1
|
Tricoci P, Newby LK, Clare RM, Leonardi S, Gibson CM, Giugliano RP, Armstrong PW, Van de Werf F, Montalescot G, Moliterno DJ, Held C, Aylward PE, Wallentin L, Harrington RA, Braunwald E, Mahaffey KW, White HD. Prognostic and Practical Validation of Current Definitions of Myocardial Infarction Associated With Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2019; 11:856-864. [PMID: 29747915 DOI: 10.1016/j.jcin.2018.02.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In 13,038 patients with non-ST-segment elevation acute coronary syndrome undergoing index percutaneous coronary intervention (PCI) in the EARLY ACS (Early Glycoprotein IIb/IIIa Inhibition in Non-ST-Segment Elevation Acute Coronary Syndrome) and TRACER (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) trials, the relationship between PCI-related myocardial infarction (MI) and 1-year mortality was assessed. BACKGROUND The definition of PCI-related MI is controversial. The third universal definition of PCI-related MI requires cardiac troponin >5 times the 99th percentile of the normal reference limit from a stable or falling baseline and PCI-related clinical or angiographic complications. The definition from the Society for Cardiovascular Angiography and Interventions (SCAI) requires creatine kinase-MB elevation >10 times the upper limit of normal (or 5 times if new electrocardiographic Q waves are present). Implications of these definitions on prognosis, prevalence, and implementation are not established. METHODS In our cohort of patients undergoing PCI, PCI-related MIs were classified using the third universal type 4a MI definition and SCAI criteria. In the subgroup of patients included in the angiographic core laboratory (ACL) substudy of EARLY ACS (n = 1,401) local investigator- versus ACL-reported angiographic complications were compared. RESULTS Altogether, 2.0% of patients met third universal definition of PCI-related MI criteria, and 1.2% met SCAI criteria. One-year mortality was 3.3% with the third universal definition (hazard ratio: 1.96; 95% confidence interval: 1.24 to 3.10) and 5.3% with SCAI criteria (hazard ratio: 2.79; 95% confidence interval: 1.69 to 4.58; p < 0.001). Agreement between ACL and local investigators in detecting angiographic complications during PCI was overall moderate (κ = 0.53). CONCLUSIONS The third universal definition of MI and the SCAI definition were both associated with significant risk for mortality at 1 year. Suboptimal concordance was observed between ACL and local investigators in identifying patients with PCI complications detected on angiography. (Trial to Assess the Effects of Vorapaxar [SCH 530348; MK-5348] in Preventing Heart Attack and Stroke in Participants With Acute Coronary Syndrome [TRA·CER] [Study P04736]; NCT00527943; EARLY ACS: Early Glycoprotein IIb/IIIa Inhibition in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome [Study P03684AM2]; NCT00089895).
