Meaningful Endpoints for Idiopathic Pulmonary Fibrosis (IPF) Clinical Trials: Emphasis on 'Feels, Functions, Survives'. Report of a Collaborative Discussion in a Symposium with Direct Engagement from Representatives of Patients, Investigators, the National Institutes of Health, a Patient Advocacy Organization, and a Regulatory Agency

Background: Idiopathic pulmonary fibrosis (IPF) carries significant mortality and unpredictable progression, with limited therapeutic options. Designing trials with patient-meaningful endpoints, enhancing the reliability and interpretability of results, and streamlining the regulatory approval process are of critical importance to advancing clinical care in IPF. Methods: A landmark in-person symposium in June 2023 assembled 43 participants from the US and internationally, including patients with IPF, investigators, and regulatory representatives, to discuss the immediate future of IPF clinical trial endpoints. Patient advocates were central to discussions, which evaluated endpoints according to regulatory standards and the FDA's 'feels, functions, survives' criteria. Results: Three themes emerged: 1) consensus on endpoints mirroring the lived experiences of patients with IPF; 2) consideration of replacing forced vital capacity (FVC) as the primary endpoint, potentially by composite endpoints that include 'feels, functions, survives' measures or FVC as components; 3) support for simplified, user-friendly patient-reported outcomes (PROs) as either components of primary composite endpoints or key secondary endpoints, supplemented by functional tests as secondary endpoints and novel biomarkers as supportive measures (FDA Guidance for Industry (Multiple Endpoints in Clinical Trials) available at: https://www.fda.gov/media/162416/download). Conclusions: This report, detailing the proceedings of this pivotal symposium, suggests a potential turning point in designing future IPF clinical trials more attuned to outcomes meaningful to patients, and documents the collective agreement across multidisciplinary stakeholders on the importance of anchoring IPF trial endpoints on real patient experiences-namely, how they feel, function, and survive. There is considerable optimism that clinical care in IPF will progress through trials focused on patient-centric insights, ultimately guiding transformative treatment strategies to enhance patients' quality of life and survival.

A Boxed Warning for Montelukast: The FDA Perspective

The U.S. Food and Drug Administration (FDA) became aware of postmarketing reports of neuropsychiatric adverse events with Singulair (montelukast) use in 2007. Over the years, the FDA has conducted reviews of the clinical trial safety data, focused analyses of postmarketing reports, and reviews of the published literature. These activities have resulted in successive labeling updates and public communications. However, there has been continued concern among stakeholders about the risk of neuropsychiatric events and the lack of awareness among prescribers and patients/caregivers. On the basis of these concerns, the FDA embarked on another comprehensive review and also conducted a new observational study using claims data in the Sentinel Distributed Database. In September 2019, the FDA held a public Advisory Committee meeting to discuss its review and solicit recommendations from the panel regarding labeling and communication strategies. After careful consideration of the available data and feedback received during the FDA Advisory Committee meeting, the FDA required a boxed warning and a revision specifically for the allergic rhinitis indication to reserve use of montelukast to patients who have an inadequate response or intolerance to alternative therapies. Based on benefit-risk considerations, the asthma indication was not changed. To provide insight into the process and rationale for the required labeling changes, we provide an overview of the decision-making framework we used.

Impact of Data Presentation on Physician Performance Utilizing Artificial Intelligence-Based Computer-Aided Diagnosis and Decision Support Systems

Ultrasound (US) is a valuable imaging modality used to detect primary breast malignancy. However, radiologists have a limited ability to distinguish between benign and malignant lesions on US, leading to false-positive and false-negative results, which limit the positive predictive value of lesions sent for biopsy (PPV3) and specificity. A recent study demonstrated that incorporating an AI-based decision support (DS) system into US image analysis could help improve US diagnostic performance. While the DS system is promising, its efficacy in terms of its impact also needs to be measured when integrated into existing clinical workflows. The current study evaluates workflow schemas for DS integration and its impact on diagnostic accuracy. The impact on two different reading methodologies, sequential and independent, was assessed. This study demonstrates significant accuracy differences between the two workflow schemas as measured by area under the receiver operating curve (AUC), as well as inter-operator variability differences as measured by Kendall’s tau-b. This evaluation has practical implications on the utilization of such technologies in diagnostic environments as compared to previous studies.

