheral parenteral nutrition in urologic surgery]

The use of parenteral nutrition in patients operated on for cystectomy is a basic post-operative therapeutic aid used for maintaining an adequate state of nutrition. In the present paper, the authors report the results of a study conducted for the purposes of comparing the efficacy of protein-sparing parenteral nutrition versus TPN.

Serum and sputum concentrations of azlocillin, cefoperazone and ceftazidime in patients with cystic fibrosis

Single-dose pharmacokinetics of azlocillin, cefoperazone and ceftazidime were studied in 17 patients with cystic fibrosis (CF). All patients had broncho-pulmonary infections caused by Pseudomonas aeruginosa. Three groups of five, six, and six patients were treated with azlocillin, cefoperazone, or ceftazidime, respectively. The size of the single dose was 133 mg/kg for azlocillin, 66.7 mg/kg for ceftazidime and 66.7 mg/kg for cefoperazone. The clearance values for the three antibiotics calculated from the single-dose data were, on the average, higher than the values previously reported for normal subjects. After the first dose, the patients received a repeated-dose treatment with the same antibiotic. During the first 5 days of therapy, a complement postural drainage of sputum was obtained four times a day for each patient. Cefoperazone could be measured in 47 (39.2%) of the 120 sputum samples assayed while ceftazidime was shown to be present in all 120 sputum samples examined. Azlocillin was not detected in any of the 100 sputum samples assayed.