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Yap C, Rekowski J, Ursino M, Solovyeva O, Patel D, Dimairo M, Weir CJ, Chan AW, Jaki T, Mander A, Evans TRJ, Peck R, Hayward KS, Calvert M, Rantell KR, Lee S, Kightley A, Hopewell S, Ashby D, Garrett-Mayer E, Isaacs J, Golub R, Kholmanskikh O, Richards DP, Boix O, Matcham J, Seymour L, Ivy SP, Marshall LV, Hommais A, Liu R, Tanaka Y, Berlin J, Espinasse A, de Bono J. Enhancing quality and impact of early phase dose-finding clinical trial protocols: SPIRIT Dose-finding Extension (SPIRIT-DEFINE) guidance. BMJ 2023; 383:e076386. [PMID: 37863491 DOI: 10.1136/bmj-2023-076386] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Affiliation(s)
| | - Jan Rekowski
- Institute of Cancer Research, London SM2 5NG, UK
| | - Moreno Ursino
- ReCAP/F CRIN, INSERM, Paris, France
- Unit of Clinical Epidemiology, University Hospital Centre Robert Debré, Reims, France
- INSERM Centre de Recherche des Cordeliers, Sorbonne University, Paris, France
- Health data and model driven approaches for Knowledge Acquisition team, Centre Inria, Paris, France
| | | | | | - Munyaradzi Dimairo
- Division of Population Health, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - An-Wen Chan
- Department of Medicine, Women's College Research Institute, University of Toronto, Toronto, Canada
| | - Thomas Jaki
- MRC Biostatistics Unit, Cambridge University, Cambridge, UK
- Computational Statistics Group, University of Regensburg, Regensburg, Germany
| | - Adrian Mander
- Centre For Trials Research, Cardiff University, Cardiff, UK
| | - Thomas R Jeffry Evans
- Institute of Cancer Sciences, CR-UK Beatson Institute, University of Glasgow, Glasgow, UK
| | - Richard Peck
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Hoffmann-La Roche, Basel, Switzerland
| | - Kathryn S Hayward
- Departments of Physiotherapy, and Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research Applied Research Collaboration West Midlands, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Precision Transplant and Cellular Therapeutics, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research Birmingham Biomedical Research Centre, NIHR Birmingham Biomedical Research Centre, Institute of Translational Medicine, University Hospital NHS Foundation Trust, Birmingham, UK
| | | | - Shing Lee
- Columbia University Mailman School of Public Health, New York, NY, USA
| | | | - Sally Hopewell
- Oxford Clinical Research Unit, NDORMS, University of Oxford, Oxford, UK
| | - Deborah Ashby
- School of Public Health, Imperial College London, St Mary's Hospital, London, UK
| | - Elizabeth Garrett-Mayer
- Center for Research and Analytics, American Society of Clinical Oncology, Alexandria, VA, USA
| | - John Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Robert Golub
- Department of Medicine, Northwestern University Feinberg School of Medicine, Evanston, IL, USA
| | | | | | | | - James Matcham
- Strategic Consulting, Cytel (Australia), Perth, WA, Australia
| | - Lesley Seymour
- Investigational New Drug Programme, Canadian Cancer Trials Group, Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - S Percy Ivy
- Investigational Drug Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Institute of Health, Bethesda, MD, USA
| | - Lynley V Marshall
- Institute of Cancer Research, London SM2 5NG, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | - Antoine Hommais
- Department of Clinical Research, National Cancer Institute, Boulogne-Billancourt, France
| | - Rong Liu
- Bristol Myers Squibb, New York, NY, USA
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Johann de Bono
- Institute of Cancer Research, London SM2 5NG, UK
- Royal Marsden NHS Foundation Trust, London, UK