Drug Interaction Between Febuxostat and Thiopurine Antimetabolites: A Review of the FDA Adverse Event Reporting System and Medical Literature

BACKGROUND

There is a known drug interaction (DI) between xanthine oxidase (XO) inhibitors and the thiopurine immunosuppressants, azathioprine (AZA) and mercaptopurine (6-MP). Xanthine oxidase inhibition increases concentrations of AZA and 6-MP active metabolites, possibly resulting in myelosuppression. When allopurinol is used with AZA or 6-MP, dose reduction of AZA or 6-MP is recommended. Febuxostat is a newer XO inhibitor approved for the treatment of gout.

OBJECTIVE

To determine the clinical impact of the febuxostat-thiopurine DI.

DESIGN AND SETTING

Case series derived from the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) and published medical literature.

PATIENTS

Nineteen patients who received concomitant febuxostat and either AZA or 6-MP.

MEASUREMENTS

Laboratory and clinical data.

RESULTS

Nineteen cases reporting myelosuppressive events were identified in patients receiving febuxostat with AZA or 6-MP. Eighteen cases were treated with the combination of AZA and febuxostat. A median of 1.6 months elapsed from initiation of the drug combination until discovery of the event. Sixteen cases required hospitalization; 15 reported administration of blood products. Thirteen cases reported resolution of the event with discontinuation of both drugs, two reported discontinuation of the thiopurine only, and one reported discontinuation of febuxostat only.

LIMITATIONS

Thiopurine monotherapy may cause myelosuppression. Complications of immunosuppression that may contribute to the real-world morbidity and mortality associated with the febuxostat-thiopurine DI were not examined. Finally, FAERS data are limited by the voluntary nature of reporting.

CONCLUSION

Current febuxostat labeling contraindicates concomitant administration of febuxostat with either AZA or 6-MP. This case series demonstrates that the DI can result in clinically significant adverse events and is supportive of current febuxostat labeling.

A Novel Pharmacokinetic Bridging Strategy to Support a Change in the Route of Administration for Biologics

Determination of appropriate pharmacokinetic end point to bridge different dosing regimens is often a challenge when developing a new route of administration. Trough concentrations (C_trough) are often considered the most relevant PK end point to predict efficacy (ACR20/DAS28) in the treatment of rheumatoid arthritis for biologics. However, no systematic research has been conducted to evaluate this approach. We developed a novel strategy to predict the most relevant PK variables that may be used to support a change in the route of administration for biological products. Our analysis indicated that matching only C_trough when switching from intravenous dosing to subcutaneous dosing with decreasing dosing interval may result in a lower treatment response. If only average concentration (C_ave) is considered as the relevant variable, our analysis showed that treatment response may be worsened when switching from subcutaneous dosing to intravenous dosing with increasing dosing interval. The study results demonstrated that matching a single pharmacokinetic end point (C_trough or C_ave) may not be sufficient to ensure efficacy when switching between intravenous dosing and subcutaneous dosing. A practical novel pharmacokinetic bridging approach is provided to support a change in the route of administration for biological products.

The Effect of FDA Drug Safety Communications on Patterns of Tiotropium Dispensing: A U.S. Health Plan Claims Database Study

BACKGROUND

The FDA issued 2 main drug safety communications (DSCs) on the cardiovascular safety of tiotropium in March 2008 (warning of a potential increased stroke risk) and January 2010 (informing of an absence of a significant increased stroke risk or cardiovascular events based on findings from a large trial).

OBJECTIVE

To describe the effect of the FDA DSCs on medication dispensing of tiotropium in a large U.S. claims database.

