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Balaban N, Mohyuddin GR, Kashi A, Massarweh A, Markel G, Bomze D, Goldstein DA, Meirson T. Projecting complete redaction of clinical trial protocols (RAPTURE): redacted cross sectional study. BMJ 2023; 383:e077329. [PMID: 38097263 PMCID: PMC10719744 DOI: 10.1136/bmj-2023-077329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVES To characterise redactions in clinical trials and estimate a time when all protocols are fully removed (RAPTURE). DESIGN Redacted cross sectional study. SETTING Published phase 3 randomised controlled trials from 1 January 2010 to ██████████████. PARTICIPANTS New England Journal of Medicine, ██████████, and Journal of the American Medical Association. MAIN OUTCOME MEASURES █████ ████████ ██████████████ ██████ ██████████ ████████ ████████ ██████████ ███████████ ████████████ ████████████ ████████████████████████ ██████████████████ RESULTS: ████████████████████ met the inclusion criteria, with 268 (56.7%) research protocols available and accessible. The rate of redactions in protocols has increased from 0 in 2010 to 60.8% in 2021 (P<0.001). The degree of data redaction has also increased, with the average cumulative redactions among industry funded trials rising from 0 in 2010 to 3.5 pages in 2021 (P<0.001). Modelling predicts that RAPTURE is expected to occur between 2073 and 2136. Redactions featured predominantly in ████████ sponsored trials and mostly occurred in the statistical design. CONCLUSIONS This study highlights the rise in protocol redactions and predicts that, ██████████████████████████████████████████ will be entirely redacted between 2073 and 2136. A legitimate rationale for the redactions could ███ be found. A multipronged strategy against protocol redactions is required to maintain the integrity of science. AVAILABILITY This paper is partially redacted, but for the sake of ███████████, a version without any redactions can be found in the supplementary material.
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Affiliation(s)
- Nir Balaban
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ghulam Rehman Mohyuddin
- Division of Hematology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Adi Kashi
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Massarweh
- Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
| | - Gal Markel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
- Samueli Integrative Cancer Pioneering Institute, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
| | - David Bomze
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
| | - Tomer Meirson
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
- Samueli Integrative Cancer Pioneering Institute, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
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Marsolo KA, Weinfurt KP, Staman KL, Hammill BG. Moving From Idealism to Realism With Data Sharing. Ann Intern Med 2023; 176:402-403. [PMID: 36716450 DOI: 10.7326/m22-2973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Keith A Marsolo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
| | - Kevin P Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
| | - Karen L Staman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
| | - Bradley G Hammill
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
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Sheng J, Feldhake E, Zarin DA, Kimmelman J. Completeness of clinical evidence citation in trial protocols: A cross-sectional analysis. Med (N Y) 2022; 3:335-343.e6. [PMID: 35584654 DOI: 10.1016/j.medj.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/31/2022] [Accepted: 03/10/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Human protection policies require assessment of how proposed clinical trials relate to prior and ongoing studies testing similar hypotheses. We assessed the extent to which clinical trial protocols cited relevant published and ongoing clinical trials that would have been easily accessible with reference searches. METHODS We created a random sample of trial protocols using ClinicalTrials.gov, stratifying by industry and non-industry-sponsored studies. We then conducted reference searches to determine the extent to which protocols cited clinical trials with identical intervention-indication pairings that were accessible in PubMed and ClinicalTrials.gov at the time of trial initiation. FINDINGS Of the 101 trial protocols evaluated, 73 had at least one identified citable trial. None contained statements suggesting a systematic search for relevant clinical evidence. Of industry-sponsored trial protocols with at least one identified citable trial, 7 of 23 (30.4%) did not cite any published clinical trials and 10 of 33 (30.3%) did not cite any ongoing relevant trials. Of the non-industry-sponsored trial protocols with at least one identified citable trial, 5 of 28 (17.9%) did not cite any published clinical trials and 14 of 19 (73.7%) did not cite any ongoing trials. CONCLUSIONS Clinical trial protocols undercite accessible, relevant trials and do not document systematic searches for relevant clinical trials. Consequently, ethics review committees often receive an incomplete picture of the research landscape if they review protocols similar to those deposited on ClinicalTrials.gov. FUNDING This study was funded by the Canadian Institutes of Health Research and the Greenwall Foundation.
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Affiliation(s)
- Jacky Sheng
- Department of Equity, Ethics and Policy, McGill University, 2001 McGill College, 11th Floor, Montreal, QC H3A 1G1, Canada
| | - Emma Feldhake
- Department of Equity, Ethics and Policy, McGill University, 2001 McGill College, 11th Floor, Montreal, QC H3A 1G1, Canada
| | - Deborah A Zarin
- Multi-Regional Clinical Trials Center, Brigham and Women's Hospital and Harvard, Cambridge, MA 02115, USA
| | - Jonathan Kimmelman
- Department of Equity, Ethics and Policy, McGill University, 2001 McGill College, 11th Floor, Montreal, QC H3A 1G1, Canada.
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Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is a psychiatric diagnosis increasingly used in adults. The recommended first-line pharmacological treatment is central nervous system (CNS) stimulants, such as methylphenidate, but uncertainty remains about its benefits and harms. OBJECTIVES To assess the beneficial and harmful effects of extended-release formulations of methylphenidate in adults diagnosed with ADHD. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, nine other databases and four clinical trial registries up to February 2021. We searched 12 drug regulatory databases for clinical trial data up to 13 May 2020. In addition, we cross-referenced all available trial identifiers, handsearched reference lists, searched pharmaceutical company databases, and contacted trial authors. SELECTION CRITERIA Randomised, double-blind, parallel-group trials comparing extended-release methylphenidate formulations at any dose versus placebo and other ADHD medications in adults diagnosed with ADHD. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We assessed dichotomous outcomes as risk ratios (RRs), and rating scales and continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs). We used the Cochrane risk of bias tool to assess risks of bias, and GRADE to assess the certainty of the evidence. We meta-analysed the data using a random-effects model. We assessed three design characteristics that may impair the trial results' 'generalisability'; exclusion of participants with psychiatric comorbidity; responder selection based on previous experience with CNS stimulants; and risk of withdrawal effects. Our prespecified primary outcomes were functional outcomes, self-rated ADHD symptoms, and serious adverse events. Our secondary outcomes included quality of life, ADHD symptoms rated by investigators and by peers such as family members, cardiovascular variables, severe psychiatric adverse events, and other adverse events. MAIN RESULTS We included 24 trials (5066 participants), of which 21 reported outcome data for this review. We also identified one ongoing study. We included documents from six drug regulatory agencies covering eight trials. Twenty-one trials had an outpatient setting and three were conducted in prisons. They were primarily conducted in North America and Europe. The median participant age was 36 years. Twelve trials (76% of participants) were industry-sponsored, four (14% of participants) were publicly funded with industry involvement, seven (10% of participants) were publicly funded, and one had unclear funding. The median trial duration was eight weeks. One trial was rated at overall unclear risk of bias and 20 trials were rated at overall high risk of bias, primarily due to unclear blinding of participants and investigators, attrition bias, and selective outcome reporting. All trials were impaired in at least one of the three design characteristics related to 'generalisability'; for example, they excluded participants with psychiatric comorbidity such as depression or anxiety, or included participants only with a previous positive response to methylphenidate, or similar drugs. This may limit the trials' usefulness for clinical practice, as they may overestimate the benefits and underestimate the harms. Extended-release methylphenidate versus placebo (up to 26 weeks) For the primary outcomes, we found very low-certainty evidence that methylphenidate had no effect on 'days missed at work' at 13-week follow-up (mean difference (MD) -0.15 days, 95% confidence interval (CI) -2.11 to 1.81; 1 trial, 409 participants) or serious adverse events (risk ratio (RR) 1.43, CI 95% CI 0.85 to 2.43; 14 trials, 4078 participants), whereas methylphenidate improved self-rated ADHD symptoms (small-to-moderate effect; SMD -0.37, 95% CI -0.43 to -0.30; 16 trials, 3799 participants). For secondary outcomes, we found very low-certainty evidence that methylphenidate improved self-rated quality of life (small effect; SMD -0.15, 95% CI -0.25 to -0.05; 6 trials, 1888 participants), investigator-rated ADHD symptoms (small-to-moderate effect; SMD -0.42, 95% CI -0.49 to -0.36; 18 trials, 4183 participants), ADHD symptoms rated by peers such as family members (small-to-moderate effect; SMD -0.31, 95% CI -0.48 to -0.14; 3 trials, 1005 participants), and increased the risk of experiencing any adverse event (RR 1.27, 95% CI 1.19 to 1.37; 14 trials, 4214 participants). We rated the certainty of the evidence as 'very low' for all outcomes, primarily due to high risk of bias and 'indirectness of the evidence'. One trial (419 participants) had follow-up at 52 weeks and two trials (314 participants) included active comparators, hence long-term and comparative evidence is limited. AUTHORS' CONCLUSIONS We found very low-certainty evidence that extended-release methylphenidate compared to placebo improved ADHD symptoms (small-to-moderate effects) measured on rating scales reported by participants, investigators, and peers such as family members. Methylphenidate had no effect on 'days missed at work' or serious adverse events, the effect on quality of life was small, and it increased the risk of several adverse effects. We rated the certainty of the evidence as 'very low' for all outcomes, due to high risk of bias, short trial durations, and limitations to the generalisability of the results. The benefits and harms of extended-release methylphenidate therefore remain uncertain.