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Xu C, Gu F, Liu Y, Chen R, Wang C, Lu J. The median effective analgesic concentration of ropivacaine in ultrasound-guided interscalene brachial plexus block after arthroscopic rotator cuff repair. Front Pharmacol 2022; 13:928227. [PMID: 36059976 PMCID: PMC9428620 DOI: 10.3389/fphar.2022.928227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The median effective analgesic concentration (MEAC) of ropivacaine in interscalene brachial plexus block (ISBPB) for postoperative analgesia after arthroscopic rotator cuff repair (ARCR) has not been determined. Therefore, this study aimed to evaluate the MEAC after ARCR using 10 ml ropivacaine. Method: This study was conducted on 40 patients with American Society of Anesthesiologists grade I or II who had selective ARCR. The 10 ml ropivacaine was administered for determined, with an initial concentration of 0.3% using up-and-down sequential allocation. After successful or unsuccessful postoperative analgesia, the concentration of ropivacaine was decreased or increased by 0.05% in the next patient. We defined successful postoperative analgesia as a visual analog scale score of <4 at rest within the initial 8 h after ISBPB. The analytic techniques of linear, linear-logarithmic, exponential regressions and centered isotonic regression were used for calculating MEAC. The secondary outcomes was sufentanil consumption, time to 1st rescue analgesic, onset time of sensory block and motor block. Results: The concentration of ropivacaine administered ranged from 0.1% to 0.35%. The MEAC from the four different methods (linear, linear-logarithmic, exponential regressions and centered isotonic regression) were 0.207% (95% CI, 0.168–0.355%), 0.182% (95% CI, 0.165–0.353%), 0.196% (95% CI, 0.154–0.356%), and 0.163%, respectively. Of the four models, exponential regression had the least residual standard error (0.0990). Conclusion: The MEAC derived from the four statistical models for 10 ml ropivacaine in ultrasound-guided ISBPB for postoperative analgesia was distributed within a narrow range of 0.163%–0.207%. The exponential regression model calculated by the goodness-of-fit test at a concentration of 0.196% best fits the study data. Clinical Trial Registration:http://www.chictr.org.cn/showproj.aspx?proj=127449, identifier ChiCTR2100047978
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Affiliation(s)
| | | | | | | | | | - Jie Lu
- *Correspondence: Chengyu Wang, ; Jie Lu,
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3
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Xu C, Gu F, Wang C, Liu Y, Chen R, Zhou Q, Lu J. The Median Effective Analgesic Concentration of Ropivacaine in Sciatic Nerve Block Guided by Ultrasound After Arthroscopic Anterior Cruciate Ligament Reconstruction: A Double-Blind Up-Down Concentration-Finding Study. Front Med (Lausanne) 2022; 9:830689. [PMID: 35602505 PMCID: PMC9120939 DOI: 10.3389/fmed.2022.830689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background The median effective analgesic concentration (MEAC; EC50 = effective concentration in 50% patients) of ropivacaine in sciatic nerve block guided by ultrasound (US) required for effective postoperative analgesia following arthroscopic anterior cruciate ligament (ACL) reconstruction has not yet been found. This study aimed to determine the effectiveness of MEAC of 20 ml ropivacaine of postoperative anesthesia for patients after ACL reconstruction. Methods In total, 29 patients who underwent elective arthroscopic ACL reconstruction were enrolled in this study. All the subjects were given 20 ml of 0.2% ropivacaine for femoral nerve block. A concentration of 20 ml ropivacaine administered to the sciatic nerve was measured by applying the up-and-down sequential method (UDM). The starting concentration was 0.2% in the first patient, and the next patient received decremented 0.025% ropivacaine if the prior patient's postoperative visual analog pain score was <4 in the initial 8 h. Otherwise, the participant was given an incremental dose of 0.025% ropivacaine. The EC50 of ropivacaine was determined by using centered isotonic, linear-logarithmic, exponential regressions, and linear regression. The “goodness of fit” was compared among various models by calculating the residual standard errors. Results The concentration of ropivacaine administered ranged from 0.1 to 0.2%. The EC50 [95% confidence interval (CI)] determined by four statistical methods (centered isotonic, exponential regressions, linear-logarithmic, and linear regression) was 0.115, 0.113% (0.108, 0.343%), 0.142% (0.112, 0.347%), and 0.129% (0.103, 0.359%), respectively. Among all models, the residual standard error was the smallest for the exponential regression (0.2243). Conclusion The EC50 of ropivacaine in US-guided sciatic nerve block was 0.113–0.142%, and exponential regression model best matched the data.