Collapse
Affiliation(s)
| | | | - Robert M Clare
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul W Armstrong
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Gilles Montalescot
- Sorbonne Université Paris 06, ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière (AP-HP), Paris, France
| | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala Clinical Research Center, Uppsala, Sweden
| | - Philip E Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
2
|
Glassberg MK, Nathan SD, Lin CY, Morgenthien EA, Stauffer JL, Chou W, Noble PW. Cardiovascular Risks, Bleeding Risks, and Clinical Events from 3 Phase III Trials of Pirfenidone in Patients with Idiopathic Pulmonary Fibrosis. Adv Ther 2019; 36:2910-2926. [PMID: 31401786 PMCID: PMC6822835 DOI: 10.1007/s12325-019-01052-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION This study assessed baseline cardiovascular (CV) risk factors, concomitant CV medication use, risk of major adverse cardiac events-plus (MACE-plus), and bleeding adverse events (AEs) in patients with idiopathic pulmonary fibrosis (IPF) in three randomized, placebo-controlled phase III trials of pirfenidone. METHODS Patients in the pirfenidone phase III trials were included. Patients with unstable or deteriorating cardiac disease within 6 months before enrollment were ineligible. Medical history at baseline and concomitant CV medication use during treatment were reported. A retrospective, blinded review of AE preferred terms was conducted to identify MACE-plus and bleeding events. Subgroup analyses examined the impact of concomitant CV medication use on how pirfenidone treatment affected clinical outcomes. RESULTS In total, 1247 patients were included [n = 623 pirfenidone (2403 mg/day) and n = 624 placebo]. The median age was 68 years, 74% were male, and 65% were current/former smokers. Commonly reported CV risk factors included hypertension (52%), obesity (44%), hypercholesterolemia (23%), and hyperlipidemia (23%). Pre-existing cardiac disorders included coronary artery disease (16%), myocardial infarction (5%), and atrial fibrillation (5%). Lipid-modifying agents (60%), antithrombotic agents (54%), and renin-angiotensin inhibitors (39%) were commonly used concomitant CV medications. The incidences of MACE-plus and bleeding events were similar between the pirfenidone and placebo groups (1.8% and 2.9% for MACE-plus events and 3.7% and 4.3% for bleeding events, respectively). Except for patients receiving heparin, pirfenidone had a beneficial effect compared with placebo on efficacy outcomes regardless of concomitant CV medications. CONCLUSIONS CV risk factors and comorbidities and use of concomitant CV medications are common in patients with IPF. Pirfenidone did not appear to increase the risk of CV or bleeding events. Use of several concomitant CV medications, including warfarin, did not appear to adversely impact pirfenidone's beneficial effect on efficacy outcomes. TRIAL REGISTRATION NCT00287716, NCT00287729, and NCT01366209. FUNDING F. Hoffmann-La Roche Ltd. and Genentech, Inc.
Collapse
Affiliation(s)
| | | | - Chin-Yu Lin
- Genentech, Inc., South San Francisco, CA, USA
| | | | | | | | - Paul W Noble
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
3
|
Seifert HA, Malik RE, Bhattacharya M, Campbell KR, Okun S, Pierce C, Terkowitz J, Turner JR, Krucoff MW, Powell GE. Enabling social listening for cardiac safety monitoring: Proceedings from a drug information association-cardiac safety research consortium cosponsored think tank. Am Heart J 2017; 194:107-115. [PMID: 29223428 DOI: 10.1016/j.ahj.2017.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 08/29/2017] [Indexed: 12/23/2022]
Abstract
This white paper provides a summary of the presentations and discussions from a think tank on "Enabling Social Listening for Cardiac Safety Monitoring" trials that was cosponsored by the Drug Information Association and the Cardiac Safety Research Consortium, and held at the White Oak headquarters of the US Food and Drug Administration on June 3, 2016. The meeting's goals were to explore current methods of collecting and evaluating social listening data and to consider their applicability to cardiac safety surveillance. Social listening is defined as the act of monitoring public postings on the Internet. It has several theoretical advantages for drug and device safety. First, these include the ability to detect adverse events that are "missed" by traditional sources and the ability to detect adverse events sooner than would be allowed by traditional sources, both by affording near-real-time access to data from culturally and geographically diverse sources. Social listening can also potentially introduce a novel patient voice into the conversation about drug safety, which could uniquely augment understanding of real-world medication use obtained from more traditional methodologies. Finally, it can allow for access to information about drug misuse and diversion. To date, the latter 2 of these have been realized. Although regulators from the Food and Drug Administration and the United Kingdom's Medicines and Healthcare Products Regulatory Agency participated in the think tank along with representatives from industry, academia, and patient groups, this article should not be construed to constitute regulatory guidance.