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Affiliation(s)
- Kim Boesen
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health at Charité, QUEST Center for Responsible Research, Berlin, Germany
- Nordic Cochrane Centre, Rigshospitalet Dept 7811, Copenhagen, Denmark
| | - Asger Sand Paludan-Müller
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
| | | | - Karsten Juhl Jørgensen
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
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Boesen K, Jørgensen KJ, Gøtzsche PC. Clinical trials were missing from regulatory documents of extended-release methylphenidate for ADHD in adults: A case study of public documents. J Clin Epidemiol 2021:S0895-4356(21)00351-6. [PMID: 34752938 DOI: 10.1016/j.jclinepi.2021.10.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 07/29/2021] [Accepted: 10/30/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess whether drug regulatory agencies decided on applications for extended-release methylphenidate for use in adult ADHD based on select samples of trials. STUDY DESIGN AND SETTING Case series of publicly available regulatory documents. We matched an index of extended-release methylphenidate trials for adult ADHD with trials appearing in regulatory documents of extended-release methylphenidate applications. Trials and regulatory documents were identified as part of this systematic review (https://doi.org/10.1002/14651858.CD012857). We sought to identify missing trials in the regulatory documents and to clarify regulatory submission requirements. RESULTS We indexed 18 trials and matched those with 13 drug applications (11 approved, 2 rejected) published by 7 agencies. There were trials missing in 8 (62%) of 13 applications, median 3.5 trials (range 1-6). The median proportion of missing trial participants was 42% (range 14% - 72%). Regulators seemingly require that all trials must be included in new drug applications, but wording is ambiguous. CONCLUSION In this sample of extended-release methylphenidate drug applications for adult ADHD, 8 of 13 regulatory decisions were missing entire trials according to public documents, even though regulatory requirements seem to stipulate that all available trials should be included in drug applications.
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Iudicello A, Genovese F, Strusi V, Dominici M, Ruozi B. Development and Validation of a New Storage Procedure to Extend the In-Use Stability of Azacitidine in Pharmaceutical Formulations. Pharmaceuticals (Basel) 2021; 14:ph14090943. [PMID: 34577643 PMCID: PMC8470010 DOI: 10.3390/ph14090943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 11/19/2022] Open
Abstract
Stability studies performed by the pharmaceutical industry are principally designed to fulfill licensing requirements. Thus, post-dilution or post-reconstitution stability data are frequently limited to 24 h only for bacteriological reasons, regardless of the true physicochemical stability which could, in many cases, be longer. In practice, the pharmacy-based centralized preparation may require preparation in advance for administration, for example, on weekends, holidays, or in general when pharmacies may be closed. We report an innovative strategy for storing resuspended solutions of azacitidine, a well-known chemotherapic agent, for which the manufacturer lists maximum stability of 22 h. By placing the syringe with the azacitidine reconstituted suspension between two refrigerant gel packs and storing it at 4 °C, we found that the concentration of azacitidine remained above 98% of the initial concentration for 48 h, and no change in color nor the physicochemical properties of the suspension were observed throughout the study period. The physicochemical and microbiological properties were evaluated by HPLC–UV and UHPLC-HRMS analysis, FTIR spectroscopy, pH determination, visual and subvisual examination, and sterility assay. The HPLC-UV method used for evaluating the chemical stability of azacitidine was validated according to ICH. Precise control of storage temperature was obtained by a digital data logger. Our study indicates that by changing the storage procedure of azacitidine reconstituted suspension, the usage window of the drug can be significantly extended to a time frame that better copes with its use in the clinical environment.
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Affiliation(s)
- Antonella Iudicello
- Pharmaceutical Department, Azienda USL of Modena, Largo del Pozzo 71, 41121 Modena, Italy
- Nuclear Medicine Unit, Oncology and Hematology Department, Azienda Ospedaliero-Universitaria of Modena, Largo del Pozzo 71, 41124 Modena, Italy
- Correspondence: ; Tel.: +39-0594225167
| | - Filippo Genovese
- Centro Interdipartimentale Grandi Strumenti, University of Modena and Reggio Emilia, Via Campi 213/A, 41125 Modena, Italy;
| | - Valentina Strusi
- Scientific and Technological Park of Medicine “Mario Veronesi”, Via 29 Maggio 6, 41037 Mirandola, Italy; (V.S.); (M.D.)
| | - Massimo Dominici
- Scientific and Technological Park of Medicine “Mario Veronesi”, Via 29 Maggio 6, 41037 Mirandola, Italy; (V.S.); (M.D.)
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children & Adults, University of Modena and Reggio Emilia, Hospital of Modena, Largo del Pozzo 71, 44125 Modena, Italy
| | - Barbara Ruozi
- Department of Life Sciences, University of Modena and Reggio Emilia, Via Campi 213/A, 41125 Modena, Italy;
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Paludan-Müller AS, Sharma T, Rasmussen K, Gøtzsche PC. Extensive selective reporting of quality of life in clinical study reports and publications of placebo-controlled trials of antidepressants. Int J Risk Saf Med 2021; 32:87-99. [PMID: 33044196 DOI: 10.3233/jrs-200051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Selective reporting of trial results is common. OBJECTIVE To study selective reporting in clinical study reports, company trial registers and publications of quality of life in placebo-controlled trials of antidepressants. METHODS We compared clinical study reports of four antidepressants (fluoxetine, duloxetine, paroxetine and sertraline) obtained from two European drug regulators, data from online company registers, and publications received or retrieved from Eli Lilly and GlaxoSmithKline. Pfizer was also contacted but did not provide any publications. RESULTS We included 15 trials (19,015 pages) and 4717 patients. Six trials had used SF-36, seven EQ-5D and two both instruments. Nine of the 15 CSRs (60%) displayed selective reporting. In the companies' online registers, there was selective reporting for all 15 trials (100%). We received 20 publications from Eli Lilly and retrieved six from the GlaxoSmithKline register. There was selective reporting in 24 of the 26 publications (92%). Despite extensive selective reporting, we found only small differences between placebo and active drugs. CONCLUSIONS Access to the full raw data from clinical trials and to case report forms for all patients are needed to evaluate the effect of antidepressants on quality of life. Regulatory agencies should refuse to approve drugs or new indications based on incomplete reporting.
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Paludan-Müller AS, Créquit P, Boutron I. Reporting of harms in oncological clinical study reports submitted to the European Medicines Agency compared to trial registries and publications-a methodological review. BMC Med 2021; 19:88. [PMID: 33827569 PMCID: PMC8028762 DOI: 10.1186/s12916-021-01955-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/01/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND An accurate and comprehensive assessment of harms is a fundamental part of an accurate weighing of benefits and harms of an intervention when making treatment decisions; however, harms are known to be underreported in journal publications. Therefore, we sought to compare the completeness of reporting of harm data, discrepancies in harm data reported, and the delay to access results of oncological clinical trials between three sources: clinical study reports (CSRs), clinical trial registries and journal publications. METHODS We used the EMA clinical data website to identify all trials submitted to the EMA between 2015 and 2018. We retrieved all CSRs and included all phase II, II/III or III randomised controlled trials (RCTs) assessing targeted therapy and immunotherapy for cancer. We then identified related records in clinical trial registries and journals. We extracted harms data for eight pre-specified variables and determined the completeness of reporting of harm data in each of the three sources. RESULTS We identified 42 RCTs evaluating 13 different drugs. Results were available on the EMA website in CSRs for 37 (88%) RCTs, ClinicalTrials.gov for 36 (86%), the European Clinical Trials Register (EUCTR) for 20 (48%) and in journal publications for 32 (76%). Harms reporting was more complete in CSRs than other sources. We identified marked discrepancies in harms data between sources, e.g. the number of patients discontinuing due to adverse events differed in CSRs and clinical trial registers for 88% of trials with data in both sources. For CSRs and publications, the corresponding number was 90%. The median (interquartile range) delay between the primary trial completion date and access to results was 4.34 (3.09-7.22) years for CSRs, 2.94 (1.16-4.52) years for ClinicalTrials.gov, 5.39 (4.18-7.33) years for EUCTR and 2.15 (0.64-5.04) years for publications. CONCLUSIONS Harms of recently approved oncological drugs were reported more frequently and in more detail in CSRs than in trial registries and journal publications. Systematic reviews seeking to address harms of oncological treatments should ideally use CSRs as the primary source of data; however, due to problems with access, this is currently not feasible.
