Why the ethical justification of randomized clinical trials is a scientific question

Ankle-foot orthoses for improving walking in adults with calf muscle weakness due to neuromuscular disorders

BACKGROUND

Calf muscle weakness is a common symptom in slowly progressive neuromuscular disorders that lead to walking problems like instability and increased walking effort. The mainstay of treatment to improve walking in this population is the provision of ankle-foot-orthoses (AFOs). Since we are not aware of an up-to-date and complete overview of the effects of AFOs used for calf muscle weakness in slowly progressive neuromuscular disorders, we reviewed the evidence for the effectiveness of AFOs to improve walking in this patient group, in order to support clinical decision-making.

OBJECTIVES

To review the evidence for the effects of ankle-foot orthoses (AFOs) for improving walking in adults with calf muscle weakness due to slowly progressive neuromuscular disorders.

SEARCH METHODS

On 10 February 2023, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, Embase, MEDLINE, ClinicalTrials.gov, and WHO ICTRP.

SELECTION CRITERIA

We looked for randomised controlled trials (RCTs), including randomised cross-over studies and quasi-RCTs, and non-randomised studies (NRSs) that examined the effects of AFO interventions compared with shoes-only walking in adults with calf muscle weakness due to neuromuscular disorders.

DATA COLLECTION AND ANALYSIS

We used the methodological procedures described in the Cochrane Handbook for Systematic Reviews of Interventions. We summarised findings for the primary outcome (objectively measured walking effort, assessed as walking energy cost) and secondary outcomes (perceived walking effort, physical mobility, gait parameters, AFO use, satisfaction with the AFO, and adverse events). We grouped results according to the type of AFO material and synthesised them in meta-analysis where possible. We used the GRADE approach to rate the certainty of the evidence.

MAIN RESULTS

We included four randomised cross-over studies and six NRSs with 186 participants in total (the smallest study had 8 participants and the largest had 37). All studies were designed as self-controlled studies and examined the effects of custom-made and/or prefabricated AFOs. The AFOs were made of carbon (5 studies), polypropylene (5 studies), silicone (1 study), metal (1 study), elastic materials (2 studies), or leather combined with other materials (1 study). Outcome measures with AFOs were assessed during a single session (in some studies, people already used the study AFO in daily life), when the AFO was delivered, or at three-week or three-month follow-up. We judged one study to be at moderate risk of bias, and nine studies to be at high or serious risk of bias, primarily due to bias arising from period and carryover effects, selection bias, the inability to blind participants and assessors, missing data, and selective reporting. We found that carbon AFOs may reduce walking energy cost (mean difference (MD) -0.86 J/kg/m, 95% confidence interval (CI) -1.33 to -0.39; 2 studies, 45 participants; low-certainty evidence), and may increase walking speed (MD 0.19 m/s, 95% CI 0.11 to 0.27; 4 studies, 71 participants; low-certainty evidence) compared to shoes-only walking. We found that leather AFOs may increase walking speed (MD 0.25 m/s, 95% CI 0.07 to 0.43; 1 study, 11 participants; low-certainty evidence). Little or no effect on walking speed was found with polypropylene AFOs (MD 0.00 m/s, 95% CI -0.11 to 0.11; 2 studies, 25 participants; low-certainty evidence) and elastic AFOs (MD 0.03 m/s, 95% CI -0.12 to 0.18; 1 study, 14 participants; low-certainty evidence). Carbon AFOs may also enhance satisfaction while walking (1 study, 16 participants; low-certainty evidence). We were unable to draw conclusions about perceived walking effort (one study, 8 participants), balance (two studies, 21 participants), and AFO use (two studies, 51 participants), as the evidence is very uncertain. Finally, two studies (45 participants) reported on adverse events (low-certainty evidence).

AUTHORS' CONCLUSIONS

The available evidence for ankle-foot orthoses (AFOs) to improve walking in adults with calf muscle weakness comes from a limited number of small studies with heterogeneity in intervention characteristics and outcome assessment, and is of low to very low certainty. The evidence suggests that carbon AFOs may reduce walking energy cost (effort), increase walking speed, and enhance satisfaction, and leather AFOs may increase walking speed, while polypropylene and elastic AFOs may make little or no difference to walking speed. We are unable to draw conclusions about the effects of AFOs on perceived walking effort, balance, and use. Nor can we draw conclusions about adverse effects of using AFOs. The variety in the findings for AFOs made of different materials suggests further investigation is warranted to explore how different AFO materials impact walking improvement in people with calf muscle weakness due to slowly progressive neuromuscular disorders.

