Phase III trial

Purpose Safety Pharmacology (pharmacokinetics, side effects tolerance assessment, evidence of toxicity, pharmacodynamics) Subjects 10-100 usually healthy males Duration 1 year 

Purpose Explore Therapeutic Efficacy (dose ranging and dose-response curves, pharmacodynamics, 

Purpose Confirm therapeutic efficacy and safety (indications for use, recommended dosage, contraindications, long-term administration and emergence of additional side effects) 

Subjects up to 3000 drawn from broad patient base multi-site, multi-group Duration 3-5 years or longer 

---

O Brien S, Moore JO, Boyd TE et al (2007) Randomized phase III trial of fludarabine plus cyclophosphamide with or without oblimersen sodium (Bcl-2 antisense) in patients with relapsed or refractory chronic lymphocytic leukemia. J Clin Oncol 25(9) 1114-1120... 

Most recently, a phase-I-study defined a dose of 13-ris-retinoic acid that was tolerable in patients after myeloablative therapy, and a phase-III-trial showed that postconsolidation therapy with 13-cis-retinoic acid improved EFS for patients with high-risk neuroblastoma [7]. Preclinical studies in neuroblastoma indicate that ATRA or 13-cw-RA can antagonize cytotoxic chemotherapy and radiation, such that use of 13-cis-RA in neuroblastoma is limited to maintenance after completion of cytotoxic chemotherapy and radiation. It is likely that recurrent disease seen during or after 13-cis-RA therapy in neuroblastoma is due to tumor cell resistance to retinoid-mediated differentiation induction. Studies in neuroblastoma cell lines resistant to 13-cw-RA and ATRA have shown that they can be sensitive, and in some cases collaterally hypersensitive, to the cytotoxic retinoid fenretinide. Here, fenretinide induces tumor cell cytotoxicity rather than differentiation, acts independently from RA receptors, and in initial phase-I-trials has been well tolerated. Clinical trials of fenretinide, alone and in combination with ceramide modulators, are in development. 

Antagonists of TLR-4 have been developed to prevent an excessive reaction to infection in the body. TAK-242 and Eritoran are both in phase III trials to help combat... 

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). 

In vitro release profiles on phase II and phase III clinical supplies prepared more than 2 years apart are shown in Fig. 2. SeveT al thousand doses were prepared for the phase III trial initiated in 1988. Figure 3 shows the reproducibility of six individual batches of microspheres produced by the solvent evaporation method. Other studies have been reported with similar processes (47). 

Pharmacologic neuroprotection, which might be expected to prevent tissue necrosis or apoptosis until tissue reperfusion can be achieved with rt-PA, is a theoretically attractive adjunct to rt-PA treatment. Despite positive studies in animals, all evaluations of neuroprotective agents in humans have failed. Most recently, the promising initial results for intravenous NXY-059, a ffee-radical-trapping agent, were not replicated in a confirmatory phase III trial (unpublished data). 

The ongoing IMS III trial is a randomized, multicenter, phase III trial continuing the investigation into the efficacy of the combined IV and lA approach to treat acute stroke. Patients are being randomized to IV/IA therapy and IV rt-PA alone in a 2 1 ratio. In the group allocated to combination IV/IA therapy, the physician will select either the EKOS microcatheter or a standard microcatheter to infuse rt-PA, or select the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) clot retrieval device. The primary outcome is the percentage of patients with an mRS score of 0-2 at 90 days. ... 

Direct Fibrinolytics Alfimeprase is a recombinant tmncated form of fibrolase, a fibrinolytic zinc metalloproteinase isolated from the venom of the Southern copperhead snake. It degrades fibrin directly and achieves thrombolysis independent of plasmin formation. This may result in faster recanalization and a decreased risk of hemorrhagic conversion. The initial data on the safety and efficacy of alfimeprase in peripheral arterial occlusion disease appeared very promising, but recent communication from the sponsor revealed that the phase III trials of the drug in peripheral arterial disease and catheter obstruction (NAPA-2 and SONOMA-2) failed to meet their primary and key secondary endpoints of revascularization. A trial for I AT in acute stroke (CARNEROS-1) is planned to begin soon. 

HU-210 is (8.1) among the most potent cannabinoids known. Its enantiomer HU-211 (8.2) does not bind to the cannabinoid receptor and lacks psychotropic side effects (as long as optical purity is guaranteed). In animal models it shows analgesic and antiemetic activity. It also shows neuroprotec-tive effects after brain injury and was tested in humans as anti-traiuna agent, where it did not meet the expectations in a clinical phase III trial. 

