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Fureman BE, Friedman D, Baulac M, Glauser T, Moreno J, Dixon-Salazar T, Bagiella E, Connor J, Ferry J, Farrell K, Fountain NB, French JA. Reducing placebo exposure in trials: Considerations from the Research Roundtable in Epilepsy. Neurology 2017; 89:1507-1515. [PMID: 28878049 DOI: 10.1212/wnl.0000000000004535] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 07/10/2017] [Indexed: 11/15/2022] Open
Abstract
The randomized controlled trial is the unequivocal gold standard for demonstrating clinical efficacy and safety of investigational therapies. Recently there have been concerns raised about prolonged exposure to placebo and ineffective therapy during the course of an add-on regulatory trial for new antiepileptic drug approval (typically ∼6 months in duration), due to the potential risks of continued uncontrolled epilepsy for that period. The first meeting of the Research Roundtable in Epilepsy on May 19-20, 2016, focused on "Reducing placebo exposure in epilepsy clinical trials," with a goal of considering new designs for epilepsy regulatory trials that may be added to the overall development plan to make it, as a whole, safer for participants while still providing rigorous evidence of effect. This topic was motivated in part by data from a meta-analysis showing a 3- to 5-fold increased rate of sudden unexpected death in epilepsy in participants randomized to placebo or ineffective doses of new antiepileptic drugs. The meeting agenda included rationale and discussion of different trial designs, including active-control add-on trials, placebo add-on to background therapy with adjustment, time to event designs, adaptive designs, platform trials with pooled placebo control, a pharmacokinetic/pharmacodynamic approach to reducing placebo exposure, and shorter trials when drug tolerance has been ruled out. The merits and limitations of each design were discussed and are reviewed here.
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Affiliation(s)
- Brandy E Fureman
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville.
| | - Daniel Friedman
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Michel Baulac
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Tracy Glauser
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Jonathan Moreno
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Tracy Dixon-Salazar
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Emilia Bagiella
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Jason Connor
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Jim Ferry
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Kathleen Farrell
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Nathan B Fountain
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
| | - Jacqueline A French
- From the Research and New Therapies Program (B.E.F., K.F., J.A.F.), Epilepsy Foundation of America, Landover, MD; Department of Neurology (D.F., J.A.F.), New York University, New York; Department of Neurology (M.B.), Hôpital la Salpêtrière, APHP/ICM, University Pierre et Marie Curie, Paris, France; Cincinnati Children's Research Foundation (T.G.), OH; University of Pennsylvania (J.M.), Philadelphia; LGS Foundation (Lennox-Gastaut Syndrome) (T.D.-S.), Bohemia; Mount Sinai School of Medicine (E.B.), New York, NY; Berry Consultants LLC and University of Central Florida College of Medicine (J.C.), Orlando; Eisai Inc. (J.F.), Woodcliff Lake, NJ; and Department of Neurology (N.B.F.), University of Virginia, Charlottesville
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