METHODS

Initiation of tiotropium products among patients with chronic obstructive pulmonary disease (COPD) aged 40 years and older was determined monthly from 2006-2012 using medication dispensing from the IMS Lifelink Health Plan Claims Database. Similarly, monthly initiation of products containing long-acting beta-agonists (LABAs) was calculated to explore product switching. The effect of the 2008 and 2010 FDA DSCs was measured using interrupted time-series analysis. Subgroups of patients with greater cardiovascular risk were also examined.

RESULTS

A decreasing trend in initiation of tiotropium-containing products was present before the initial 2008 DSC. The decline in tiotropium initiation continued until January 2010, accompanied by an increased initiation of LABA-containing products in patients with COPD. In the presence of the existing decreasing trend, the initial DSC was followed by an immediate 2.8% (P = 0.02) further reduction in tiotropium initiation. Tiotropium initiation increased 2.5% (P = 0.03) immediately after the 2010 DSC, reducing the overall decline in rate and stabilizing (flattening) the trend. No significant changes in dispensing level or trend were observed among COPD patients with cardiovascular comorbidity.

CONCLUSIONS

Cardiovascular safety concerns may have affected tiotropium initiation as indicated by the decrease in tiotropium dispensing shown immediately following the initial DSC. The effect was alleviated as concerns lessened following the most recent DSC.

DISCLOSURES

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors are employed by the FDA and have no conflict of interest relevant to the content of this study. The views expressed herein do not necessarily represent the views of the FDA.

The impact of FDA regulatory activities on incident dispensing of LABA-containing medication: 2005-2011

OBJECTIVE

Evidence of safety issues associated with long-acting beta₂-agonist (LABA) treatment has led to multiple regulatory activities by the U.S. Food and Drug Administration (FDA) on this class of medications. This study describes the impact of the regulatory activities on incident LABA-containing medication dispensing.

METHODS

A monthly rolling cohort of asthma patients who were eligible to initiate a LABA-containing product was created in the Mini-Sentinel Distributed Database between January 2005 and June 2011. Cohorts of individuals who initiated LABA were examined for the changes in the proportions of single-ingredient to fixed-dose inhaled corticosteroid (ICS)-LABA initiators, appropriate initiation of LABA-containing products, and use of controller medications. The impact of the 2005 and 2010 FDA regulatory activities associated with LABA-containing products was measured using interrupted time series with segmented regression.

RESULTS

LABA-containing product initiation was declining prior to the 2005 regulatory activities and continued to decline over the study period, accompanied by increased initiation of fixed dose ICS-LABA among LABA initiators. While the 2010 regulatory activities had no immediate impact on the proportion of LABA initiation in patients with prior controller medication dispensing and/or poor asthma control, there was an increasing positive trend toward LABA initiation in the appropriate patient population after the regulatory activities.

CONCLUSION

The 2005 and 2010 FDA regulatory activities likely had an impact on communicating the safety concerns of LABA products. However, the impact cannot be viewed independent of scientific publications, guidelines for asthma treatment and other regulatory activities.

The US Food and Drug Administration's drug safety recommendations and long-acting beta2-agonist dispensing pattern changes in adult asthma patients: 2003-2012

Background

Emerging safety issues associated with long-acting beta₂-agonist (LABA) have led to multiple regulatory activities by the US Food and Drug Administration (FDA) since 2003, including Drug Safety Communications (DSCs) in 2010. These DSCs had three specific recommendations for the safe use of LABA products in adult asthma treatment.

Methods

We examined the initiation of LABA-containing products for adult asthma treatment using an intermittent time series approach in a claims database from 2003 to 2012. We assessed the alignment of dispensing patterns with the following 2010 FDA recommendations: 1) contraindicated use of single-ingredient (SI)-LABA without an asthma controller medication (ACM); 2) a LABA should only be used when asthma is not adequately controlled on inhaled corticosteroids (ICSs) or ACM; and 3) step-down asthma therapy (e.g., discontinue LABA) when asthma control is achieved.