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Affiliation(s)
- Asger S Paludan-Müller
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark , Department of Clinical Research, University of Southern Denmark, JB Winsløwsvej 9b, 3rd Floor, 5000, Odence C, Denmark. .,Open Patient data Exploratory Network (OPEN) , Odense University Hospital , Odense, Denmark.
| | - Perrine Créquit
- Direction de la recherche Clinique, Hôpital Foch, Suresnes, France.,Université de Paris, CRESS, INSERM, INRA, F-75004, Paris, France.,Cochrane France, Paris, France
| | - Isabelle Boutron
- Université de Paris, CRESS, INSERM, INRA, F-75004, Paris, France.,Cochrane France, Paris, France.,Centre d'Epidémiologie Clinique, AP-HP (Assistance Publique des Hôpitaux de Paris), Hôpital Hôtel Dieu, Paris, France
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Yan D, Guha S, Ahn C, Tiwari R. Semiparametric Bayesian Markov analysis of personalized benefit–risk assessment. Ann Appl Stat 2020. [DOI: 10.1214/20-aoas1323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Affiliation(s)
- Tom Jefferson
- Senior Associate Tutor, University of Oxford;
Researcher, Nordic Cochrane Centre; Visiting Professor, Newcastle University,
UK
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Paludan-Müller AS, Ogden MC, Marquardsen M, Vive J, Jørgensen KJ, Gøtzsche PC. Do protocols for new randomised trials take previous similar trials into account? Cohort study of contemporary trial protocols. BMJ Open 2019; 9:e026661. [PMID: 31712328 PMCID: PMC6858261 DOI: 10.1136/bmjopen-2018-026661] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To investigate to what extent evidence from previous similar trials or systematic reviews was considered before conducting new trials. DESIGN Cohort study of contemporary protocols for trials with ethical approval. METHODS All protocols for randomised trials approved by the five ethical committees in Denmark between January 2012 and March 2013 were screened for eligibility. Included protocols were read in full to determine whether a systematic search had been conducted and references were checked to evaluate whether trial rationale and design could be challenged for not adequately considering previous evidence. To investigate whether protocols cited relevant trials, we used simple search strategies that could easily be conducted by researchers without experience with literature searches. RESULTS Sixty-seven protocols were included. Only two (3%) of the protocols explicitly stated to have conducted a literature search and only one (1%) provided information that allowed the search to be replicated. Eleven (16%) of the protocols described trials where we found the information insufficient to judge if the trial was ethically justified, either due to a comparator that was not supported by the presented evidence (six protocols), because they did not present a rationale for conducting the trial (two protocols), or for both reasons (three protocols). For eight (12%) of the protocols, our search identified trials that could have been relevant to cite as justification. CONCLUSIONS While most protocols seem to adequately consider existing evidence, a substantial minority of trials might lack a sufficient evidence base. Very few trials seemed to have been based on a literature search which makes it impossible to know whether all relevant previous trials had been considered. Rules for ethical approval should include requirements for systematic literature searches to ensure that research participants are not exposed to sub-optimal treatments or unnecessary harms as well as to reduce research waste.
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Affiliation(s)
| | | | | | - Jonas Vive
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark
| | | | - Peter Christian Gøtzsche
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark
- Institute of Scientific Freedom, Copenhagen, Denmark
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Gøtzsche PC. Institute for Scientific Freedom. BMJ Evid Based Med 2019; 24:123-124. [PMID: 30917997 DOI: 10.1136/bmjebm-2019-111185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2019] [Indexed: 11/03/2022]
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Abstract
OBJECTIVES To investigate whether the conclusion of a recent systematic review and network meta-analysis (Cipriani et al) that antidepressants are more efficacious than placebo for adult depression was supported by the evidence. DESIGN Reanalysis of a systematic review, with meta-analyses. DATA SOURCES 522 trials (116 477 participants) as reported in the systematic review by Cipriani et al and clinical study reports for 19 of these trials. ANALYSIS We used the Cochrane Handbook's risk of bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the risk of bias and the certainty of evidence, respectively. The impact of several study characteristics and publication status was estimated using pairwise subgroup meta-analyses. RESULTS Several methodological limitations in the evidence base of antidepressants were either unrecognised or underestimated in the systematic review by Cipriani et al. The effect size for antidepressants versus placebo on investigator-rated depression symptom scales was higher in trials with a 'placebo run-in' study design compared with trials without a placebo run-in design (p=0.05). The effect size of antidepressants was higher in published trials compared with unpublished trials (p<0.0001). The outcome data reported by Cipriani et al differed from the clinical study reports in 12 (63%) of 19 trials. The certainty of the evidence for the placebo-controlled comparisons should be very low according to GRADE due to a high risk of bias, indirectness of the evidence and publication bias. The mean difference between antidepressants and placebo on the 17-item Hamilton depression rating scale (range 0-52 points) was 1.97 points (95% CI 1.74 to 2.21). CONCLUSIONS The evidence does not support definitive conclusions regarding the benefits of antidepressants for depression in adults. It is unclear whether antidepressants are more efficacious than placebo.
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Affiliation(s)
- Klaus Munkholm
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark
| | | | - Kim Boesen
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark
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Wiktorowicz M, Moscou K, Lexchin J. Transnational pharmacogovernance: emergent patterns in the jazz of pharmaceutical policy convergence. Global Health 2018; 14:86. [PMID: 30134929 PMCID: PMC6106922 DOI: 10.1186/s12992-018-0402-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/30/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND As a transnational policy network, the International Council for Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) aligns international regulatory standards to address the pressures of globalization on the pharmaceutical industry and increase access to new medicines. Founding ICH members include regulators and pharmaceutical industry trade associations in the European Union, the United States and Japan. In this paper we explore the manner in which state interdependence fosters the conditions for regulatory harmonization by tracing the underlying parallels between ICH and member state pharmacogovernance to clarify emergent patterns in regulatory policy convergence. RESULTS A shift to the life cycle approach to pharmaceutical regulation corresponded with international convergence in pre-market standards as emphasis shifted to post-market standards where convergence remains unresolved. Transnational pharmacogovernance was found to concentrate regulatory authority within a co-regulatory model of bilateral negotiation with pharmaceutical trade associations in defining safety and efficacy standards. Given a context of state interdependence, parallels were found between transnational and ICH member pharmacogovernance modes that guide policy development. Divergent modes of state regulatory governance that re-calibrate perceptions of risk and risk mitigation were found to coincide with post-market policy dissonance. CONCLUSION Although interdependence fostered harmonization in pre-market standards and aligned with increased focus on post-market approaches, the confluence of divergent state governance modes and perceptions of risk may inspire improvisation in post-market standards. As the ICH expands to an ensemble with a greater global reach, further research is needed to clarify the manner in which interdependence shapes transnational pharmacogovernance and the conditions that foster policy convergence in the public interest.
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Affiliation(s)
- Mary Wiktorowicz
- School of Health Policy and Management, York University, Toronto, Canada
| | - Kathy Moscou
- School of Health Policy and Management, York University, Toronto, Canada
- WHO Collaborating Centre for Governance, Accountability and Transparency in the Pharmaceutical Sector, University of Toronto, Toronto, Canada
- Faculty of Education, Brandon University, Brandon, Canada
| | - Joel Lexchin
- School of Health Policy and Management, York University, Toronto, Canada
- WHO Collaborating Centre for Governance, Accountability and Transparency in the Pharmaceutical Sector, University of Toronto, Toronto, Canada
- University Health Network, Faculty of Medicine, University of Toronto, Toronto, Canada
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Hodkinson A, Dietz KC, Lefebvre C, Golder S, Jones M, Doshi P, Heneghan C, Jefferson T, Boutron I, Stewart L. The use of clinical study reports to enhance the quality of systematic reviews: a survey of systematic review authors. Syst Rev 2018; 7:117. [PMID: 30089508 PMCID: PMC6083614 DOI: 10.1186/s13643-018-0766-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/27/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Clinical study reports (CSRs) are produced for marketing authorisation applications. They often contain considerably more information about, and data from, clinical trials than corresponding journal publications. Use of data from CSRs might help circumvent reporting bias, but many researchers appear to be unaware of their existence or potential value. Our survey aimed to gain insight into the level of familiarity, understanding and use of CSRs, and to raise awareness of their potential within the systematic review community. We also aimed to explore the potential barriers faced when obtaining and using CSRs in systematic reviews. METHODS Online survey of systematic reviewers who (i) had requested or used CSRs, (ii) had considered but not used CSRs and (iii) had not considered using CSRs was conducted. Cochrane reviewers were contacted twice via the Cochrane monthly digest. Non-Cochrane reviewers were reached via journal and other website postings. RESULTS One hundred sixty respondents answered an open invitation and completed the questionnaire; 20/160 (13%) had previously requested or used CSRs and other regulatory documents, 7/160 (4%) had considered but not used CSRs and 133/160 (83%) had never considered this data source. Survey respondents mainly sought data from the European Medicines Agency (EMA) and/or the Food and Drug Administration (FDA). Motivation for using CSRs stemmed mainly from concerns about reporting bias 11/20 (55%), specifically outcome reporting bias 11/20 (55%) and publication bias 5/20 (25%). The barriers to using CSRs noted by all types of respondents included current limited access to these documents (43 respondents), the time and resources needed to obtain and include these data in evidence syntheses (n = 25) and lack of guidance about how to use these sources in systematic reviews (n = 26). CONCLUSIONS Most respondents (irrespective of whether they had previously used them) agreed that access to CSRs is important, and suggest that further guidance on how to use and include these data would help to promote their use in future systematic reviews. Most respondents who received CSRs considered them to be valuable in their systematic review and/or meta-analysis.