Collapse
Affiliation(s)
- Harry A Seifert
- Vaccine Clinical Safety and Pharmacovigilance, GlaxoSmithKline Vaccines, King of Prussia, PA.
| | | | - Mondira Bhattacharya
- Benefit-Risk Management and Innovative Platforms Initiative and Epidemiology, Pharmacovigilance and Patient Safety (PPS), AbbVie Inc, North Chicago, IL.
| | | | - Sally Okun
- Policy and Patient Safety, PatientsLikeMe, Cambridge, MA.
| | | | | | | | | | - Gregory E Powell
- SERM Classic and Established Products, Global Clinical Safety and Pharmacovigilance, Research Triangle Park, NC.
| |
Collapse
|
4
|
Cardiovascular Outcome Trials of Diabetes and Obesity Drugs: Implications for Conditional Approval and Early Phase Clinical Development. Pharmaceut Med 2017. [DOI: 10.1007/s40290-017-0209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
5
|
Use of endpoint adjudication to improve the quality and validity of endpoint assessment for medical device development and post marketing evaluation: Rationale and best practices. A report from the cardiac safety research consortium. Am Heart J 2017; 190:76-85. [PMID: 28760216 DOI: 10.1016/j.ahj.2017.05.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 05/19/2017] [Indexed: 12/11/2022]
Abstract
This white paper provides a summary of presentations, discussions and conclusions of a Thinktank entitled "The Role of Endpoint Adjudication in Medical Device Clinical Trials". The think tank was cosponsored by the Cardiac Safety Research Committee, MDEpiNet and the US Food and Drug Administration (FDA) and was convened at the FDA's White Oak headquarters on March 11, 2016. Attention was focused on tailoring best practices for evaluation of endpoints in medical device clinical trials, practical issues in endpoint adjudication of therapeutic, diagnostic, biomarker and drug-device combinations, and the role of adjudication in regulatory and reimbursement issues throughout the device lifecycle. Attendees included representatives from medical device companies, the FDA, Centers for Medicare and Medicaid Services (CMS), end point adjudication specialist groups, clinical research organizations, and active, academically based adjudicators. The manuscript presents recommendations from the think tank regarding (1) rationale for when adjudication is appropriate, (2) best practices establishment and operation of a medical device adjudication committee and (3) the role of endpoint adjudication for post market evaluation in the emerging era of real world evidence.
Collapse
|
6
|
Hwang TJ, Franklin JM, Kesselheim AS. Effect of US Food and Drug Administration's Cardiovascular Safety Guidance on Diabetes Drug Development. Clin Pharmacol Ther 2017; 102:290-296. [PMID: 28390139 DOI: 10.1002/cpt.705] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/03/2017] [Accepted: 04/03/2017] [Indexed: 12/15/2022]
Abstract
In 2008, the US Food and Drug Administration (FDA) issued guidance on the need for cardiovascular outcome trials to assess the safety of new diabetes medications. Using two large commercial databases, we evaluated the effect of the FDA's cardiovascular safety guidance on drug development for type 2 diabetes as well as a comparison group of drugs intended to treat other alimentary and metabolic conditions. The FDA's guidance was associated with a 31% differential decrease in the rate of diabetes drugs entering phase II trials, but the remaining drugs were significantly more likely to target novel biological pathways (72% of drugs had novel mechanisms after the guidance vs. 49% before the guidance). No differential changes were observed for phase I and phase III trials. There was no measurable improvement during the study period in glycemic efficacy among investigational products entering phase III trials. This research highlights how regulatory actions can impact pharmaceutical innovation.