Results

There were 477,922 adults (18–64 years old) dispensed a new LABA during 2003–2012. Among LABA initiators, patients who initiated an SI-LABA and who did “not” have an ACM dispensed on the same date decreased from >9% in 2003 (the initial labeling change) to <2% post 2010 DSCs (p-value <0.0001 in the segmented regression model). The proportion of asthma patients dispensed an ICS in 6 months prior to initiating LABA treatment did not increase. The proportion of patients with longer than 4 months of continuous treatment did not decrease over the study period.

Conclusion

Although the decrease in SI-LABA initiation is consistent with FDA’s recommendations, low ICS dispensing before initiating a LABA and LABA continuation practices require further efforts to move toward the recommended safe practices.

Toward a Theory of Self-Directed Learning: a Study of Experts Without Formal Training

The authors analyzed the biographies of twenty acknowledged experts with out formal training beyond high school in search of commonalities that might suggest ways people become effectively self-directed in learning and accom plishment. Of the 154 characteristics identified, the fifty rated as most im portant were examined. They outline a pattern of education that is sharply focussed, active, experiential, self-directed, situational, and often personally challenging. They indicate a personality that is both traditional and radical, and they suggest a life theme of gathering purpose and drive. The authors transform their analyses into fourteen hypotheses about education, about a form of schooling that would prepare students for a life of self-directed learning and attainment.

Changing patterns of asthma medication use related to US Food and Drug Administration long-acting β2-agonist regulation from 2005-2011

BACKGROUND

Safety concerns associated with long-acting β2-agonists (LABAs) have led to many US Food and Drug Administration (FDA) regulatory activities for this class of drugs. Little is known about the effect of these regulatory activities on use of LABA-containing agents or other asthma medications.

METHODS

We created rolling cohorts of pediatric and adult asthmatic patients in the Mini-Sentinel Distributed Database between January 2005 and June 2011. The proportions of asthmatic patients using LABA-containing products, inhaled corticosteroids (ICSs), leukotriene modifiers, short-acting β2-agonists, oral corticosteroids, other bronchodilators, and no medications were measured on a monthly basis, and the changes were evaluated by using interrupted time series with segmented regression analysis.

RESULTS

When the 2005 regulatory activity was announced, there were statistically significant decreases in the use of fixed-dose ICS-LABA agents in children (-0.98 percentage points) and adults (-1.24 percentage points). Increased use of ICSs and leukotriene modifiers was observed just after the regulatory activities were announced in both children and adults. Although of smaller magnitude, continued favorable changes in the use of LABA agents were observed after the 2010 FDA regulatory activity.

CONCLUSION

The 2005 and 2010 FDA regulatory activities might have contributed to reduced use of LABA agents, as intended; however, their effect, independent of other factors, cannot be determined. Use of other classes of asthma medications was similarly affected.

Use of Screening Tests for Colorectal Cancer Among Gynecologists in Puerto Rico

OBJECTIVE

To determine the use of screening tests for colorectal cancer (CRC) among Gynecologists in Puerto Rico. This study evaluates the screening practices used by Gynecologists in PR to diagnose CRC and adherence to screening guidelines.

METHODS

A self-administered anonymous questionnaire was mailed to 440 practicing gynecologists through the College of Physicians and Surgeons of PR. The questionnaire included general and specific questions.

RESULTS

Response rate was 23.2% (102/440). Of this group of gynecologists, 77.5% referred screening patients, while 22.5% did not. The majority (28.4%) use Fecal Occult Blood Test (FOBT) as a first screening test, while 27.5% use Colonoscopy. Screening is started by 49% at age 50. Only 7% stop screening at 75 years and 31% never stop screening. CRC Screening performed by participants were: 35% screen annually, 6% screen 2-3 years, 10% screen every 5 years, 6% screen every 10 years and 6% screen 5-10 years. Data for CRC Screening reveals 7% gynecologists comply with all the guidelines; 49% comply with the recommendations regarding the start screening age and 7% stop screening as per guidelines.