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Affiliation(s)
- Alex Hodkinson
- LCentre for Primary Care, Division of Population Health, Health Services Research & Primary Care, Williamson Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Kristina Charlotte Dietz
- Centre for Reviews and Dissemination, A/B Block, Alcuin College, University of York, York, YO10 5DD, UK
| | | | - Su Golder
- Department of Health Sciences, University of York, York, UK
| | - Mark Jones
- School of Public Health, University of Queensland, Brisbane, Australia
| | - Peter Doshi
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Carl Heneghan
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, Primary Sciences Division, University of Oxford, Oxford, UK
| | - Tom Jefferson
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, Primary Sciences Division, University of Oxford, Oxford, UK
| | - Isabelle Boutron
- METHODs Team, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité, INSERM UMR, University Paris Descartes, Paris, France
| | - Lesley Stewart
- Centre for Reviews and Dissemination, A/B Block, Alcuin College, University of York, York, YO10 5DD, UK
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Affiliation(s)
- Tom Jefferson
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
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Abstract
BACKGROUND Recognizing the value of promoting public access to clinical trial protocols, Trials pioneered the way for their publication over a decade ago. However, despite major advances in the public accessibility of information about trial methods and results, protocol sharing remains relatively rare. MAIN BODY Protocol sharing facilitates the critical appraisal of clinical trials and helps to identify and deter the selective reporting of outcomes and analyses. Challenges to the routine availability of high quality trial protocols include the gaps in incentives and adherence mechanisms, limited venues for sharing the original and final protocol versions, and the need for mechanisms to ensure transparent and complete protocol content. CONCLUSIONS We propose recommendations for addressing key challenges to protocol sharing in order to promote routine public access to protocols for the benefit of patients and other users of evidence from clinical trials.
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Affiliation(s)
- An-Wen Chan
- Women’s College Research Institute, Women’s College Hospital, 76 Grenville St, Rm 6416, Toronto, ON M5S 1B2 Canada
- Department of Medicine, University of Toronto, Toronto, ON Canada
| | - Asbjørn Hróbjartsson
- Center for Evidence-Based Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Heneghan CJ, Onakpoya I, Jones MA, Doshi P, Del Mar CB, Hama R, Thompson MJ, Spencer EA, Mahtani KR, Nunan D, Howick J, Jefferson T. Neuraminidase inhibitors for influenza: a systematic review and meta-analysis of regulatory and mortality data. Health Technol Assess 2018; 20:1-242. [PMID: 27246259 DOI: 10.3310/hta20420] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Neuraminidase inhibitors (NIs) are stockpiled and recommended by public health agencies for treating and preventing seasonal and pandemic influenza. They are used clinically worldwide. OBJECTIVES To (1) describe the potential benefits and harms of NIs for influenza in all age groups by reviewing all clinical study reports (CSRs) of published and unpublished randomised, placebo-controlled trials and regulatory comments; and (2) determine the effect of oseltamivir (Tamiflu(®), Roche) treatment on mortality in patients with 2009A/H1N1 influenza. METHODS We searched trial registries, electronic databases and corresponded with regulators and sponsors to identify randomised trials of NIs. We requested full CSRs and accessed regulators' comments. We included only those trials for which we had CSRs. To examine the effects of oseltamivir on 2009A/H1N1 influenza mortality, we requested individual patient data (IPD) from corresponding authors of all included observational studies. RESULTS Effect of oseltamivir and zanamivir (Relenza®, GlaxoSmithKline) in the prevention and treatment of influenza: Oseltamivir reduced the time to first alleviation of symptoms in adults by 16.8 hours [95% confidence interval (CI) 8.4 to 25.1 hours]. Zanamivir reduced the time to first alleviation of symptoms in adults by 0.60 days (95% CI 0.39 to 0.81 days). Oseltamivir reduced unverified pneumonia in adult treatment [risk difference (RD) 1.00%, 95% CI 0.22% to 1.49%]; similar findings were observed with zanamivir prophylaxis in adults (RD 0.32%, 95% CI 0.09% to 0.41%). Oseltamivir treatment of adults increased the risk of nausea (RD 3.66%, 95% CI 0.90% to 7.39%) and vomiting (RD 4.56%, 95% CI 2.39% to 7.58%). In the treatment of children, oseltamivir induced vomiting (RD 5.34%, 95% CI 1.75% to 10.29%). Both oseltamivir and zanamivir prophylaxis reduced the risk of symptomatic influenza in individuals (oseltamivir RD 3.05%, 95% CI 1.83% to 3.88%; zanamivir RD 1.98%, 95% CI 0.98% to 2.54%) and in households (oseltamivir RD 13.6%, 95% CI 9.52% to 15.47%; zanamivir RD 14.84%, 95% CI 12.18% to 16.55%). Oseltamivir increased psychiatric adverse events in the combined on- and off-treatment periods (RD 1.06%, 95% CI 0.07% to 2.76%) and the risk of headaches while on treatment (RD 3.15%, 95% CI 0.88% to 5.78%). Effect of oseltamivir on mortality in patients with 2009A/H1N1 influenza: Analysis of summary data of 30 studies as well as IPD of four studies showed evidence of time-dependent bias. After adjusting for time-dependent bias and potential confounding variables, competing risks analysis of the IPD showed insufficient evidence that oseltamivir reduced the risk of mortality (hazard ratio 1.03, 95% CI 0.64 to 1.65). CONCLUSIONS Oseltamivir and zanamivir cause small reductions in the time to first alleviation of influenza symptoms in adults. The use of oseltamivir increases the risk of nausea, vomiting, psychiatric events in adults and vomiting in children. Oseltamivir has no protective effect on mortality among patients with 2009A/H1N1 influenza. Prophylaxis with either NI may reduce symptomatic influenza in individuals and in households. The balance between benefits and harms should be considered when making decisions about use of NIs for either prophylaxis or treatment of influenza. STUDY REGISTRATION This study is registered as PROSPERO CRD42012002245. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Carl J Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Igho Onakpoya
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark A Jones
- School of Population Health, The University of Queensland, Brisbane, QLD, Australia
| | - Peter Doshi
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Chris B Del Mar
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Robina, QLD, Australia
| | - Rokuro Hama
- Japan Institute of Pharmacovigilance, Osaka, Japan
| | - Matthew J Thompson
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Elizabeth A Spencer
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamal R Mahtani
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Nunan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jeremy Howick
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Abstract
Objective To describe the redactions in contemporary protocols for industry-sponsored randomised drug trials with patient relevant outcomes and to evaluate whether there was a legitimate rationale for the redactions. Design Cohort study. Under the Freedom of Information Act, we requested access to trial protocols approved by a research ethics committee in Denmark from October 2012 to March 2013. We received 17 consecutive protocols, which had been redacted before we got them, and nine protocols without redactions. In five additional cases, the companies refused to let the committees give us access, and in three other cases, documents were missing. Participants Not applicable. Setting Not applicable. Main outcome measure Amount and nature of redactions in 22 predefined key protocol variables. Results The redactions were most widespread in those sections of the protocol where there is empirical evidence of substantial problems with the trustworthiness of published drug trials: data analysis, handling of missing data, detection and analysis of adverse events, definition of the outcomes, interim analyses and premature termination of the study, sponsor's access to incoming data while the study is running, ownership to the data and investigators' publication rights. The parts of the text that were redacted differed widely, both between companies and within the same company. Conclusions We could not identify any legitimate rationale for the redactions. The current mistrust in industry-sponsored drug trials can only change if the industry offers unconditional access to its trial protocols and other relevant documents and data.
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Jørgensen L, Gøtzsche PC, Jefferson T. Index of the human papillomavirus (HPV) vaccine industry clinical study programmes and non-industry funded studies: a necessary basis to address reporting bias in a systematic review. Syst Rev 2018; 7:8. [PMID: 29347995 PMCID: PMC5774129 DOI: 10.1186/s13643-018-0675-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 01/08/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Unabridged access to drug industry and regulatory trial registers and data reduces reporting bias in systematic reviews and may provide a complete index of a drug's clinical study programme. Currently, there is no public index of the human papillomavirus (HPV) vaccine industry study programmes or a public index of non-industry funded studies. METHODS By cross-verification via study programme enquiries to the HPV vaccine manufacturers and regulators and searches of trial registers and journal publication databases, we indexed clinical HPV vaccine studies as a basis to address reporting bias in a systematic review of clinical study reports. RESULTS We indexed 206 clinical studies: 145 industry and 61 non-industry funded studies. One of the four HPV vaccine manufacturers (GlaxoSmithKline) provided information on its study programme. Most studies were cross-verified from two or more sources (160/206, 78%) and listed on regulatory or industry trial registers or journal publication databases (195/206, 95%)-in particular, on ClinicalTrials.gov (176/195, 90%). However, study results were only posted for about half of the completed studies on ClinicalTrials.gov (71/147, 48%). Two thirds of the industry studies had a study programme ID, manufacturer specific ID, and national clinical trial (NCT) ID (91/145, 63%). Journal publications were available in journal publication databases (the Cochrane Collaboration's Central Register of Controlled Trials, Google Scholar and PubMed) for two thirds of the completed studies (92/149, 62%). CONCLUSION We believe we came close to indexing complete HPV vaccine study programmes, but only one of the four manufacturers provided information for our index and a fifth of the index could not be cross-verified. However, we indexed larger study programmes than those listed by major regulators (i.e., the EMA and FDA that based their HPV vaccine approvals on only half of the available trials). To reduce reporting bias in systematic reviews, we advocate the registration and publication of all studies and data in the public domain.