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Wesselink EJ, Koopman SJ, Vegt RVD, Ven PMVD, Aa JPVD, Stapper C, Wesdorp F, Kok LD, Zhang Y, Franssen EJ, Swart EL, Boer C, Leeuw MAD. ED90 of spinal 2-chloroprocaine 1% in ambulatory knee arthroscopy up to 45 min: a randomized biased-coin- up-and-down sequential allocation trial. Reg Anesth Pain Med 2022; 47:212-216. [DOI: 10.1136/rapm-2021-103089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/28/2021] [Indexed: 11/03/2022]
Abstract
BackgroundA short acting spinal anesthetic facilitates smooth flow since quick recovery of motor function will facilitate unassisted ambulation. The aim of this study was to estimate the effective dose (ED90) of intrathecal 2-chloroprocaine 1% in outpatient knee arthroscopy.MethodsTwo cohorts were included in two different hospitals. In cohort I, a randomized biased-coin up-and-down design with 40 patients was used to find the ED90. Four dose-levels of plain 2-chloroprocaine 1% were used: 25, 30, 35 and 40 mg. The identified primary outcome, the ED90, was validated in 50 patients in cohort II with an open label design. Secondary outcomes included time to complete recovery from motor and sensory block with spinal injection as time zero, peak sensory block level, urine retention and time until hospital discharge.ResultsForty patients were included in the final analysis in cohort I. The ED90 was estimated at 27.8 mg, successful spinal anesthesia was obtained in 38 patients (95%). Fifty patients were included in the final analysis in cohort II, 49 patients had successful anesthesia with a fixed round dose of 28 mg. In this Cohort, peak sensory block was T10/T11 (range: (L4–T4)). The median time to full recovery of the motor block was 60 min (45–60) and 90 min (75–105) for the sensory block. The mean time to hospital discharge was 2.9 hours (0.7).ConclusionThe ED90 of 2-chloroprocaine 1% in knee arthroscopy was estimated to be 27.8 mg. In an external population, the ED90 resulted in successful anesthesia in 98% of the patients (95% CI 89% to 100%).Trial registration numberNetherlands Trial Registry (NL6769).
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Saxena A, Rubens M, Ramamoorthy V, Zhang Z, Ahmed MA, McGranaghan P, Das S, Veledar E. A Brief Overview of Adaptive Designs for Phase I Cancer Trials. Cancers (Basel) 2022; 14:cancers14061566. [PMID: 35326715 PMCID: PMC8946506 DOI: 10.3390/cancers14061566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 12/18/2022] Open
Abstract
Simple Summary Phase I cancer trials are important for new drug developments to test the safety and optimal dosage of cancer drugs which are usually toxic. Understanding biostatistical methodologies of these designs is important for developing phase I studies that are both safe for the participants and which use optimal dosages for better outcomes. Currently there are several phase I designs that are being refined and modified for better outcomes and newer designs are being continuously developed. In this review article, we described several important phase I study designs to provide a brief overview of existing methods. Our review could be helpful to the research community who intent to have a better and yet a concise summary of existing methods. Abstract Phase I studies are used to estimate the dose-toxicity profile of the drugs and to select appropriate doses for successive studies. However, literature on statistical methods used for phase I studies are extensive. The objective of this review is to provide a concise summary of existing and emerging techniques for selecting dosages that are appropriate for phase I cancer trials. Many advanced statistical studies have proposed novel and robust methods for adaptive designs that have shown significant advantages over conventional dose finding methods. An increasing number of phase I cancer trials use adaptive designs, particularly during the early phases of the study. In this review, we described nonparametric and algorithm-based designs such as traditional 3 + 3, accelerated titration, Bayesian algorithm-based design, up-and-down design, and isotonic design. In addition, we also described parametric model-based designs such as continual reassessment method, escalation with overdose control, and Bayesian decision theoretic and optimal design. Ongoing studies have been continuously focusing on improving and refining the existing models as well as developing newer methods. This study would help readers to assimilate core concepts and compare different phase I statistical methods under one banner. Nevertheless, other evolving methods require future reviews.
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Affiliation(s)
- Anshul Saxena
- Center for Advanced Analytics, Baptist Health South Florida, Miami, FL 33176, USA; (V.R.); (Z.Z.); (M.A.A.); (E.V.)
- Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL 33199, USA
- Correspondence: (A.S.); (P.M.)
| | - Muni Rubens
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA;
| | - Venkataraghavan Ramamoorthy
- Center for Advanced Analytics, Baptist Health South Florida, Miami, FL 33176, USA; (V.R.); (Z.Z.); (M.A.A.); (E.V.)
| | - Zhenwei Zhang
- Center for Advanced Analytics, Baptist Health South Florida, Miami, FL 33176, USA; (V.R.); (Z.Z.); (M.A.A.); (E.V.)
| | - Md Ashfaq Ahmed
- Center for Advanced Analytics, Baptist Health South Florida, Miami, FL 33176, USA; (V.R.); (Z.Z.); (M.A.A.); (E.V.)
| | - Peter McGranaghan
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA;
- Department of Internal Medicine and Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, 10117 Berlin, Germany
- Correspondence: (A.S.); (P.M.)
| | - Sankalp Das
- Wellness and Employee Health, Baptist Health South Florida, Miami, FL 33176, USA;
| | - Emir Veledar
- Center for Advanced Analytics, Baptist Health South Florida, Miami, FL 33176, USA; (V.R.); (Z.Z.); (M.A.A.); (E.V.)
- Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL 33199, USA
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Median Effective Volume of 0.5% Ropivacaine for Ultrasound-guided Costoclavicular Block. Anesthesiology 2021; 134:617-625. [PMID: 33636000 DOI: 10.1097/aln.0000000000003731] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The median effective dose of ropivacaine required for producing an effective costoclavicular block has not yet been determined. The authors conducted this dose-finding study with the objective of determining the median effective dose of 0.5% ropivacaine required to produce a successful costoclavicular block for surgical anesthesia in 50% of the patients (ED50) as well as the calculated dose required for effective blockade in 95% of the patients (ED95). METHODS This single-armed prospective study was conducted on 40 American Society of Anesthesiologists physical status I or II patients, aged 18 to 60 yr, with a body mass index of 18 to 30 kg/m2, scheduled to undergo forearm and hand surgeries under ultrasound-guided costoclavicular block. A volume of 0.5% ropivacaine administered in the costoclavicular space was determined using the sample up-and-down sequential allocation study design of binary response variables. The first patient received a volume of 26 ml of 0.5% ropivacaine. After a successful or unsuccessful block, the volume of local anesthetic was decreased or increased, respectively, by 2 ml in the next patient. Evaluation of sensory and motor block was performed every 5 min for 30 min and graded using a 3-point scale. Surgical anesthesia was considered to be successful if a minimum score of 14 was achieved and the surgeon was able to proceed with surgery without needing to supplement anesthesia. RESULTS The volume of local anesthetic administered ranged from 8 to 26 ml. Centered isotonic regression with a bias-corrected Morris 95% CI derived by bootstrapping showed ED50 of 13.5 ml (95% CI, 11.5 to 15.4 ml) and ED95 of 18.9 ml (95% CI, 17.9 to 27.5 ml). CONCLUSIONS A 19-ml dose of 0.5% ropivacaine is likely to produce an effective ultrasound-guided costoclavicular block for providing adequate surgical anesthesia to 95% of the patients. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Nancy Flournoy
- Department of Statistics University of Missouri Columbia MO USA
| | - José Moler
- Departamento de Estadística, Informática y Matemáticas Universidad Pública de Navarra, Campus Arrosadia s/n Pamplona 31006 Spain
| | - Fernando Plo
- Department of Statistical Methods Universidad de Zaragoza Pedro Cerbuna, 12 Zaragoza 50009 Spain
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Wang CY, Chen F, Wu J, Fu SY, Xu XM, Chen J, Jiang YF, Lian Q, Liu HC. The association of the optimal bolus of dexmedetomidine with its favourable haemodynamic outcomes in adult surgical patients under general anaesthesia. Br J Clin Pharmacol 2019; 86:85-92. [PMID: 31656042 DOI: 10.1111/bcp.14137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 08/30/2019] [Accepted: 09/03/2019] [Indexed: 11/29/2022] Open
Abstract