CONCLUSION

The recommendations are not followed by most of the gynecologists in PR that participated in the study, Further research should be directed towards the reasons for not complying and how to educatethemedical population to achieve adequate screening in the PR female population.

International Guidelines for Bioequivalence of Locally Acting Orally Inhaled Drug Products: Similarities and Differences

International regulatory agencies have developed recommendations and guidances for bioequivalence approaches of orally inhaled drug products (OIDPs) for local action. The objective of this article is to discuss the similarities and differences among these approaches used by international regulatory authorities when applications of generic and/or subsequent entry locally acting OIDPs are evaluated. We focused on four jurisdictions that currently have published related guidances for generic and/or subsequent entry OIDPs. They are Therapeutic Goods Administration (TGA) in Australia, Health Canada (HC) in Canada, European Medicines Association (EMA) of European Union (EU), and the Food and Drug Administration (FDA) in the United States of America (USA). The comparisons of these bioequivalence (BE) recommendations are based on selection of reference products, formulation and inhaler device comparisons, and in vitro tests and in vivo studies, including pharmacokinetic (PK), pharmacodynamics (PD), and clinical studies. For the in vivo studies, the study design, choices of dose, subject inclusion/ exclusion criteria, study period, study endpoint, and equivalence criteria are elaborated in details. The bioequivalence on multiple-strength products and waiver options are also discussed.

Long-acting beta2-adrenergic agonist in pediatric and adolescent asthma patients, 2003-2011

OBJECTIVES

To evaluate changes in the dispensing patterns of long-acting beta2-adrenergic agonist (LABA) in pediatric and adolescent asthma patients in relation to multiple Food and Drug Administration (FDA) regulatory activities from 2003 to 2011.

METHODS

We estimated LABA dispensing to pediatric asthma patients across three periods: 2003-2004 (after the first labeling change), 2005-2009 (after regulatory activities in 2005 and before 2010 LABA labeling change) and 2010-2011 (after 2010 LABA labeling change), using the IMS Health Plan Claims database. We estimated dispensing patterns over time for single-ingredient (SI) LABA and fixed-dose combination (FDC) of inhaled corticosteroid (ICS) and LABA (FDC-ICS/LABA). We also evaluated prior use of non-LABA asthma-control medication (ACM) before LABA initiation.

RESULTS

Of the 147 862 pediatric and adolescent asthma patients who initiated a LABA during the entire study period, the majority (96%) were FDC-ICS/LABA initiators. The proportion of SI-LABA among any LABA initiators was small and declined (9%, 4% and 2%, trend test p < 0.001) for the three periods. Among the patients who initiated, the proportions with prior use of an ACM (1-90 days prior) were 35%, 36% and 39% for the three periods.

CONCLUSIONS

The significant decline in the proportion of SI-LABA initiation over these years is consistent with FDA's recommendations. However, the favorable trend cannot be solely attributed to FDA activities as changes to clinical practice guidelines, and media publicity may have played a role. Investigating the reasons for the low ACM use before LABA initiation may inform approaches to further improve appropriate use of LABA in young asthma patients.

Exposure to copper induces oxidative and stress responses and DNA damage in the coral Montastraea franksi

Copper is a common chemical contaminant in coastal environments, including coral reefs. Ecotoxicological studies have demonstrated that exposure to copper can cause stress and detrimental effects in both host cnidarian and algal symbionts. The objective of this study was to investigate the sublethal effects of copper on the reef-building coral Montastraea franksi, by identifying genes with altered expression in corals exposed to dissolved copper, and by measuring the extent of damage to DNA in response to copper exposure. Corals exposed to 30 μg L(-1) copper for 48 h experienced significant DNA damage and displayed changes in expression patterns of genes that are known to play role cellular and oxidative stress responses. Corals also experienced changes in gene expression of genes that are not already known to play roles in oxidative stress in corals. Our data suggest that these genes may either play roles directly in mediating a stress response, or may be genes acting downstream of the stress response. These include an ETS domain-containing transcription factor related to the ETS1 family of transcription factors, known in mammals to mediate development, disease, and stress response, and two genes that are associated with biomineralization: galaxin, a protein from the organic matrix of the coral skeleton, and a coral-specific gene SCRIP2.