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Affiliation(s)
- Lars Jørgensen
- Nordic Cochrane Centre, Rigshospitalet 7811, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Peter C. Gøtzsche
- Nordic Cochrane Centre, Rigshospitalet 7811, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Tom Jefferson
- Nordic Cochrane Centre, Rigshospitalet 7811, Blegdamsvej 9, 2100 Copenhagen, Denmark
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22
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Gautier I, Janiaud P, Rollet N, André N, Tsimaratos M, Cornu C, Malik S, Gentile S, Kassaï B. Trends in the number and the quality of trial protocols involving children submitted to a French Institutional Review Board. BMC Med Res Methodol 2017; 17:130. [PMID: 28835231 PMCID: PMC5569539 DOI: 10.1186/s12874-017-0395-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 08/02/2017] [Indexed: 02/07/2023] Open
Abstract
Background There is a great need for high quality clinical research for children. The European Pediatric Regulation aimed to improve the quality of clinical trials in order to increase the availability of treatments for children. The main purpose of this study was to assess the evolution of both the number and the quality of pediatric trial protocols that were submitted to a French Institutional Review Board (IRB00009118) before and after the initiation of the EU Pediatric Regulation. Methods All protocols submitted to the IRB00009118 between 2003 and 2014 and conducting research on subjects under eighteen years of age were eligible. The quality of randomized clinical trials was assessed according to the guidelines developed by the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network and ranked using the Jadad score. Results Out of 622 protocols submitted to the Institutional Review Board (IRB), 21% (133/622) included children. Among these 133 pediatric protocols, the number of submitted pediatric protocols doubled between the two studied periods. From 2003 to 2008, 47 protocols including 21 institutionally sponsored were submitted to the IRB and from 2009 until 2014, 86 protocols including 48 institutionally sponsored were submitted. No significant trend was observed on the quality of RCTs. The overall median score of RCTs on the Jadad scale was high (3.5), 70.0% of protocols had a Jadad score ≥ 3, and 30.0% had a score < 3. Conclusion Following the EU Pediatric Regulation, the number of pediatric protocols submitted to the IRB00009118 tends to increase, but no change was noticed regarding their quality.
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Affiliation(s)
- Isabelle Gautier
- Centre d'investigation Clinique Pédiatrique, INSERM CIC 9502, Hôpital d'Enfants de la Timone, AP-HM, 264, rue Saint-Pierre, 13005, Marseille, France. .,EA3279 - Santé Publique: Maladies Chroniques et Qualité de Vie, Aix-Marseille Université, 13385, Marseille, France.
| | - Perrine Janiaud
- Evolutive Biology and Biometric Laboratory UMR5558 CNRS, Université Claude Bernard Lyon 1, 8 rue Guillaume Paradin, BP8071, 69376-CEDEX-08, Lyon, France
| | - Nelly Rollet
- Evolutive Biology and Biometric Laboratory UMR5558 CNRS, Université Claude Bernard Lyon 1, 8 rue Guillaume Paradin, BP8071, 69376-CEDEX-08, Lyon, France
| | - Nicolas André
- Centre d'investigation Clinique Pédiatrique, INSERM CIC 9502, Hôpital d'Enfants de la Timone, AP-HM, 264, rue Saint-Pierre, 13005, Marseille, France
| | - Michel Tsimaratos
- Centre d'investigation Clinique Pédiatrique, INSERM CIC 9502, Hôpital d'Enfants de la Timone, AP-HM, 264, rue Saint-Pierre, 13005, Marseille, France
| | - Catherine Cornu
- Evolutive Biology and Biometric Laboratory UMR5558 CNRS, Université Claude Bernard Lyon 1, 8 rue Guillaume Paradin, BP8071, 69376-CEDEX-08, Lyon, France.,EPICIME, Centre d'Investigation Clinique, INSERM CIC 1407, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677-CEDEX, Bron, France
| | - Salma Malik
- Evolutive Biology and Biometric Laboratory UMR5558 CNRS, Université Claude Bernard Lyon 1, 8 rue Guillaume Paradin, BP8071, 69376-CEDEX-08, Lyon, France.,EPICIME, Centre d'Investigation Clinique, INSERM CIC 1407, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677-CEDEX, Bron, France
| | - Stéphanie Gentile
- EA3279 - Santé Publique: Maladies Chroniques et Qualité de Vie, Aix-Marseille Université, 13385, Marseille, France
| | - Behrouz Kassaï
- Evolutive Biology and Biometric Laboratory UMR5558 CNRS, Université Claude Bernard Lyon 1, 8 rue Guillaume Paradin, BP8071, 69376-CEDEX-08, Lyon, France.,EPICIME, Centre d'Investigation Clinique, INSERM CIC 1407, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677-CEDEX, Bron, France
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Abstract
BACKGROUND Hypertension is a chronic condition associated with an increased risk of mortality and morbidity. Renin is the enzyme responsible for converting angiotensinogen to angiotensin I, which is then converted to angiotensin II. Renin inhibitors are a new class of drugs that decrease blood pressure (BP) by preventing the formation of both angiotensin I and angiotensin II. OBJECTIVES To quantify the dose-related BP lowering efficacy of renin inhibitors compared to placebo in the treatment of primary hypertension.To determine the change in BP variability, pulse pressure, and heart rate and to evaluate adverse events (mortality, non-fatal serious adverse events, total adverse events, withdrawal due to adverse effects and specific adverse events such as dry cough, diarrhoea and angioedema). SEARCH METHODS The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCTs) up to February 2017: the Cochrane Hypertension Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2017, Issue 2), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. There was no restriction by language or publication status. We also searched the European Medicines Agency (EMA) for clinical study reports, the Novartis Clinical Study Results Database, bibliographic citations from retrieved references, and contacted authors of relevant papers regarding further published and unpublished work. SELECTION CRITERIA We included randomized, double-blinded, placebo-controlled studies evaluating BP lowering efficacy of fixed-dose monotherapy with renin inhibitor compared with placebo for a minimum duration of three to 12 weeks in adult patients with primary hypertension. DATA COLLECTION AND ANALYSIS This systematic review is a comprehensive update which includes four additional studies and extensive detail from nine clinical study reports (CSRs) of previously included studies obtained from EMA. The remaining three CSRs are not available.Two review authors independently assessed study eligibility and extracted data. In all cases where there was a difference between the CSR and the published report, data from the CSR was used. Dichotomous outcomes were reported as risk ratio (RR) with 95% confidence intervals (CIs) and continuous outcomes as mean difference (MD) with 95% CIs. MAIN RESULTS 12 studies (mean duration of eight weeks) in 7439 mostly Caucasian patients (mean age 54 years) with mild-to-moderate uncomplicated hypertension were eligible for inclusion in the review. Aliskiren was the only renin inhibitor evaluated. All included studies were assessed to have high likelihood of attrition, reporting and funding bias.Aliskiren has a dose-related systolic/diastolic blood pressure (SBP/DBP) lowering effect as compared with placebo MD with 95% CI: aliskiren 75 mg (MD -2.97, 95% CI -4.76 to -1.18)/(MD -2.05, 95% CI -3.13 to -0.96) mm Hg (moderate-quality evidence), aliskiren 150 mg (MD -5.95, 95% CI -6.85 to -5.06)/ (MD -3.16, 95% CI -3.74 to -2.58) mm Hg (moderate-quality evidence), aliskiren 300 mg (MD -7.88, 95% CI -8.94 to -6.82)/ (MD -4.49, 95% CI -5.17 to -3.82) mm Hg (moderate-quality evidence), aliskiren 600 mg (MD -11.35, 95% CI -14.43 to -8.27)/ (MD -5.86, 95% CI -7.73 to -3.99) mm Hg (low-quality evidence). There was a dose-dependent decrease in blood pressure for aliskiren 75 mg, 150 mg and 300 mg. The blood pressure lowering effect of aliskiren 600 mg was not different from 300 mg (MD -0.61, 95% CI -2.78 to 1.56)/(MD -0.68, 95% CI -2.03 to 0.67). Aliskiren had no effect on blood pressure variability. Due to very limited information available regarding change in heart rate and pulse pressure, it was not possible to meta-analyze these outcomes.Mortality and non-fatal serious adverse events were not increased. This review found that in studies of eight week duration aliskiren may not increase withdrawal due to adverse events (low-quality evidence). Diarrhoea was increased in a dose-dependent manner (RR 7.00, 95% CI 2.48 to 19.72) with aliskiren 600 mg (low-quality evidence). The most frequent adverse events reported were headache, nasopharyngitis, diarrhoea, dizziness and fatigue. AUTHORS' CONCLUSIONS Compared to placebo, aliskiren lowered BP and this effect is dose-dependent. This magnitude of BP lowering effect is similar to that for angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). There is no difference in mortality, nonfatal serious adverse events or withdrawal due to adverse effects with short term aliskiren monotherapy. Diarrhoea was considerably increased with aliskiren 600 mg.
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Affiliation(s)
- Vijaya M Musini
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Science MallVancouverBCCanadaV6T 1Z3
| | | | - Patricia M Fortin
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Ken Bassett
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Science MallVancouverBCCanadaV6T 1Z3
| | - James M Wright
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Science MallVancouverBCCanadaV6T 1Z3
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Affiliation(s)
- Beate Wieseler
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Natalie McGauran
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
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25
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Abstract
The regulation of medical drugs and devices involves competing goals of assuring safety and efficacy while providing rapid movement of innovative therapies through the investigative and regulatory processes as quickly as possible. The United States and the European Union approach these challenges in different ways. Whereas the United States has always relied on a strictly centralized process through 1 agency, the Food and Drug Administration (FDA), the European Commission synchronized the regulations of 28 different countries as they combined to create the European Union. The FDA historically developed as a consumer protection agency, whereas the regulations from the European Commission arose out of a need to harmonize inter-state commercial interests while preserving national "autonomy." Thus, whereas the FDA has the advantages of centralization and common rules, the European Union regulates medical drug and device approvals through a network of centralized and decentralized agencies throughout its member states. This study explores some of the similarities and differences in European and U.S. regulation of drugs and devices, and discusses challenges facing each.