AIMS Dexmedetomidine is highly specific α2-adrenoceptor agonist. A single bolus of dexmedetomidine can achieve clinical therapeutic effect. Therefore, it is essential to know the safety margin between the clinical effectiveness dosages of dexmedetomidine and its side effect. METHODS A total of 42 patients who underwent elective thyroidectomy were enrolled in this study. Dexmedetomidine was given as a single bolus injection 30 min towards the end of surgery. The up-and-down sequential schedule was used in this study. The starting dose of dexmedetomidine was set at 0.1 μg/kg in the first patient and the next patient would then receive a dose of dexmedetomidine decremented by 0.05 μg/kg if the prior patient's baseline heart rate (HR) had a decrease of ≥20% and/or mean arterial blood pressure (MAP) increase or decrease of ≥20%, otherwise, the following patient would receive an incremental 0.05 μg/kg dose of dexmedetomidine. The analytic techniques of linear, linear-logarithmic, exponential regressions and centred isotonic regression were used to determine the ED50 of dexmedetomidine and the residual standard errors were calculated for the comparison of goodness of fit among the different models. RESULTS The median (interquartile range [range]) lowest HR was 57 beats/min (53-63.3[46-76]) with an average HR decrease of 8.0 beats/min (5-13 [4 to 23]). The median (interquartile range [range]) highest MAP was 98 mmHg (91.8-105 [83-126]) with a MAP increase of 10.0 mmHg (6.8-18.0 [2-24]). The ED50 (95% confidence interval) from 4 different statistical approaches (linear, linear-logarithmic, exponential regressions and centred isotonic regression) were 0.262 μg/kg (0.243, 0.306), 0.252 μg/kg (0.238, 0.307), 0.283 μg/kg (0.238, 0.307), and 0.278 μg/kg, respectively. Among the 4 models, the exponential regression had the least residual standard error (0.03618). CONCLUSION The ED50 derived from 4 statistical models for an intravenous bolus of dexmedetomidine without significant haemodynamic effects was distributed in a narrow range of 0.252-0.283 μg/kg, and the exponential regression was the model to best match the study data.
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Affiliation(s)
- Cheng-Yu Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China.,Department of Anesthesia and Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Fang Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China.,Department of Anesthesia and Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Junzheng Wu
- Key Laboratory of Anesthesiology of Zhejiang Province, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Shu-Ying Fu
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China.,Department of Anesthesia and Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Xi-Mou Xu
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China.,Department of Anesthesia and Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Jia Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China.,Department of Anesthesia and Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Yi-Fei Jiang
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China.,Department of Anesthesia and Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Qingquan Lian
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China.,Department of Anesthesia and Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Hua-Cheng Liu
- Department of Anesthesiology, Perioperative and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China.,Department of Anesthesia and Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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Abstract
In phase I dose-finding trials, model-assisted designs are a novel class of designs that combine the simplicity of algorithm-based methods with the superior performance of model-based methods. Examples of model-assisted designs include the modified toxicity probability (mTPI), Bayesian optimal interval (BOIN) and keyboard designs. To achieve simplicity, these model-assisted methods model only "local" data observed at the current dose, typically using a binomial model, to guide dose assignments. This potentially causes efficiency loss, however, by ignoring the data observed in other doses. To investigate this issue, we propose a conditional approach that utilizes the data from both current and adjacent (i.e., next higher or lower) doses to make the dose-assignment decisions. Specifically, we propose the conditional optimal interval (COIN) design, as the conditional approach extension of the BOIN design. We investigate the theoretical properties of the COIN design and conduct extensive numerical studies to examine its performance in comparison with existing model-assisted designs. We also present the conditional approach to the keyboard design. We observe that the conditional approach improves patient allocation, but yields similar maximum-tolerated dose (MTD) identification accuracy as the model-assisted designs, suggesting only minor efficiency loss using local data under the model-assisted designs.