Collapse
Affiliation(s)
- T J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - J M Franklin
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - A S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
7
|
Significance of integrated in silico transmural ventricular wedge preparation models of human non-failing and failing hearts for safety evaluation of drug candidates. J Pharmacol Toxicol Methods 2017; 83:30-41. [DOI: 10.1016/j.vascn.2016.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/08/2016] [Accepted: 08/17/2016] [Indexed: 01/20/2023]
|
8
|
Abstract
INTRODUCTION Dipeptidyl peptidase-4 (DPP4) inhibitors, glucagon-like peptide-1 (GLP-1) analogs and sodium-glucose cotransporter 2 (SGLT2) inhibitors are relatively new therapies for the treatment of type 2 diabetes mellitus. Given the high prevalence of cardiovascular complications in patients with type 2 diabetes and recent concerns questioning CV safety of newer antidiabetic medications, cardiovascular safety of these medications requires evaluation. Areas covered: Cardiovascular effects of these drug classes from preclinical and clinical data as well as non-cardiovascular safety issues are delineated from literature searches covering the last decade and up to June 2016. Major clinical trials assessing the cardiovascular safety of GLP-1 agonists (ELIXA and LEADER), DPP-4 inhibitors (SAVOR-TIMI 53, EXAMINE, and TECOS) and SGLT2 inhibitors (EMPA-REG OUTCOME) are reviewed and interpreted. Expert opinion: Based on review of the present evidence, these 3 classes of antihyperglycemic therapies have acceptably safe CV safety profiles for patients with type 2 diabetes. The latest evidence from LEADER and EMPA-REG OUTCOME trials indicate that liraglutide and empagliflozin have cardiovascular benefits that may prove to be of clinical importance in the management of type 2 DM.
Collapse
Affiliation(s)
- Puneet Gupta
- a Division of Hypertension and Clinical Pharmacology, Calhoun Cardiology Center , University of Connecticut School of Medicine , Farmington , CT , USA
| | - William B White
- a Division of Hypertension and Clinical Pharmacology, Calhoun Cardiology Center , University of Connecticut School of Medicine , Farmington , CT , USA
| |
Collapse
|
9
|
Hoogwerf BJ, Manner DH, Fu H, Moscarelli E, Gaydos BL, Heine RJ. Perspectives on Some Controversies in Cardiovascular Disease Risk Assessment in the Pharmaceutical Development of Glucose-Lowering Medications. Diabetes Care 2016; 39 Suppl 2:S219-27. [PMID: 27440836 DOI: 10.2337/dcs15-3025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The U.S. Food and Drug Administration (FDA) issued guidance on requirements to assess cardiovascular disease (CVD) risk with drugs being developed for approval for clinical use. The guidance was triggered by a meta-analysis published by Nissen and Wolski that suggested an increased risk for myocardial infarction with the use of rosiglitazone. This article discusses controversies around CVD trials in diabetes beginning with the University Group Diabetes Program. This is followed by a brief description of the FDA guidance for evaluating CVD risk with glucose-lowering medications. Limitations of meta-analyses of data from phase 2 and 3 (phase 2/3) trials to inform CVD risk are highlighted. These include the differences between patient characteristics in phase 2/3 trials and those in cardiovascular outcome trials (CVOTs) and the relatively short exposure time in phase 2/3 trials. The differences may partly explain the observed disparity between phase 2/3 meta-analyses and the results of completed CVOTs. Approaches to understanding CVD risk with a new medication should get to the answer about risk as efficiently as possible to minimize any potential harm to patients. In that context, we discuss options for clinical trial design and an alternative approach for statistical analyses.
Collapse
Affiliation(s)
| | | | - Haoda Fu
- Eli Lilly and Company, Indianapolis, IN
| | | | | | | |
Collapse
|
10
|
Turner JR, Kowey PR, Rodriguez I, Cabell CH, Gintant G, Green CL, Kunz BL, Mortara J, Sager PT, Stockbridge N, Wright TJ, Finkle J, Krucoff MW. The Cardiac Safety Research Consortium enters its second decade: An invitation to participate. Am Heart J 2016; 177:96-101. [PMID: 27297854 DOI: 10.1016/j.ahj.2016.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 04/20/2016] [Indexed: 01/06/2023]
Abstract
The Cardiac Safety Research Consortium (CSRC), a transparent, public-private partnership established in 2005 as a Critical Path Program and formalized in 2006 under a Memorandum of Understanding between the United States Food and Drug Administration and Duke University, is entering its second decade. Our continuing goal is to advance paradigms for more efficient regulatory science related to the cardiovascular safety of new therapeutics, both in the United States and globally, particularly where such safety questions add burden to innovative research and development. Operationally, CSRC brings together a broad base of stakeholders from academia, industry, and government agencies in a collaborative forum focused on identifying barriers and then creating novel solutions through shared data, expertise, and collaborative research. This white paper provides a brief overview of the Consortium's activities in its first decade and a context for some of our current activities and future directions. The growth and success of the CSRC have been primarily driven by members' active participation and the development of goodwill and trust throughout our membership, which have facilitated novel collaborations across traditionally competitive or contentious stakeholder boundaries. The continued expansion of our base of participating academicians, industry experts, and regulators will define the Consortium's success in our second decade. It is our hope that sharing our endeavors to date will stimulate additional participation in the CSRC and also provide a model for other groups starting to develop similar collaborative forums.