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Key Words
- BMJ, British Medical Journal
- CE, Conformité Européenne
- DAD, drugs and devices
- EC, European Commission
- EMA
- EMA, European Medicines Agency
- EU, European Union
- European Commission
- FDA
- FDA, Food and Drug Administration
- MHRA, Medicines and Healthcare Products Regulatory Agency
- NB, Notified Bodies
- PMA, pre-market approval
- device approval
- drug approval
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Affiliation(s)
- Gail A. Van Norman
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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Schroll JB, Penninga EI, Gøtzsche PC. Assessment of Adverse Events in Protocols, Clinical Study Reports, and Published Papers of Trials of Orlistat: A Document Analysis. PLoS Med 2016; 13:e1002101. [PMID: 27529343 PMCID: PMC4987052 DOI: 10.1371/journal.pmed.1002101] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 06/21/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Little is known about how adverse events are summarised and reported in trials, as detailed information is usually considered confidential. We have acquired clinical study reports (CSRs) from the European Medicines Agency through the Freedom of Information Act. The CSRs describe the results of studies conducted as part of the application for marketing authorisation for the slimming pill orlistat. The purpose of this study was to study how adverse events were summarised and reported in study protocols, CSRs, and published papers of orlistat trials. METHODS AND FINDINGS We received the CSRs from seven randomised placebo controlled orlistat trials (4,225 participants) submitted by Roche. The CSRs consisted of 8,716 pages and included protocols. Two researchers independently extracted data on adverse events from protocols and CSRs. Corresponding published papers were identified on PubMed and adverse event data were extracted from this source as well. All three sources were compared. Individual adverse events from one trial were summed and compared to the totals in the summary report. None of the protocols or CSRs contained instructions for investigators on how to question participants about adverse events. In CSRs, gastrointestinal adverse events were only coded if the participant reported that they were "bothersome," a condition that was not specified in the protocol for two of the trials. Serious adverse events were assessed for relationship to the drug by the sponsor, and all adverse events were coded by the sponsor using a glossary that could be updated by the sponsor. The criteria for withdrawal due to adverse events were in one case related to efficacy (high fasting glucose led to withdrawal), which meant that one trial had more withdrawals due to adverse events in the placebo group. Finally, only between 3% and 33% of the total number of investigator-reported adverse events from the trials were reported in the publications because of post hoc filters, though six of seven papers stated that "all adverse events were recorded." For one trial, we identified an additional 1,318 adverse events that were not listed or mentioned in the CSR itself but could be identified through manually counting individual adverse events reported in an appendix. We discovered that the majority of patients had multiple episodes of the same adverse event that were only counted once, though this was not described in the CSRs. We also discovered that participants treated with orlistat experienced twice as many days with adverse events as participants treated with placebo (22.7 d versus 14.9 d, p-value < 0.0001, Student's t test). Furthermore, compared with the placebo group, adverse events in the orlistat group were more severe. None of this was stated in the CSR or in the published paper. Our analysis was restricted to one drug tested in the mid-1990s; our results might therefore not be applicable for newer drugs. CONCLUSIONS In the orlistat trials, we identified important disparities in the reporting of adverse events between protocols, clinical study reports, and published papers. Reports of these trials seemed to have systematically understated adverse events. Based on these findings, systematic reviews of drugs might be improved by including protocols and CSRs in addition to published articles.
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Hodkinson A, Gamble C, Smith CT. Reporting of harms outcomes: a comparison of journal publications with unpublished clinical study reports of orlistat trials. Trials 2016; 17:207. [PMID: 27103582 PMCID: PMC4840982 DOI: 10.1186/s13063-016-1327-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 03/17/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The quality of harms reporting in journal publications is often poor, which can impede the risk-benefit interpretation of a clinical trial. Clinical study reports can provide more reliable, complete, and informative data on harms compared to the corresponding journal publication. This case study compares the quality and quantity of harms data reported in journal publications and clinical study reports of orlistat trials. METHODS Publications related to clinical trials of orlistat were identified through comprehensive literature searches. A request was made to Roche (Genentech; South San Francisco, CA, USA) for clinical study reports related to the orlistat trials identified in our search. We compared adverse events, serious adverse events, and the reporting of 15 harms criteria in both document types and compared meta-analytic results using data from the clinical study reports against the journal publications. RESULTS Five journal publications with matching clinical study reports were available for five independent clinical trials. Journal publications did not always report the complete list of identified adverse events and serious adverse events. We found some differences in the magnitude of the pooled risk difference between both document types with a statistically significant risk difference for three adverse events and two serious adverse events using data reported in the clinical study reports; these events were of mild intensity and unrelated to the orlistat. The CONSORT harms reporting criteria were often satisfied in the methods section of the clinical study reports (70-90 % of the methods section criteria satisfied in the clinical study reports compared to 10-50 % in the journal publications), but both document types satisfied 80-100 % of the results section criteria, albeit with greater detail being provided in the clinical study reports. CONCLUSIONS In this case study, journal publications provided insufficient information on harms outcomes of clinical trials and did not specify that a subset of harms data were being presented. Clinical study reports often present data on harms, including serious adverse events, which are not reported or mentioned in the journal publications. Therefore, clinical study reports could support a more complete, accurate, and reliable investigation, and researchers undertaking evidence synthesis of harm outcomes should not rely only on incomplete published data that are presented in the journal publications.
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Affiliation(s)
- Alex Hodkinson
- Centre for Reviews and Dissemination, University of York, Heslington, York, YO10 5DD, UK.
| | - Carrol Gamble
- Department of Biostatistics, MRC North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, England, UK
| | - Catrin Tudur Smith
- Department of Biostatistics, MRC North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, England, UK
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Affiliation(s)
- Nav Persaud
- Department of Family and Community Medicine (Persaud) and Li Ka Shing Knowledge Institute (Persaud), St. Michael's Hospital, Toronto, Ont.; Department of Family and Community Medicine (Persaud), University of Toronto, Toronto, Ont.; Department of Pharmaceutical Health Services Research (Doshi), School of Pharmacy, University of Maryland, Baltimore, Md.
| | - Peter Doshi
- Department of Family and Community Medicine (Persaud) and Li Ka Shing Knowledge Institute (Persaud), St. Michael's Hospital, Toronto, Ont.; Department of Family and Community Medicine (Persaud), University of Toronto, Toronto, Ont.; Department of Pharmaceutical Health Services Research (Doshi), School of Pharmacy, University of Maryland, Baltimore, Md
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Abstract
In recent years, European pharmaceutical regulators have increasingly committed to heightening access to raw safety-related data as part of a wave of transparency initiatives (e.g., providing public Internet-mediated access to clinical trials data). Yet, the regulators--who are under significant pressure--have not yet benefited from a systematic review of this new policy. In seeking to inject much needed evidence, this article explores the effects of new transparency policies designed to promote meaningful communication of risks and benefits to patients. Results of a cross-national European survey with respondents from Great Britain, the Netherlands, Spain, France, Germany, and Sweden (N = 5,648) shed light on how patients and the public are likely to react to the regulators' new transparency policies. The findings demonstrate clear national variations in how European citizens are likely to react and emphasize the need to develop evidence-based, reasoned transparency policies that integrate benefit-risk communication. The authors conclude by providing six specific recommendations, informed by the study, that seek to improve the European transparency model both within the medical field and across health, safety, and environmental policy domains.
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Affiliation(s)
- Frederic Bouder
- Department of Technology and Society Studies, Grote Gracht 76, 6211, SZ, Maastricht, The Netherlands
| | - Dominic Way
- King's College London, King's Centre for Risk Management, Strand London, WC2R 2LS
| | - Ragnar Löfstedt
- King's College London, King's Centre for Risk Management, Strand London, WC2R 2LS
| | - Darrick Evensen
- Oberlin College and Conservatory, A.J. Lewis Center for Environmental Studies, 122 Elm Street, Oberlin, OH, USA
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Meerpohl JJ, Schell LK, Bassler D, Gallus S, Kleijnen J, Kulig M, La Vecchia C, Marušić A, Ravaud P, Reis A, Schmucker C, Strech D, Urrútia G, Wager E, Antes G. Evidence-informed recommendations to reduce dissemination bias in clinical research: conclusions from the OPEN (Overcome failure to Publish nEgative fiNdings) project based on an international consensus meeting. BMJ Open 2015; 5:e006666. [PMID: 25943371 PMCID: PMC4431130 DOI: 10.1136/bmjopen-2014-006666] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Dissemination bias in clinical research severely impedes informed decision-making not only for healthcare professionals and patients, but also for funders, research ethics committees, regulatory bodies and other stakeholder groups that make health-related decisions. Decisions based on incomplete and biased evidence cannot only harm people, but may also have huge financial implications by wasting resources on ineffective or harmful diagnostic and therapeutic measures, and unnecessary research. Owing to involvement of multiple stakeholders, it remains easy for any single group to assign responsibility for resolving the problem to others. OBJECTIVE To develop evidence-informed general and targeted recommendations addressing the various stakeholders involved in knowledge generation and dissemination to help overcome the problem of dissemination bias on the basis of previously collated evidence. METHODS Based on findings from systematic reviews, document analyses and surveys, we developed general and targeted draft recommendations. During a 2-day workshop in summer 2013, these draft recommendations were discussed with external experts and key stakeholders, and refined following a rigorous and transparent methodological approach. RESULTS Four general, overarching recommendations applicable to all or most stakeholder groups were formulated, addressing (1) awareness raising, (2) implementation of targeted recommendations, (3) trial registration and results posting, and (4) systematic approaches to evidence synthesis. These general recommendations are complemented and specified by 47 targeted recommendations tailored towards funding agencies, pharmaceutical and device companies, research institutions, researchers (systematic reviewers and trialists), research ethics committees, trial registries, journal editors and publishers, regulatory agencies, benefit (health technology) assessment institutions and legislators. CONCLUSIONS Despite various recent examples of dissemination bias and several initiatives to reduce it, the problem of dissemination bias has not been resolved. Tailored recommendations based on a comprehensive approach will hopefully help increase transparency in biomedical research by overcoming the failure to disseminate negative findings.