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Affiliation(s)
- Ruitao Lin
- a Department of Biostatistics, The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Ying Yuan
- a Department of Biostatistics, The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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Subramani S, Garg S. Challenges to implement minimum effective volume in regional anesthesia. J Anaesthesiol Clin Pharmacol 2019; 35:47-48. [PMID: 31057239 PMCID: PMC6495624 DOI: 10.4103/joacp.joacp_279_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
| | - Shuchita Garg
- Department of Anesthesia and Pain Medicine, University of Cincinnati Medical Center, Ohio, USA
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Ruppert AS, Shoben AB. Overall success rate of a safe and efficacious drug: Results using six phase 1 designs, each followed by standard phase 2 and 3 designs. Contemp Clin Trials Commun 2018; 12:40-50. [PMID: 30225393 PMCID: PMC6139598 DOI: 10.1016/j.conctc.2018.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/09/2018] [Accepted: 08/23/2018] [Indexed: 12/27/2022] Open
Abstract
To evaluate the overall success rate of a new drug, phase 1, 2, and 3 trials were simulated using eight toxicity and two non-decreasing efficacy profiles. Six phase 1 designs including the standard 3 + 3, CCD, BOIN, mTPI, mTPI-2, and CRM were considered with standard phase 2 and 3 designs. Based on our results, phase 1 design recommendations are provided when data informing the general shape of the dose-toxicity curve exist. If a large jump in toxicity between dose levels is expected, the standard 3 + 3 design is recommended; it more often recognized when the MTD was exceeded and had the highest overall success rates. If gradually increasing toxicity is expected, a nonstandard design other than the CRM is recommended. Nonstandard designs were more aggressive in dosing and MTD estimation than the standard 3 + 3 and had higher overall success rates, but the CRM was too aggressive and most frequently overestimated the true MTD. If fairly constant, safe toxicity is expected across dose levels, the BOIN or CRM designs are recommended; they escalated to the highest dose most frequently with superior overall success rates. Without data informing the shape of the dose-toxicity curve, nonstandard phase 1 designs with a modified excessive toxicity rule more easily eliminating unsafe dose levels are recommended. With this modification, MTD overestimation error decreased and overall success rates were similar or higher with nonstandard designs. Among nonstandard designs, the modified CCD and BOIN perform well and are as transparent and simple to implement as the standard 3 + 3 design.
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Affiliation(s)
- Amy S. Ruppert
- Division of Hematology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, 43210, USA
- Corresponding author. Division of Hematology, College of Medicine, The Ohio State University, Columbus, OH, 43210, USA.
| | - Abigail B. Shoben
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, 43210, USA
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12
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Lin R. Bayesian optimal interval design with multiple toxicity constraints. Biometrics 2018; 74:1320-1330. [DOI: 10.1111/biom.12912] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 04/01/2018] [Accepted: 04/01/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Ruitao Lin
- Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonTexas 77030U.S.A
- Key Laboratory for Applied Statistics of MOENortheast Normal UniversityChangchunJilinChina
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13
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Harrington JA, Hernandez-Guerrero TC, Basu B. Early Phase Clinical Trial Designs - State of Play and Adapting for the Future. Clin Oncol (R Coll Radiol) 2017; 29:770-777. [PMID: 29108786 DOI: 10.1016/j.clon.2017.10.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 09/20/2017] [Indexed: 11/25/2022]
Abstract
The process of anti-cancer drug development is complex, with high attrition rates. Factors that may optimise this process include well-constructed and relevant pre-clinical testing and use of biomarkers for patient selection. However, the design of early phase clinical trials will probably play a vital role in both the robust clinical investigation of new targeted therapies and in streamlining drug development. In this overview, we assess current concepts in phase I clinical trials, highlighting issues and opportunities to improve their meaningfulness. The particular challenge of how to design combination trials is addressed, with focus on the potential of new adaptive and model-based designs.
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Affiliation(s)
- J A Harrington
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - T C Hernandez-Guerrero
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - B Basu
- Department of Oncology, University of Cambridge, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK.
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14
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Cai C, Rahbar MH, Hossain MM, Yuan Y, Gonzales NR. A placebo-controlled Bayesian dose finding design based on continuous reassessment method with application to stroke research. Contemp Clin Trials Commun 2017; 7:11-17. [PMID: 29062975 PMCID: PMC5650116 DOI: 10.1016/j.conctc.2017.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Traditional dose-finding designs do not require assignment of patients to a control group. Motivated by SHRINC (Safety of Pioglitazone for hematoma resolution in intracerebral hemorrhage), we developed a placebo-controlled dose-finding study to identify the maximum tolerated dose for pioglitazone in stroke patients with spontaneous intracerebral hemorrhage. We designed an extension of the continuous reassessment method that allowed to incorporate information from the control group (i.e., the standard of care), and utilized it to determine the maximum tolerated dose in the SHRINC trial. We evaluated the operating characteristics of our design by conducting extensive simulation studies. Our findings from the simulation studies demonstrate that our proposed design is robust and performs well. By estimating the toxicity rate in the control group, we were able to obtain more accurate information about the natural history of the disease and identify appropriate dose for the next phase of this study. The proposed design provides a tool to incorporate the information from the control group into the dose-finding framework for trials with similar objectives.