Collapse
Affiliation(s)
| | - Peter R Kowey
- Lankenau Institute for Medical Research & Thomas Jefferson University, PA
| | | | | | | | - Cynthia L Green
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC
| | | | | | | | | | | | | | - Mitchell W Krucoff
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
11
|
Ames D, Carr-Lopez SM, Gutierrez MA, Pierre JM, Rosen JA, Shakib S, Yudofsky LM. Detecting and Managing Adverse Effects of Antipsychotic Medications: Current State of Play. Psychiatr Clin North Am 2016; 39:275-311. [PMID: 27216904 DOI: 10.1016/j.psc.2016.01.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Antipsychotics are some of the most frequently prescribed medications not only for psychotic disorders and symptoms but also for a wide range of on-label and off-label indications. Because second-generation antipsychotics have largely replaced first-generation antipsychotics as first-line options due to their substantially decreased risk of extrapyramidal side effects, attention has shifted to other clinically concerning adverse events associated with antipsychotic therapy. The focus of this article is to update the nonextrapyramidal side effects associated with second-generation antipsychotics. Issues surrounding diagnosis and monitoring as well as clinical management are addressed.
Collapse
Affiliation(s)
- Donna Ames
- Department of Psychiatry, Psychosocial Rehabilitation and Recovery Center, West Los Angeles Veterans Affairs Medical Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA; David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA.
| | - Sian M Carr-Lopez
- Pharmacy Service, Veterans Affairs Northern California Health Care System, 10535 Hospital Way, Mather, CA 95655, USA; Department of Pharmacy Practice, University of the Pacific, 3601 Pacific Avenue, Stockton, CA 95211, USA
| | - Mary A Gutierrez
- Chapman University School of Pharmacy, 9401 Jeronimo Road, Irvine, CA 92618, USA
| | - Joseph M Pierre
- Schizophrenia Treatment Unit, West Los Angeles VA Medical Center, Los Angeles, CA 90073, USA; Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Jennifer A Rosen
- Department of Pharmacy, Veterans Affairs Northern California Healthcare System, 150 Muir Road, Martinez, CA 94553, USA; University of the Pacific School of Pharmacy, 3601 Pacific Avenue, Stockton, CA 95211, USA; University of Southern California School of Pharmacy, 1985 Zonal Avenue, Los Angeles, CA 90089, USA
| | - Susan Shakib
- Thomas J. Long School of Pharmacy & Health Sciences, University of the Pacific 3601 Pacific Avenue, Stockton, CA 95211, USA; Department of Pharmacy, Veterans Affairs Long Beach Healthcare System, 5901 East 7th Street, Long Beach, CA 90822, USA
| | - Lynn M Yudofsky
- Semel Institute for Neuroscience & Human Behavior, UCLA, 760 Westwood Plaza, Suite C8-193, Los Angeles, CA 90024, USA
| |
Collapse
|
12
|
|
13
|
John M, Gopalakrishnan Unnikrishnan A, Kalra S, Nair T. Cardiovascular outcome trials for anti-diabetes medication: A holy grail of drug development? Indian Heart J 2016; 68:564-71. [PMID: 27543483 PMCID: PMC4990725 DOI: 10.1016/j.ihj.2016.02.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 01/28/2016] [Accepted: 02/15/2016] [Indexed: 01/21/2023] Open
Abstract
Since the time questions arose on cardiovascular safety of Rosiglitazone, FDA has suggested guidelines on conduct of studies on anti-diabetic drugs so as to prove that the cardiovascular risk is acceptable. Based on the cardiovascular risks of pre-approval clinical trials, guidelines have been made to conduct cardiovascular safety outcome trials (CVSOTs) prior to the drug approval or after the drug has been approved. Unlike the trials comparing the efficacy of antidiabetic agents, the CVSOTs examine the cardiovascular safety of a drug in comparison to standard of care. These trials are expensive aspects of drug development and are associated with various technical and operational challenges. More cost effective models of assessing cardiovascular safety like use of biomarkers, electronic medical records, pragmatic and factorial designs can be adopted. This article critically looks at the antidiabetic drug approval from a cardiovascular perspective by asking a few questions and arriving at answers.