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Affiliation(s)
- Joerg J Meerpohl
- German Cochrane Centre, Medical Center—University of Freiburg, Freiburg, Germany
| | - Lisa K Schell
- German Cochrane Centre, Medical Center—University of Freiburg, Freiburg, Germany
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
- Center for Pediatric Clinical Studies, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Silvano Gallus
- Department of Epidemiology, IRCCS—Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Michael Kulig
- Medical Consultancy Department, Gemeinsamer Bundesausschuss (G-BA), Berlin, Germany
| | - Carlo La Vecchia
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Ana Marušić
- Department of Research in Biomedicine and Health, University of Split School of Medicine, Split, Croatia
| | - Philippe Ravaud
- INSERM U738 Research Unit, Paris Descartes University, Paris, France
| | - Andreas Reis
- Global Health Ethics, Department of Knowledge, Ethics and Research, World Health Organization, Geneva, Switzerland
| | - Christine Schmucker
- German Cochrane Centre, Medical Center—University of Freiburg, Freiburg, Germany
| | - Daniel Strech
- CELLS—Centre for Ethics and Law in the Life Sciences, Institute of History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Gerard Urrútia
- Centro Cochrane Iberoamericano-Servei d'Epidemiologia Clínica i Salut Pública, Institut d'Investigació Biomèdica Sant Pau, CIBERSP, Barcelona, Spain
| | | | - Gerd Antes
- German Cochrane Centre, Medical Center—University of Freiburg, Freiburg, Germany
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Wienroth M, McCormack P, Joyce TJ. Precaution, governance and the failure of medical implants: the ASR((TM)) hip in the UK. Life Sci Soc Policy 2014; 10:19. [PMID: 26573983 PMCID: PMC4480348 DOI: 10.1186/s40504-014-0019-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 11/01/2014] [Indexed: 06/05/2023]
Abstract
Hip implants have provided life-changing treatment, reducing pain and improving the mobility and independence of patients. Success has encouraged manufacturers to innovate and amend designs, engendering patient hopes in these devices. However, failures of medical implants do occur. The failure rate of the Articular Surface Replacement metal-on-metal hip system, implanted almost 100,000 times world-wide, has re-opened debate about appropriate and timely implant governance. As commercial interests, patient hopes, and devices' governance converge in a socio-technical crisis, we analyse the responses of relevant governance stakeholders in the United Kingdom between 2007 and 2014. We argue that there has been a systemic failure of the governance system entrusted with the safety of patients fitted with medical implants. Commercial considerations of medical implants and the status quo of medical implant governance have been given priority over patient safety despite the availability of significant failure data in an example of uncertainty about what constitutes appropriate precautionary action.
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Affiliation(s)
- Matthias Wienroth
- Centre for Forensic Science, University of Northumbria at Newcastle, Northumberland Building, Northumberland Road, Newcastle upon Tyne, NE1 8ST, UK.
| | - Pauline McCormack
- Policy, Ethics & Life Sciences Research Centre, Newcastle University, Claremont Bridge, Claremont Road, Newcastle upon Tyne, NE1 7RU, UK.
| | - Thomas J Joyce
- School of Mechanical and Systems Engineering, Newcastle University, Stephenson Building, Claremont Road, Newcastle upon Tyne, NE1 7RU, UK.
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Rathi VK, Strait KM, Gross CP, Hrynaszkiewicz I, Joffe S, Krumholz HM, Dzara K, Ross JS. Predictors of clinical trial data sharing: exploratory analysis of a cross-sectional survey. Trials 2014; 15:384. [PMID: 25277128 PMCID: PMC4192345 DOI: 10.1186/1745-6215-15-384] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 09/22/2014] [Indexed: 11/24/2022] Open
Abstract
Background A number of research funders, biomedical journals, pharmaceutical companies, and regulatory agencies have adopted policies advocating or mandating that clinical trialists share data with external investigators. We therefore sought to determine whether certain characteristics of trialists or their trials are associated with more unfavorable perceptions of data sharing. To date, no prior research has addressed this issue. Methods We conducted an exploratory analysis of responses to a cross-sectional, web-based survey. The survey sample consisted of trialists who were corresponding authors of clinical trials published in 2010 or 2011 in one of six general medical journals with the highest impact factors in 2011. The following key characteristics were examined: trialists’ academic productivity and geographic location, trial funding source and size, and the journal in which it was published. Main outcome measures included: support for data sharing in principle, concerns with data sharing through repositories, and reasons for granting or denying requests. Chi-squared tests and Fisher’s exact tests were used to assess statistical significance. Results Of 683 potential respondents, 317 completed the survey (response rate 46%). Both support for data sharing and reporting of specific concerns with sharing data through repositories exceeded 75%, but neither differed by trialist or trial characteristics. However, there were some significant differences in explicit reasons to share or withhold data. Respondents located in Western Europe more frequently indicated they have or would share data in order to receive academic benefits or recognition when compared with respondents located in the United States or Canada (58 versus 31%). In addition, respondents who were the most academically productive less frequently indicated they have or would withhold data in order to protect research subjects when compared with less academically productive respondents (24 versus 40%), as did respondents who received industry funding when compared with those who had not (24 versus 43%). Conclusions Respondents indicated strong support for data sharing overall. There were few notable differences in how trialists viewed the benefits and risks of data sharing when categorized by trialists’ academic productivity and geographic location, trial funding source and size, and the journal in which it was published. Electronic supplementary material The online version of this article (doi:10.1186/1745-6215-15-384) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | | | | | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 1 Church Street, Suite 200, New Haven, CT 06510, USA.
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Naci H, Ioannidis JPA. How good is "evidence" from clinical studies of drug effects and why might such evidence fail in the prediction of the clinical utility of drugs? Annu Rev Pharmacol Toxicol 2014; 55:169-89. [PMID: 25149917 DOI: 10.1146/annurev-pharmtox-010814-124614] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Promising evidence from clinical studies of drug effects does not always translate to improvements in patient outcomes. In this review, we discuss why early evidence is often ill suited to the task of predicting the clinical utility of drugs. The current gap between initially described drug effects and their subsequent clinical utility results from deficits in the design, conduct, analysis, reporting, and synthesis of clinical studies-often creating conditions that generate favorable, but ultimately incorrect, conclusions regarding drug effects. There are potential solutions that could improve the relevance of clinical evidence in predicting the real-world effectiveness of drugs. What is needed is a new emphasis on clinical utility, with nonconflicted entities playing a greater role in the generation, synthesis, and interpretation of clinical evidence. Clinical studies should adopt strong design features, reflect clinical practice, and evaluate outcomes and comparisons that are meaningful to patients. Transformative changes to the research agenda may generate more meaningful and accurate evidence on drug effects to guide clinical decision making.
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Affiliation(s)
- Huseyin Naci
- LSE Health, London School of Economics and Political Science, London WC2A 2AE, United Kingdom;
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Naci H, Alexander GC. Regulators should better leverage effectiveness standards to enhance drug value. Pharmacotherapy 2014; 34:1005-11. [PMID: 25041851 DOI: 10.1002/phar.1467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Regulators show some flexibility in the evidentiary standards of effectiveness that must be demonstrated for a drug prior to its market authorization. Adopting a more formal framework for when and how effectiveness standards should vary would improve the therapeutic value of new medicines at the time of market entry. We identify three factors-the number and effectiveness of existing treatment alternatives, magnitude of unmet need, and expected clinical application-to guide the effectiveness threshold for a given therapy. Using these factors, regulators should actively guide sponsors regarding appropriate comparators and end points in pivotal trials, as well as determining the size and characteristics of the patient populations enrolled.