Preoperative fluid restrictions: hospital policy and clinical practice

This study examined the practice of preoperative fluid restrictions and the influence of the hospital 'nil by mouth' policy on clinical practice. Structured interviews were used to assess the knowledge of nurses and anaesthetists relating to current hospital policy, their attitudes to fluid fasting and the constituents of clear fluids. The interval between the last intake of fluid and the induction of anaesthesia was measured in 90 adult patients to determine actual periods of fasting. It was found that most patients on the same operating list commenced fasting simultaneously with little or no attempt made to individualize the timing which contributed to prolonged periods without fluids, ranging from 3 hours 30 minutes to 17 hours and 45 minutes. Only 30% of nurses were aware of the hospital policy compared with 75% of anaesthetists. The evidence from this study demonstrated that the hospital policy was not reflected in clinical practice which continued to be based on tradition.

A comparison of descriptive variables for clinical patients and symptomatic volunteers with depressive disorders

Uncertainty about the generalizability of results from clinical trials is a nagging issue plaguing psychiatric research. The possible bias introduced by the use of subjects recruited from advertisements is one source of concern. Investigators question whether these subjects are representative of the types of individuals who seek treatment in clinical practice. This article compares and contrasts demographic characteristics, functional disabilities, symptomatologies, and the health beliefs and expectations of a cohort seeking treatment at a university outpatient clinic with a cohort of symptomatic volunteers recruited by advertisements. These two groups were alike in most variables; however, the clinical subjects reported more recent exposure to psychotropic medications and were more likely to indicate that they wanted psychotherapy. The symptomatic volunteers were slightly older, endorsed more psychiatric symptoms, drank more alcohol, and believed that combined pharmacology and psychotherapy would most help them. These findings suggest that the two cohorts were remarkably similar on most variables.

Comparison of descriptive variables for symptomatic volunteers and clinical patients with anxiety disorders

Worry about the generalizability of findings derived from clinical trials is a nagging problem. Because most clinical trials use individuals recruited by advertisements rather than patients solicited from clinical practice, bias in subject recruitment is a major concern. This paper compares and contrasts the demographic characteristics, symptomatologies, functional disabilities, health beliefs, and health expectations of clinical outpatients to those of subjects recruited from the media (symptomatic volunteers) for pharmacologic trials. Clinical patients were slightly younger, better educated, wealthier, and were more likely to be married. They had more recent exposure to benzodiazepines and antidepressants and were more likely to view their current condition as amenable to psychotherapy. They were more likely to feel that their symptoms would get worse without some type of treatment and to believe that treatment would cure them. The symptomatic volunteers had more presenting symptoms than the clinical patients. The two groups had similar Sheehan Disability Scale scores. These results suggest that further study is warranted of the characteristics of clinical patients and symptomatic volunteers.

Interface skin pressures on four pressure-relieving devices

Nurses employed in acute care hospitals frequently encounter patients who require a pressure-relieving device. It is often difficult for nurses to decide which support surface should be used to best meet a patient's need for a pressure-reducing device because of the multiplicity of products available. One of the variables studied was found not to statistically influence the effectiveness of the various pressure-relieving devices. Body build is not a consideration when determining which support surface is effective in a healthy population of subjects. The two air-flotation low air-loss beds would be defined as effective pressure-relieving devices. The interface pressure readings vary from individual to individual on various bony prominences. The population studied was that of healthy volunteers. Healthy subjects have an increased fat pad in their sacral area compared with the critically ill patient. The heel had the highest interface pressure of the five that were studied. This is a bony prominence that requires additional attention if skin integrity is to be maintained.