Collapse
Affiliation(s)
- Mathew John
- Consultant Endocrinologist, Department of Endocrinology and Diabetes, Providence Endocrine and Diabetes Specialty Centre, TC 1/2138, Murinjapalam, Trivandrum 695011, India.
| | | | - Sanjay Kalra
- Endocrinologist, Bharti Hospital and B.R.I.D.E., Karnal, Haryana 132001, India.
| | - Tiny Nair
- Head, Department of Cardiology, PRS Hospital, Trivandrum, Kerala 695012, India.
| |
Collapse
|
14
|
Zannad F, Stough WG, Lipicky RJ, Tamargo J, Bakris GL, Borer JS, Alonso García MDLA, Hadjadj S, Koenig W, Kupfer S, McCullough PA, Mosenzon O, Pocock S, Scheen AJ, Sourij H, Van der Schueren B, Stahre C, White WB, Calvo G. Assessment of cardiovascular risk of new drugs for the treatment of diabetes mellitus: risk assessment vs. risk aversion. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2016; 2:200-5. [PMID: 27418973 DOI: 10.1093/ehjcvp/pvw007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 03/25/2016] [Indexed: 01/21/2023]
Abstract
The Food and Drug Administration issued guidance for evaluating the cardiovascular risk of new diabetes mellitus drugs in 2008. Accumulating evidence from several completed trials conducted within this framework raises questions as to whether requiring safety outcome studies for all new diabetes mellitus therapies remains justified. Given the burden of cardiovascular disease in patients with diabetes, the focus should shift towards cardiovascular outcome studies designed to evaluate efficacy (i.e. to determine the efficacy of a drug over placebo or standard care) rather than demonstrating that risk is not increased by a pre-specified safety margin. All stakeholders are responsible for ensuring that new drug approvals occur under conditions of appropriate safety and effectiveness. It is also a shared responsibility to avoid unnecessary hurdles that may compromise access to useful drugs and threaten the sustainability of health systems. It is critical to renew this debate so that stakeholders can collectively determine the optimal approach for developing new drugs to treat type 2 diabetes mellitus.