What do we talk about when we talk about "equipoise"? Stakeholder interviews assessing the use of equipoise in clinical research ethics

INTRODUCTION

Equipoise, generally defined as uncertainty about the relative effects of the treatments being compared in a trial, is frequently referenced as an ethical standard for the conduct of randomized clinical trials. However, it seems to be defined in several different ways and may be used differently by different individuals. We explored how clinical researchers, chairs of research ethics boards, and philosophers of science define and reason with this term.

METHODS

We completed semi-structured interviews about clinical trial ethics with 15 clinical researchers, 15 research ethics board chairs, and 15 philosophers of science/bioethicists. Each participant was asked a standardized set of 10 questions, 4 of which were specifically about equipoise. All interviews were conducted telephonically and transcribed. Responses were grouped and analysed via a modified grounded theory method.

RESULTS

Forty-three respondents defined equipoise in 7 logically distinct ways, and 2 respondents could not explicitly define it. The most common definition, offered by 14 respondents (31%), defined "equipoise" as a disagreement at the level of a community of physicians. There was significant variability in definitions offered between and within groups. When asked how they would "operationalize" equipoise - i.e. check or test for its presence - respondents provided 7 alternatives, the most common being in relation to a literature review (15/45, 33%). The vast majority of respondents (35/45, 78%) felt the concept was helpful, though many acknowledged that the lack of a clear definition or operationalization was problematic.

CONCLUSION

There is significant variation in definitions of equipoise offered by respondents, suggesting that parties within groups and between groups may be referring to different concepts when they reference "equipoise". This non-uniformity may impact fairness and transparency and opens the door to potential ethical problems in the evaluation of clinical trials - for instance, a patient may understand equipoise very differently than the researchers enrolling her in a trial, which could cause her agreement to participate to be based upon false premises.

Many trials of hydroxychloroquine for SARS-CoV-2 were redundant and potentially unethical: an analysis of the NIH clinical trials registry

OBJECTIVE

We sought to map the landscape of trials investigating hydroxychloroquine (HCQ) for SARS-CoV-2 in order to draw conclusions about how clinical trials have been conducted in the pandemic environment and offer potential regulatory recommendations.

STUDY DESIGN AND SETTING

We identified and captured data related to registered studies using HCQ to treat SARS-CoV-2 registered with the publicly available National Institutes of Health (NIH) Clinical Trials Registry between February and November 2020.

RESULTS

Between February and November 2020, 206 studies investigating HCQ in SARS-CoV-2 were registered with the NIH Clinical Trials Registry. As of November 2020, 135 studies were listed as ongoing, 22 have been completed, and 46 are either suspended or have been terminated. Reasons for suspension or termination included difficulties with patient recruitment (n = 9), emerging evidence showing a lack of benefit of HCQ (n = 7), and recommendations by regulatory boards to discontinue (n = 10).

CONCLUSION

Many clinical trials of HCQ were launched in the first months of the pandemic, and a significant proportion of them remained active as of November 2020. The medical community appears to have responded very quickly to political interest in HCQ, while responding much more slowly to the evolving medical evidence of its lack of efficacy.

Identifying sex-specific differences in the carotid revascularisation literature: findings from a scoping review

OBJECTIVE

No systematic review of the literature has dedicated itself to looking at the management of symptomatic carotid stenosis in female patients. In this scoping review, we aimed to identify all randomised controlled trials (RCTs) that reported sex-specific outcomes for patients who underwent carotid revascularisation, and determine whether sufficient information is reported within these studies to assess short-term and long-term outcomes in female patients.

DESIGN, SETTING AND PARTICIPANTS

We systematically searched Medline, Embase, Pubmed and Cochrane libraries for RCTs published between 1991 and 2020 that included female patients and compared either endarterectomy with stenting, or any revascularisation (endarterectomy or stenting) with medical therapy in patients with symptomatic high-grade (>50%) carotid stenosis.

