Endpoints clinical trials

Compound 34 (BCZ-1812, RWJ-270201, peramivir) showed selective inhibition of influenza virus sialidases over bacterial and mammalian sialidases (Babu et al. 2000 Bantia et al. 2001 Sidwell and Smee 2002). Successful inhibition of influenza virus infectivity in vitro (Smee et al. 2001) and upon oral administration in vivo [mice (Bantia et al. 2001) and ferrets, reviewed in Sidwell and Smee 2002] led to human clinical trials of orally administered peramivir (Barroso et al. 2005). While orally administrated peramivir successfully completed animal studies and Phase I and Phase II clinical trials, in which the compound was showing neither major side effects nor toxicity (Sidwell and Smee 2002), preliminary results of the Phase III trials (June 2002) demonstrated no statistically significant difference in the primary efficacy endpoint, possibly due to low bioavailability (Barroso et al. 2005). 

Ticlopidine inhibits the P2Yj2 platelet ADP receptor, thus inhibiting ADP-dependent activation of the GP Ilb/IIIa receptor. It has a slow onset of action and takes 3-7 days to reach its maximal antiplatelet effect. It is inactive in vitro and must undergo activation by the hepatic cytochrome p450 enzyme system. Secondary prevention trials have found that ticlopidine-treated patients have an estimated RRR of 33% for the composite endpoint of stroke, myocardial infarction, or vascular death after ischemic stroke. Significant adverse effects include bone marrow depression, rash, diarrhea, and thrombotic thrombocytopenic purpura. No clinical trials have studied ticlopidine for the treatment of stroke in the acute phase. 

Either UFH or LMWH should be administered to patients with NSTE ACS. Therapy should be continued for up to 48 hours or until the end of the angiography or PCI procedure. In patients initiating warfarin therapy, UFH or LMWHs should be continued until the International Normalized Ratio (INR) with warfarin is in the therapeutic range for 2 consecutive days. The addition of UFH to aspirin reduces the rate of death or MI in patients with NSTE ACS.47 Enoxaparin was mentioned as preferred over UFH in the 2002 ACC/AHA clinical practice guidelines, as two large clinical trials found a reduction in the combined endpoint of death, MI, or need for PCI in patients... 

Quality of life Measured by validated scales and patient interviews to determine the effect of therapy on a patient s lifestyle. An improvement in quality of life may be an endpoint in clinical trials. 

In this form, event would be replaced by some clinical finding such as myocardial infarction, stroke, seizure, or the like. This example form is extremely simplified, as there are usually a number of associated data variables captured as well. The event/endpoint page data must be clean, because it likely captures the primary efficacy data for the clinical trial. 

Time is a critical measure for clinical trial analysis. Time is captured in clinical trial databases in a study day variable. Study day can be defined as the number of days from therapeutic intervention to any given time point or event. By defining study day, you create a common metric for measuring time across a population of patients in a clinical trial. There can be a study day calculation for any time point of interest. Adverse event start, study termination, and clinical endpoint event date all make good choices for study day calculations. The study day calculation is performed with one of the two following approaches. 

CSline. CSline [84] provides information on well-designed and well-executed clinical trials of drugs currently under study or in use in humans. This information includes study objectives, design, population, intervention groups, withdrawals, adverse reactions, endpoints and results, conclusions, and references. The CSline database covers more than 500 drugs currently on the market or in development. Pharmacological data from more than 2000 journal articles, congresses, and books are added each year. The product is commercially available on CD-ROM from Prous Science and is updated every 2 months. 

Phase II investigates the compound s efficacy and safety in controlled clinical trials for a specific therapeutic indication. To eliminate as many competing factors as possible, Phase II trials are narrowly controlled. They are characterized as small—several hundred subjects with the indicated disease or symptoms—and are closely monitored. The control may be either a placebo study arm or an active control arm. The endpoint measured may be the clinical outcome of interest or a surrogate. Phase II trials may last for several months or even several years. Early pilot trials to evaluate safety and efficacy are called Phase Ila. Later trials, called Phase lib, are important tests of the compound s efficacy. These trials may constitute the pivotal trials used to establish the drug s safety and efficacy. At least one pivotal trial (most frequently a large, randomized Phase III study) is done. Only about one third of compounds entered into Phase II will begin Phase III studies [61],... 

Major drawback Dose, indication, timing may not be standardized and therefore could confound associations if prospective, then same drawback as clinical trial if retrospective, same drawback as case-control Prospective study requiring follow-up time until endpoints develop to measure response... 

If there is no evidence of interaction, and yet there is evidence of an association between genotype and disease progression, the SNP still may be useful. Identifying fast disease progressors up front may be a mechanism to enrich clinical trials, decreasing the time needed to reach progression-related endpoints. 

Additionally, there are specialized studies designed to address endpoints of concern for almost all drugs (carcinogenicity, reproductive or developmental toxicity) or concerns specific to a compound or family of compounds (local irritation, neurotoxicity, or immunotoxicity, for example). When these are done, timing also requires careful consideration. It must always be kept in mind that the intention is to ensure the safety of people in whom the drug is to be evaluated (clinical trials) or used therapeutically. An understanding of special concerns for both populations should be considered essential. 