Nearly all the clinical data comes from the use of atosiban (see Peptide Antagonists), a peptide oxytocin antagonist that is licensed in Europe for acute (48 h) treatment of preterm labour. Early clinical studies demonstrated the ability of atosiban to inhibit uterine contractions associated with labour [14]. Following these successful phase II trials, full phase III trials were... 

Fondaparinux has been used for the treatment of DVT and PE in two large Phase III trials and is approved by the FDA for these indications. Fondaparinux is as safe and effective as IV UFH for the treatment of PE and SC LMWH for DVT treatment.36,40 The recommended dose for fondaparinux in the treatment of VTE is based on the patient s weight (Table 7-3). Fondaparinux is renally eliminated and accumulation can occur in patients with renal dysfunction. Due to the lack of specific dosing guidelines, fondaparinux is contraindicated in patients with severe renal impairment (CrCl less than 30 mL/minute). Baseline renal function should be measured and monitored closely during the course... 

Ozols RF, Bundy BN, Greer BE, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer a gynecologic oncology group study. J Clin Oncol 2003 21 3194-3200. 

Lenalidomide is an immunomodulating agent related to thalidomide that was recently approved for the treatment of patients with multiple myeloma and myelodysplastic syndrome (MDS). Lenalidomide lacks the common side effects of thalidomide, such as constipation and peripheral neuropathy. Interim analyses of two phase III trials show that lenalidomide in combination with dexamethasone produces higher response rates than dexamethasone alone in relapsed and refractory myeloma. Adverse effects of lenalidomide include diarrhea, nausea, muscle cramps, hematologic side effects and deep vein thrombosis.42... 

Rimonabant is a selective CB1 receptor antagonist that is currently under investigation in phase III trials. CB1 receptors are found in the brain, adipose tissue, the GI tract, pituitary and adrenal glands, sympathetic ganglia, heart, lungs, liver, and bladder.17,18 Food cravings are diminished following inhibition of this receptor.19... 

On completion of phase III trials, the data will be checked to see that it fulfils all the criteria required to generate a viable, marketable drag. The company will then file a New Drug Application (NDA), with the intention of proving the efficacy and safety of the drug in this therapeutic application. The NDA will contain all the clinical data and all relevant preclinical data for review by the FDA. Application reviews were 16.2 months on average in 1997 [75]. 

Diet drugs that are in development take years to be approved and marketed in the United States. First, these compounds are studied in the laboratory. Then, they are tested in animals. The next step is to be tested in people. There are three rounds of study—called Phases 1,11, and III trials—to establish safety and effectiveness of the drug in humans. Drugs that are in Phase III trials are closest to approval and are usually available in the United States within a couple of years if they prove to be safe and effective. Drugs in Phase II trials are a little further behind in the approval process. 

The main side effects associated with Axokine are nausea and cough. Unlike the other drugs discussed in this book, Axokine is an injection, not a pill. Axokine must be given with a needle, which may cause some pain at the site where it is injected. Axokine is currently being studied in a Phase III trial for weight loss. If Axokine proves to be safe and effective, it should be available in the United States within a few years. 

If the drug proves safe and effective, phase III trials are initiated. (In the context of clinical trials, safe and effective are rarely used in the absolute sense. Safe generally refers to a favourable risk beneht ratio, i.e. the benefits should outweigh any associated risk. A drug is rarely 100 per cent effective in all patients. Thus, an acceptable level of efficacy must be defined, ideally prior to trial commencement. Depending upon the trial context, efficacy could be defined as prevention of death/prolonging of life by a specific time-frame. It could also be defined as alleviation of disease symptoms or enhancement of the quality of life of sufferers (often difficult parameters to measure objectively). An acceptable incidence of efficacy should also be defined (particularly for phase II and III trials), e.g. the drug should be efficacious in, say, 25 per cent of all patients. If the observed incidence is below the minimal acceptable level, then clinical trials are normally terminated. 

Whereas a comprehensive phase III trial would normally require at least several hundred patients, smaller trials would suffice if, for example ... 

During the clinical trial phase, the sponsor and FDA will meet on one or more occasions. A particularly important meeting is often the end of phase II meeting. This aims primarily to evaluate and agree upon phase III plans and protocols. This is particularly important, as phase III trials are the most costly and generate the greatest quantity of data, used later to support the drug approval application. 

Three randomized phase III trials have evaluated the efficacy of fulvestrant. The first two trials were designed to compare the efficacy of fulvestrant... 

---