Collapse
Affiliation(s)
- Faiez Zannad
- INSERM, Centre d'Investigation Clinique - 1433 and Unité 1116, CHU Nancy, Université de Lorraine and F-CRIN INI-CRCT, 54500 Nancy, France
| | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | | | - Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Madrid, Spain
| | - George L Bakris
- ASH Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL, USA
| | - Jeffrey S Borer
- The Howard Gilman Institute, State University of New York Downstate Medical Center, Brooklyn, NY, USA
| | - Maria de Los Angeles Alonso García
- Scientific Advice Working Party, European Medicines Agency, London, UK Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Samy Hadjadj
- CHU de Poitiers, Endocrinologie, Université de Poitiers, INSERM CIC1402, Poitiers, France
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Stuart Kupfer
- Takeda Pharmaceuticals International, Deerfield, IL, USA
| | - Peter A McCullough
- Baylor University Medical Center, Baylor Heart and Vascular Institute, Dallas, TX, USA
| | - Ofri Mosenzon
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - André J Scheen
- Division of Diabetes, Nutrition, and Metabolic Disorders, Division of Clinical Pharmacology, CHU de Liège, University of Liège, Liège, Belgium
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Medical University of Graz, Centre for Biomarker Research in Medicine, Graz, Austria
| | - Bart Van der Schueren
- Laboratory of Experimental Medicine and Endocrinology, University of Leuven, Leuven, Belgium
| | | | - William B White
- Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, USA
| | | |
Collapse
|
15
|
Sachinidis A. Highlight report: Cardiotoxicity screening. EXCLI JOURNAL 2016; 15:163-5. [PMID: 27047323 PMCID: PMC4817422 DOI: 10.17179/excli2016-180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 02/16/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Agapios Sachinidis
- Institute of Neurophysiology and Centre for Molecular Medicine Cologne (CMMC), Robert-Koch-Str. 39, 50931 Cologne, Germany
| |
Collapse
|
16
|
Abstract
The incretin-based therapies, dipeptidyl peptidase-4 (DPP4) inhibitors and glucagon-like peptide-1 (GLP-1) analogs, are important new classes of therapy for type 2 diabetes mellitus (T2DM). These agents prolong the action of the incretin hormones, GLP-1 and glucose-dependent insulinotropic polypeptide (GIP), by inhibiting their breakdown. The incretin hormones improve glycemic control in T2DM by increasing insulin secretion and suppressing glucagon levels. The cardiovascular (CV) effects of the incretin-based therapies have been of substantial interest since 2008, when the US Food and Drug Administration began to require that all new therapies for diabetes undergo rigorous assessment of CV safety through large-scale CV outcome trials. This article reviews the most recent CV outcome trials of the DPP-4 inhibitors (SAVOR-TIMI 53, EXAMINE, and TECOS) as evidence that the incretin-based therapies have acceptable CV safety profiles for patients with T2DM. The studies differ with regard to patient population, trial duration, and heart failure outcomes but show similar findings for CV death, nonfatal myocardial infarction, and stroke, as well as hospitalization for unstable angina.
Collapse
Affiliation(s)
- William B. White
- Division of Hypertension and Clinical Pharmacology, Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut 06032
| | - William L. Baker
- University of Connecticut School of Pharmacy, Storrs, Connecticut 06269
| |
Collapse
|
17
|
Cardiotoxicity screening: a review of rapid-throughput in vitro approaches. Arch Toxicol 2015; 90:1803-16. [PMID: 26676948 DOI: 10.1007/s00204-015-1651-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 11/18/2015] [Indexed: 01/07/2023]
Abstract
Cardiac toxicity represents one of the leading causes of drug failure along different stages of drug development. Multiple very successful pharmaceuticals had to be pulled from the market or labeled with strict usage warnings due to adverse cardiac effects. In order to protect clinical trial participants and patients, the International Conference on Harmonization published guidelines to recommend that all new drugs to be tested preclinically for hERG (Kv11.1) channel sensitivity before submitting for regulatory reviews. However, extensive studies have demonstrated that measurement of hERG activity has limitations due to the multiple molecular targets of drug compound through which it may mitigate or abolish a potential arrhythmia, and therefore, a model measuring multiple ion channel effects is likely to be more predictive. Several phenotypic rapid-throughput methods have been developed to predict the potential cardiac toxic compounds in the early stages of drug development using embryonic stem cells- or human induced pluripotent stem cell-derived cardiomyocytes. These rapid-throughput methods include microelectrode array-based field potential assay, impedance-based or Ca(2+) dynamics-based cardiomyocytes contractility assays. This review aims to discuss advantages and limitations of these phenotypic assays for cardiac toxicity assessment.
Collapse
|