RESULTS

From 1537 references examined, 27 eligible studies were identified. Sex-specific outcomes were reported in 13 studies. Baseline patient characteristics of enrolled female patients were reported in 2 of those 13 studies. Common outcomes reported included stroke and death, however, there was significant heterogeneity in the reporting of both periprocedural and long-term outcomes. Sex-specific differences relating to the degree of stenosis and time from index event to treatment are largely limited to studies comparing endarterectomy to medical therapy. Adverse events were not reported by sex.

CONCLUSIONS

Only half of the previously published RCTs and systematic reviews report sex-specific outcomes. Detailed analyses on the results of carotid artery intervention for female patients with symptomatic stenosis are limited.

Ethics of Pharma Clinical Trials in the Era of Precision Oncology

Pharmaceutical industry clinical trials are ethically problematic: human research subjects are being used as a means to the end of demonstrating statistically significant efficacy of novel anticancer agents to achieve regulatory registration and marketing approval. Randomized controlled trial design is inequitable since control arm patients are denied access to the postulated best treatment. Most pharma studies do not provide clinically meaningful benefit of increased overall survival and enhanced quality of life (QOL) to cohorts and are not reliably generalizable to real-world patients. Precision oncology now enables prospective identification of patients expressing a specific cancer biomarker to determine their particular eligibility for evaluation of efficiency of molecular-targeted treatments. A patient-centered approach, collecting prospective real-world data in large populations, could provide real-world evidence of cost-effective, sustained clinical benefits of survival and QOL, while preserving the ethical beneficent compact between patient and doctor.

First-in-human dose: current status review for better future perspectives

AIM

The aim of this article is to understand the pros and cons of various methods involved in first-in-human (FIH) dose calculation and act decisively in dose escalations when calculating the maximum tolerated dose.

SUBJECTS AND METHODS

We reviewed early phase clinical trials for methods of FIH dose and dose-escalation steps and discuss them in line with existing guidelines. We also reviewed the clinical trial registry to recognize trends in trial registration in recent years and after a massive failure in a few trials.

RESULTS

Phase 1 trials of TGN 1412 and BIA10-2474 would always be remembered as catastrophes for pharmaceutical development plans. Quite often than not, healthy human volunteers are the guinea pigs in this stage of drug development. And, the most important aspect of designing an early phase study is deciding upon the dose to be started with, apart from the selection of cohort and escalation steps. The common principles used for FIH dose calculation include no observed adverse effect level, minimum anticipated biological effect level, pharmacologically active dose, pharmacokinetic/pharmacodynamic approach, and similar drug comparison approach.

CONCLUSION

Early phase clinical trials are basically foundation stones on which lies the entire onus of the later stages of development. Deciding FIH dose is a crucial step that necessitates the incorporation of detailed data from the preclinical stages and application of the most conservative approach for the safety/benefit of the volunteers in these studies.

An Efficient Development Paradigm for Biosimilars

The current development paradigm for biosimilars required by regulators in highly regulated jurisdictions is derived from the development of novel drugs and is unnecessarily burdensome and inefficient. It requires the accumulation of data from analytical, nonclinical (including in vivo studies in some jurisdictions), and clinical studies (including powered efficacy studies in most cases); this paradigm is known as 'totality of evidence' (ToE) and does not admit a conclusion of biosimilarity from analytical data alone. The record of biosimilar approvals in these jurisdictions shows that no biosimilar candidate that has been found highly similar to its reference in analytical and pharmacokinetic studies has failed to be approved. We propose a new paradigm ('confirmation of sufficient likeness', CSL) that emphasizes the demonstration of analytical resemblance between the biosimilar candidate and its reference, and permits the conclusion of biosimilarity upon this basis. CSL does not entail bridging studies between reference products, in vivo nonclinical studies, or powered efficacy studies and is, therefore, substantially more efficient than ToE while maintaining equivalent scientific rigor. Such efficiency will contribute to the attractiveness as well as the sustainability of biosimilars as a therapeutic modality.

Benefit of carotid revascularisation for women with symptomatic carotid stenosis: protocol for a systematic review

INTRODUCTION

Carotid intervention in the form of endarterectomy or stenting is the current standard of care for the majority of patients with symptomatic high-grade carotid stenosis. However, some randomised controlled trials (RCT) have demonstrated that women benefited significantly less from intervention than men. It is unclear if this is a true phenomenon or a study sampling artefact, as women were severely under-represented in all RCTs of carotid revascularisation. A systematic review is needed to summarise the existing data and to answer the question of whether a women-only trial for symptomatic patients with ipsilateral carotid stenosis is scientifically necessary and ethically permissible.

