Reassessing Phase II Heart Failure Clinical Trials: Consensus Recommendations

The increasing burden and the continued suboptimal outcomes for patients with heart failure underlines the importance of continued research to develop novel therapeutics for this disorder. This can only be accomplished with successful translation of basic science discoveries into direct human application through effective clinical trial design and execution that results in a substantially improved clinical course and outcomes. In this respect, phase II clinical trials play a pivotal role in determining which of the multitude of potential basic science discoveries should move to the large and expansive registration trials in humans. A critical examination of the phase II trials in heart failure reveals multiple shortcomings in their concept, design, execution, and interpretation. To further a dialogue on the challenges and potential for improvement and the role of phase II trials in patients with heart failure, the Food and Drug Administration facilitated a meeting on October 17, 2016, represented by clinicians, researchers, industry members, and regulators. This document summarizes the discussion from this meeting and provides key recommendations for future directions.

Exploring New Endpoints for Patients With Heart Failure With Preserved Ejection Fraction

The epidemiological, clinical, and societal implications of the heart failure (HF) epidemic cannot be overemphasized. Approximately half of all HF patients have HF with preserved ejection fraction (HFpEF). HFpEF is largely a syndrome of the elderly, and with aging of the population, the proportion of patients with HFpEF is expected to grow. Currently, there is no drug known to improve mortality or hospitalization risk for these patients. Besides mortality and hospitalization, it is imperative to realize that patients with HFpEF have significant impairment in their functional capacity and their quality of life on a daily basis, underscoring the need for these parameters to ideally be incorporated within a regulatory pathway for drug approval. Although attempts should continue to explore therapies to reduce the risk of mortality or hospitalization for these patients, efforts should also be directed to improve other patient-centric concerns, such as functional capacity and quality of life. To initiate a dialogue about the compelling need for and the challenges in developing such alternative endpoints for patients with HFpEF, the US Food and Drug Administration on November 12, 2015, facilitated a meeting represented by clinicians, academia, industry, and regulatory agencies. This document summarizes the discussion from this meeting.

In vitro effects of nonsteroidal anti-inflammatory drugs on cyclooxygenase activity in dogs

OBJECTIVE

To establish an in vitro assay and determine the differential suppressive activity of non steroidal anti-inflammatory drugs (NSAID) on cyclooxygenase (COX)-1 and COX-2 isoenzymes in dogs.

PROCEDURE

COX activity was evaluated in the presence and absence of 4 NSAID (meloxicam, tolfenamic acid, carprofen, and ketoprofen), using a canine monocyte/macrophage cell line that constitutively expresses COX-1, but can be induced to express COX-2 when incubated with lipopolysaccharide. Inhibition of prostaglandin E2 TPGE2) synthesis by each NSAID was measured by enzyme immunoassay and attributed to specific COX-1 or COX-2 activity through assessment of COX messenger RNA expression by use of northern blot analysis and reverse transcription-polymerase chain reaction (RT-PCR). The COX selectivity of each drug was evaluated from dose-response curves by calculating a ratio (COX-1:COX-2) of inhibitory concentration values on the basis of concentrations that reduced PGE2 by 50% in each COX model.

RESULTS

Meloxicam and tolfenamic acid preferentially inhibited COX-2, with meloxicam inhibiting COX-2 activity 12 times more effectively than COX-1 activity. Carprofen was only 1.75 times more selective for COX-2 than for COX-1, and ketoprofen was slightly more selective for COX-1.

CONCLUSIONS

COX-1 and COX-2 were differentially sensitive to inhibition in vitro by NSAID. Meloxicam and tolfenamic acid were selective for COX-2. Effects of carprofen and ketoprofen approached equipotency against both isoenzymes. Selective COX-2 inhibitors are a new class of drugs with anti-inflammatory effects similar to conventional NSAID but with fewer adverse effects. Development of these agents for veterinary use would be facilitated by the convenience of using a canine cell line as a model system to screen COX-1 and COX-2 inhibitor activities in vitro.