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Affiliation(s)
- Chunyan Cai
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA.,Biostatistics/Epidemiology/Research Design Component, Center for Clinical and Translational Sciences, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Mohammad H Rahbar
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA.,Biostatistics/Epidemiology/Research Design Component, Center for Clinical and Translational Sciences, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA.,Division of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas School of Public Health at Houston, Houston, TX 77030, USA
| | - Md Monir Hossain
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Ying Yuan
- Department of Biostatistics, Division of Quantitative Sciences, The University of Texas MD Anderson, Houston, TX 77030, USA
| | - Nicole R Gonzales
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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15
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Colin P, Delattre M, Minini P, Micallef S. An Escalation for Bivariate Binary Endpoints Controlling the Risk of Overtoxicity (EBE-CRO): Managing Efficacy and Toxicity in Early Oncology Clinical Trials. J Biopharm Stat 2017; 27:1054-1072. [DOI: 10.1080/10543406.2017.1295248] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- P. Colin
- AgroParisTech, UMR 518 MIA, Paris, France
- Statistical Science & Modeling, Sanofi R&D, Chilly-Mazarin, France
| | - M. Delattre
- AgroParisTech, UMR 518 MIA, Paris, France
- INRA, UMR 518 MIA, Paris, France
| | - P. Minini
- Biostatistiques, Sanofi R&D, Chilly-Mazarin, France
| | - S. Micallef
- Clinical Pharmacometrics, Roche Pharma Research and Early Development, Basel, Switzerland
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16
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Systematic comparison of the statistical operating characteristics of various Phase I oncology designs. Contemp Clin Trials Commun 2016; 5:34-48. [PMID: 29740620 PMCID: PMC5936704 DOI: 10.1016/j.conctc.2016.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 11/16/2016] [Accepted: 11/22/2016] [Indexed: 11/21/2022] Open
Abstract
Dose finding Phase I oncology designs can be broadly categorized as rule based, such as the 3 + 3 and the accelerated titration designs, or model based, such as the CRM and Eff-Tox designs. This paper systematically reviews and compares through simulations several statistical operating characteristics, including the accuracy of maximum tolerated dose (MTD) selection, the percentage of patients assigned to the MTD, over-dosing, under-dosing, and the trial dose-limiting toxicity (DLT) rate, of eleven rule-based and model-based Phase I oncology designs that target or pre-specify a DLT rate of ∼0.2, for three sets of true DLT probabilities. These DLT probabilities are generated at common dosages from specific linear, logistic, and log-logistic dose-toxicity curves. We find that all the designs examined select the MTD much more accurately when there is a clear separation between the true DLT rate at the MTD and the rates at the dose level immediately above and below it, such as for the DLT rates generated using the chosen logistic dose-toxicity curve; the separations in these true DLT rates depend, in turn, not only on the functional form of the dose-toxicity curve but also on the investigated dose levels and the parameter set-up. The model based mTPI, TEQR, BOIN, CRM and EWOC designs perform well and assign the greatest percentages of patients to the MTD, and also have a reasonably high probability of picking the true MTD across the three dose-toxicity curves examined. Among the rule-based designs studied, the 5 + 5 a design picks the MTD as accurately as the model based designs for the true DLT rates generated using the chosen log-logistic and linear dose-toxicity curves, but requires enrolling a higher number of patients than the other designs. We also find that it is critical to pick a design that is aligned with the true DLT rate of interest. Further, we note that Phase I trials are very small in general and hence may not provide accurate estimates of the MTD. Thus our work provides a map for planning Phase I oncology trials or developing new ones.
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17
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Yuan Y, Hess KR, Hilsenbeck SG, Gilbert MR. Bayesian Optimal Interval Design: A Simple and Well-Performing Design for Phase I Oncology Trials. Clin Cancer Res 2016; 22:4291-301. [PMID: 27407096 DOI: 10.1158/1078-0432.ccr-16-0592] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/02/2016] [Indexed: 11/16/2022]
Abstract
Despite more than two decades of publications that offer more innovative model-based designs, the classical 3 + 3 design remains the most dominant phase I trial design in practice. In this article, we introduce a new trial design, the Bayesian optimal interval (BOIN) design. The BOIN design is easy to implement in a way similar to the 3 + 3 design, but is more flexible for choosing the target toxicity rate and cohort size and yields a substantially better performance that is comparable with that of more complex model-based designs. The BOIN design contains the 3 + 3 design and the accelerated titration design as special cases, thus linking it to established phase I approaches. A numerical study shows that the BOIN design generally outperforms the 3 + 3 design and the modified toxicity probability interval (mTPI) design. The BOIN design is more likely than the 3 + 3 design to correctly select the MTD and allocate more patients to the MTD. Compared with the mTPI design, the BOIN design has a substantially lower risk of overdosing patients and generally a higher probability of correctly selecting the MTD. User-friendly software is freely available to facilitate the application of the BOIN design. Clin Cancer Res; 22(17); 4291-301. ©2016 AACR.