METHODS AND ANALYSIS

We will systematically search Medline, Embase, PubMed and the Cochrane libraries for all studies with data from RCTs that included women and compared either endarterectomy with stenting or revascularisation (by means of endarterectomy or stenting) with medical therapy in patients with symptomatic carotid stenosis. Search dates will be restricted to 1991-2018. Two reviewers will conduct screening search results, study selection, data extraction and quality assessment. We will include all studies reporting outcomes of interest. Planned subgroup analysis based on revascularisation technique, degree of stenosis and timing of intervention from the index event will be conducted with enough data.

ETHICS AND DISSEMINATION

This research is exempt of ethics approval as no primary data will be collected. The results will be published in peer-reviewed journals and disseminated through national and international-level conferences and scientific meetings. The result of this comprehensive review will provide useful information on whether further RCTs are required to study a women-only population with symptomatic carotid disease.

PROSPERO REGISTRATION NUMBER

CRD42019134967.

Influenza vaccination in the elderly: Is a trial on mortality ethically acceptable?

The effectiveness of influenza vaccination in the elderly has long been a topic of debate, fueled by the absence of direct evidence from randomized trials on its effect on mortality and the methodological limitations of observational studies pointing this direction. It is argued that new placebo-controlled trials should be undertaken to resolve this uncertainty. However, such trials may be ethically questionable. To bring this discussion forward, we provide a comprehensive overview of the ethical challenges of an influenza vaccine efficacy trial designed to evaluate mortality in the elderly. An important condition in the justification of a trial is the existence of genuine uncertainty in regard to the answer to a research question. Therefore an extensive analysis of the existing levels of knowledge is needed to support the conclusion that an effect of vaccination on mortality is uncertain. Even if a so called "clinical equipoise" status applies, denying a control group vaccination would be problematic because vaccination is considered "competent care" and withholding vaccination could substantially increase patients' risk for influenza and its complications. Given the high burden of disease and already proven benefits of vaccination, such a trial is unlikely to meet the Declaration of Helsinki stating that the importance of a trial must outweigh the risk patients are exposed to. While a placebo-controlled trial in vaccine refusers may be considered, such a trial is unlikely to meet substantial methodological barriers regarding trial size and generalizability. We conclude that a new trial is unlikely to provide for a direct answer, let alone change current policy. At the same time, given the lack of consensus on the ethical acceptability of a placebo-controlled trial on the effect of influenza vaccination on mortality in the elderly, we invite researchers considering such trials to address the ethical challenges discussed in this manuscript.

Many randomized clinical trials may not be justified: a cross-sectional analysis of the ethics and science of randomized clinical trials

OBJECTIVE

We have proposed that three scientific criteria are important for the ethical justification of randomized clinical trials (RCTs): (1) they should be designed around a clear hypothesis; (2) uncertainty should exist around that hypothesis; (3) that uncertainty should be as established through a systematic review. We hypothesized that the majority of a sample of recently published RCTs would not explicitly incorporate these criteria, therefore rendering them potentially unjustified on scientific grounds.

STUDY DESIGN AND SETTING

Cross-sectional analysis of all RCTs published in the New England Journal of Medicine and the Journal of the American Medical Association in 2015. Each article and protocol was reviewed for: (1) a clearly stated central hypothesis; (2) references to "equipoise," or "consensus;" (3) some indication of evidentiary uncertainty; (4) a meta-analysis or systematic review surrounding the hypothesis or study question.

RESULTS

We included 208 RCT articles and 199 protocols. Among combined articles and protocols, 76% had a clearly stated hypothesis, 99% referenced some form of uncertainty, and 54% cited a relevant systematic review or meta-analysis. Only 44% of combined texts contained all three scientific criteria. There were few references to "equipoise" (10%) or "consensus" (11%), and those references to equipoise were most often inconsistent with accepted definitions.

CONCLUSION

The majority of RCTs (56%) did not meet the three scientific criteria described previously and therefore may be scientifically and therefore ethically unjustified. We recommend that "equipoise," "clinical equipoise," and "lack of consensus" be abandoned as scientific criteria for RCTs and be replaced by an expectation that RCTs have a clearly stated, meaningful hypothesis around which uncertainty has been established through a systematic review of the literature.