Additional objectives of clinical trials conducted in Phase II may include evaluation of potential study endpoints, therapeutic regimens (including concomitant medications) and target populations (e.g., mild versus severe disease) for further study in Phase II or III. These objectives may be served by exploratory analyses, examining subsets of data and by including multiple endpoints in trials. 

These scales may be used either as part of a clinical trial or as major endpoints in an efficacy trial. Here they are described as a means of obtaining ancillary data on psychological factors in a clinical trial. If these scales are used to demonstrate efficacy, it is mandatory to include only those scales known to be valid. 

Exposure-response data, using short-term biomarkers or surrogate endpoints, can sometimes make further exposure-response studies from clinical endpoints xmnecessary. For example, if it can be shown that the short-term effect does not increase beyond a particular dose or concentration, there may be no reason to explore higher doses or concentrations in the clinical trials. Similarly, short-term exposure-response studies with biomarkers might be used to evaluate early (i.e., first dose) responses seen in clinical trials. 

A much more conventional approach was required for the approval of pemefrexed for the treatment of patients with advanced mesothelioma. In a trial of cisplafinum plus pemetrexed vs. cisplafinum alone, there was a significant improvement in patient survival (a median of 13 vs. 10 months). In addition to an improvement in survival, the trial also had patient-oriented endpoints such as amount of dyspnea and an improvemenf in vital capacity (e.g., clinical benefit). There is no doubt that future clinical trials should build upon these important patient-oriented endpoints, particularly trials in which response (tumor shrinkage) may not be as commonly seen as the response with cytotoxic agents. ... 

In clinical trials, biomarkers are used to indicate a particular disease state and its progression. They may be used as surrogate markers in the evaluation of the effectiveness of a drug as representative of the natural endpoint such as survival rate or irreversible morbidity. 

The important point for patients is not so much that plasma cholesterol decreases but that the clinical endpoints decrease nonfatal heart attacks, coronary artery disease deaths, surgery for coronary artery disease, and total mortality. Subsequent to the approval of statins based on reduction of plasma cholesterol levels, several large, controlled clinical trials have been carried out to establish the effects of statin use on these clinical endpoints. ... 

There are several inherent weaknesses in observational trials, hi controlled clinical trials, every effort is made to select patient populations in a way that excludes as many variables as possible between the placebo- and drug-treated groups, leaving drug treatment as the only variable. This ideal cannot be strictly realized in practice but experienced investigators come pretty close. Beyond that, controlled clinical trials state upfront what the primary and secondary endpoints... 

The limitations of the use of biomarkers in healthy volunteers must be recognised. For example, although there have been attempts to simulate migraine headache in volunteers, to date none of these models can be considered adequate to serve as a surrogate endpoint. Patients with migraine are not difficult to recruit and are usually healthy apart from their migraine. In this case, it maybe more appropriate to establish tolerability and pharmacokinetics in healthy volunteers and then to select a maximum well-tolerated dose with which to perform a small proof of principle clinical trial in patients. This will need to be followed by larger trials to establish the dose-response relationship. 

A good clinical trial is designed to take account of the variability in response (either efficacy or adverse event) that is expected when a new active drug is tested. This response depends on an individual s genetic make-up, and on a number of environmental factors, such as disease state, other drugs and age. The size of the trial and the selection of study subjects are carefully determined to reduce the variability in response to a minimum (i.e. to maximise the sensitivity of the trial) so that the trial endpoints can be determined with as much certainty as possible. 

The impact of these considerations on study subject selection, sample size and endpoint measures will need to figure in future clinical trial designs. 

Clinical trials generate vast quantities of data, most of which are processed by the sponsor. Assessments should be kept to the minimum that is compatible with the safety and comfort of the subject. Highest priority needs to be given to assessment and recording of primary endpoints, as these will determine the main outcome of the study. The power calculation for sample size should be based on the primary critical endpoint. Quite frequently, trials have two or more evaluable endpoints. It must be stated clearly in the protocol whether the secondary endpoints are to be statistically evaluated, in which case power statements will need to be given, or are simply... 

Improvements in medical treatments have been substantial, so much so that benefits of recently introduced medicines over existing ones are smaller than when these standard treatments were originally developed and compared with remedies that existed then. The mean difference in some clinical efficacy endpoints between treatments maybe less than 20%. This requires a large population sample in clinical trials in order to achieve sufficient power to detect a difference, if it really exists, with confidence. Most medical conditions (for instance, peptic ulcers) present rather infrequently at any single hospital centre and it would therefore be impossible for a single... 

The aim of any clinical trial is to have low risk of Type I and II errors and sufficient power to detect a difference between treatments, if it exists. Of the three factors in determining sample size, the power (probability of detecting a true difference) is arbitrarily chosen. The magnitude of the drug s effect can be estimated with more or less accuracy from previous experience with drugs of the same or similar action, and the variability of the measurements is often known from published experiments on the primary endpoint, with or without the drug. These data will, however, not be available for novel substances in a new class and frequently the sample size in the early phase of development has to be chosen on an arbitrary basis. 

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