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Affiliation(s)
- Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Kenneth R Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Mark R Gilbert
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
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Isakoff SJ, Wang D, Campone M, Calles A, Leip E, Turnbull K, Bardy-Bouxin N, Duvillié L, Calvo E. Bosutinib plus capecitabine for selected advanced solid tumours: results of a phase 1 dose-escalation study. Br J Cancer 2014; 111:2058-66. [PMID: 25290090 PMCID: PMC4260032 DOI: 10.1038/bjc.2014.508] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 07/01/2014] [Accepted: 08/25/2014] [Indexed: 01/19/2023] Open
Abstract
Background: This phase 1 study evaluated the maximum tolerated dose (MTD), safety, and efficacy of bosutinib (competitive Src/Abl tyrosine kinase inhibitor) plus capecitabine. Methods: Patients with locally advanced/metastatic breast, pancreatic, or colorectal cancers; cholangiocarcinoma; or glioblastoma received bosutinib plus capecitabine at eight of nine possible dose combinations using an ‘up-down' design to determine the toxicity contour of the combination. Results: Among 32 enrolled patients, none of the 9 patients receiving MTD (bosutinib 300 mg once daily plus capecitabine 1000 mg m−2 twice daily) experienced dose-limiting toxicities (DLTs). Overall, 2 out of 31 (6%) evaluable patients experienced DLTs (grade 3 neurologic pain (n=1); grade 3 pruritus/rash and increased alanine aminotransferase (n=1)). Most common treatment-related adverse events (AEs) were diarrhoea, nausea, vomiting, palmar-plantar erythrodysesthesia (PPE), fatigue; most frequent grade 3/4 AEs: PPE, fatigue, and increased alanine/aspartate aminotransferase. Although diarrhoea was common, 91% of affected patients experienced maximum grade 1/2 events that resolved. Best overall confirmed partial response or stable disease >24 weeks (all tumour types) was observed in 6 and 13% of patients. Conclusions: In this population of patients with advanced solid tumours, bosutinib plus capecitabine demonstrated a safety profile similar to that previously reported for bosutinib or capecitabine monotherapy; limited efficacy was observed.
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Affiliation(s)
- S J Isakoff
- Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center, and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - D Wang
- Phase I Clinical Trials Program, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - M Campone
- Institut de Cancerologie de l'Quest-Rene Gauducheau, Saint Herblain, Nantes Cedex 44805, France
| | - A Calles
- START Madrid, Centro Integral Oncológico Clara Campal, Hospital Madrid Norte-Sanchinarro, C/Oña n°10, 28050 Madrid, Spain
| | - E Leip
- Oncology Clinical Statistics, Pfizer Inc, 10 Fawcett Street, Suite 2013, Cambridge, MA 02138, USA
| | - K Turnbull
- Oncology Clinical Development, Pfizer Inc, 10 Fawcett Street, Suite 2013, Cambridge, MA 02138, USA
| | - N Bardy-Bouxin
- Oncology Late Phase Strategy Development, Pfizer Global Research and Development, 23-25 av du Dr Lannelongue, Paris 75668, France
| | - L Duvillié
- Oncology Clinical Development, Pfizer Global Research and Development, 23-25 av du Dr Lannelongue, Paris 75668, France
| | - E Calvo
- START Madrid, Centro Integral Oncológico Clara Campal, Hospital Madrid Norte-Sanchinarro, C/Oña n°10, 28050 Madrid, Spain
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Sverdlov O, Wong WK, Ryeznik Y. Adaptive clinical trial designs for phase I cancer studies. STATISTICS SURVEYS 2014. [DOI: 10.1214/14-ss106] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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