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Affiliation(s)
- Huseyin Naci
- LSE Health, London School of Economics and Political Science, London, UK
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Maund E, Tendal B, Hróbjartsson A, Jørgensen KJ, Lundh A, Schroll J, Gøtzsche PC. Benefits and harms in clinical trials of duloxetine for treatment of major depressive disorder: comparison of clinical study reports, trial registries, and publications. BMJ 2014; 348:g3510. [PMID: 24899650 PMCID: PMC4045316 DOI: 10.1136/bmj.g3510] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2014] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To determine, using research on duloxetine for major depressive disorder as an example, if there are inconsistencies between protocols, clinical study reports, and main publicly available sources (journal articles and trial registries), and within clinical study reports themselves, with respect to benefits and major harms. DESIGN Data on primary efficacy analysis and major harms extracted from each data source and compared. SETTING Nine randomised placebo controlled trials of duloxetine (total 2878 patients) submitted to the European Medicines Agency (EMA) for marketing approval for major depressive disorder. DATA SOURCES Clinical study reports, including protocols as appendices (total 13,729 pages), were obtained from the EMA in May 2011. Journal articles were identified through relevant literature databases and contacting the manufacturer, Eli Lilly. Clinicaltrials.gov and the manufacturer's online clinical trial registry were searched for trial results. RESULTS Clinical study reports fully described the primary efficacy analysis and major harms (deaths (including suicides), suicide attempts, serious adverse events, and discontinuations because of adverse events). There were minor inconsistencies in the population in the primary efficacy analysis between the protocol and clinical study report and within the clinical study report for one trial. Furthermore, we found contradictory information within the reports for seven serious adverse events and eight adverse events that led to discontinuation but with no apparent bias. In each trial, a median of 406 (range 177-645) and 166 (100-241) treatment emergent adverse events (adverse events that emerged or worsened after study drug was started) in the randomised phase were not reported in journal articles and Lilly trial registry reports, respectively. We also found publication bias in relation to beneficial effects. CONCLUSION Clinical study reports contained extensive data on major harms that were unavailable in journal articles and in trial registry reports. There were inconsistencies between protocols and clinical study reports and within clinical study reports. Clinical study reports should be used as the data source for systematic reviews of drugs, but they should first be checked against protocols and within themselves for accuracy and consistency.
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Affiliation(s)
- Emma Maund
- Nordic Cochrane Centre, Rigshospitalet Dept 7811, Copenhagen, Denmark
| | - Britta Tendal
- Nordic Cochrane Centre, Rigshospitalet Dept 7811, Copenhagen, Denmark
| | | | | | - Andreas Lundh
- Nordic Cochrane Centre, Rigshospitalet Dept 7811, Copenhagen, Denmark Department of Infectious Diseases, Hvidovre University Hospital, Kettegårds Allé 30, 2650 Hvidovre, Denmark
| | - Jeppe Schroll
- Nordic Cochrane Centre, Rigshospitalet Dept 7811, Copenhagen, Denmark
| | - Peter C Gøtzsche
- Nordic Cochrane Centre, Rigshospitalet Dept 7811, Copenhagen, Denmark
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Eriksson R, Aagaard L, Jensen LJ, Borisova L, Hørlück D, Brunak S, Hansen EH. Discrepancies in listed adverse drug reactions in pharmaceutical product information supplied by the regulatory authorities in Denmark and the USA. Pharmacol Res Perspect 2014; 2:e00038. [PMID: 25505588 PMCID: PMC4186409 DOI: 10.1002/prp2.38] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 02/21/2014] [Accepted: 02/27/2014] [Indexed: 11/07/2022] Open
Abstract
Pharmaceutical product information (PI) supplied by the regulatory authorities serves as a source of information on safe and effective use of drugs. The objectives of this study were to qualitatively and quantitatively compare PIs for selected drugs marketed in both Denmark and the USA with respect to consistency and discrepancy of listed adverse drug reaction (ADR) information. We compared individual ADRs listed in PIs from Denmark and the USA with respect to type and frequency. Consistency was defined as match of ADRs and of ADR frequency or match could not be ruled out. Discrepancies were defined as ADRs listed only in one country or listed with different frequencies. We analyzed PIs for 40 separate drugs from ten therapeutic groups and assigned the 4003 identified ADRs to System Organ Classes (Medical Dictionary for Regulatory Activities [MedDRA] terminology). Less than half of listed ADRs (n = 1874; 47%) showed consistency. Discrepancies (n = 2129; 53%) were split into ADRs listed only in the USA (n = 1558; 39%), ADRs listed only in Denmark (n = 325; 8%) and ADRs listed with different frequencies (n = 246; 6%). The majority of listed ADRs were of the type “gastrointestinal disorders” and “nervous system disorders”. Our results show great differences in PIs for drugs approved in both Denmark and the USA illuminating concerns about the credibility of the publicly available PIs. The results also represent an argument for further harmonization across borders to improve consistency between authority-supplied information.
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Affiliation(s)
- Robert Eriksson
- Department of Disease Systems Biology, NNF Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen Blegdamsvej 3B, DK-2200, Copenhagen, Denmark ; Center for Biological Sequence Analysis, Department of Systems Biology, Technical University of Denmark Kemitorvet, DK-2800, Lyngby, Denmark
| | - Lise Aagaard
- Institute of Public Health, Clinical Pharmacology, Faculty of Health Sciences, University of Southern Denmark J.B. Winsløws Vej 19, DK-5000, Odense, Denmark ; Danish Pharmacovigilance Research Project (DANPREP) Copenhagen, Denmark
| | - Lars Juhl Jensen
- Department of Disease Systems Biology, NNF Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen Blegdamsvej 3B, DK-2200, Copenhagen, Denmark
| | - Liza Borisova
- Danish Pharmacovigilance Research Project (DANPREP) Copenhagen, Denmark ; Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen Universitetsparken 2, DK-2100, Copenhagen, Denmark
| | - Dorte Hørlück
- Danish Pharmacovigilance Research Project (DANPREP) Copenhagen, Denmark ; Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen Universitetsparken 2, DK-2100, Copenhagen, Denmark
| | - Søren Brunak
- Department of Disease Systems Biology, NNF Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen Blegdamsvej 3B, DK-2200, Copenhagen, Denmark ; Center for Biological Sequence Analysis, Department of Systems Biology, Technical University of Denmark Kemitorvet, DK-2800, Lyngby, Denmark
| | - Ebba Holme Hansen
- Danish Pharmacovigilance Research Project (DANPREP) Copenhagen, Denmark ; Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen Universitetsparken 2, DK-2100, Copenhagen, Denmark
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Jefferson T, Jones MA, Doshi P, Del Mar CB, Hama R, Thompson MJ, Spencer EA, Onakpoya IJ, Mahtani KR, Nunan D, Howick J, Heneghan CJ. Neuraminidase inhibitors for preventing and treating influenza in adults and children. Cochrane Database Syst Rev 2014; 2014:CD008965. [PMID: 24718923 PMCID: PMC6464969 DOI: 10.1002/14651858.cd008965.pub4] [Citation(s) in RCA: 269] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Neuraminidase inhibitors (NIs) are stockpiled and recommended by public health agencies for treating and preventing seasonal and pandemic influenza. They are used clinically worldwide. OBJECTIVES To describe the potential benefits and harms of NIs for influenza in all age groups by reviewing all clinical study reports of published and unpublished randomised, placebo-controlled trials and regulatory comments. SEARCH METHODS We searched trial registries, electronic databases (to 22 July 2013) and regulatory archives, and corresponded with manufacturers to identify all trials. We also requested clinical study reports. We focused on the primary data sources of manufacturers but we checked that there were no published randomised controlled trials (RCTs) from non-manufacturer sources by running electronic searches in the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE (Ovid), EMBASE, Embase.com, PubMed (not MEDLINE), the Database of Reviews of Effects, the NHS Economic Evaluation Database and the Health Economic Evaluations Database. SELECTION CRITERIA Randomised, placebo-controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. DATA COLLECTION AND ANALYSIS We extracted clinical study reports and assessed risk of bias using purpose-built instruments. We analysed the effects of zanamivir and oseltamivir on time to first alleviation of symptoms, influenza outcomes, complications, hospitalisations and adverse events in the intention-to-treat (ITT) population. All trials were sponsored by the manufacturers. MAIN RESULTS We obtained 107 clinical study reports from the European Medicines Agency (EMA), GlaxoSmithKline and Roche. We accessed comments by the US Food and Drug Administration (FDA), EMA and Japanese regulator. We included 53 trials in Stage 1 (a judgement of appropriate study design) and 46 in Stage 2 (formal analysis), including 20 oseltamivir (9623 participants) and 26 zanamivir trials (14,628 participants). Inadequate reporting put most of the zanamivir studies and half of the oseltamivir studies at a high risk of selection bias. There were inadequate measures in place to protect 11 studies of oseltamivir from performance bias due to non-identical presentation of placebo. Attrition bias was high across the oseltamivir studies and there was also evidence of selective reporting for both the zanamivir and oseltamivir studies. The placebo interventions in both sets of trials may have contained active substances. Time to first symptom alleviation. For the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.8 hours (95% confidence interval (CI) 8.4 to 25.1 hours, P < 0.0001). This represents a reduction in the time to first alleviation of symptoms from 7 to 6.3 days. There was no effect in asthmatic children, but in otherwise healthy children there was (reduction by a mean difference of 29 hours, 95% CI 12 to 47 hours, P = 0.001). Zanamivir reduced the time to first alleviation of symptoms in adults by 0.60 days (95% CI 0.39 to 0.81 days, P < 0.00001), equating to a reduction in the mean duration of symptoms from 6.6 to 6.0 days. The effect in children was not significant. In subgroup analysis we found no evidence of a difference in treatment effect for zanamivir on time to first alleviation of symptoms in adults in the influenza-infected and non-influenza-infected subgroups (P = 0.53). Hospitalisations. Treatment of adults with oseltamivir had no significant effect on hospitalisations: risk difference (RD) 0.15% (95% CI -0.78 to 0.91). There was also no significant effect in children or in prophylaxis. Zanamivir hospitalisation data were unreported. Serious influenza complications or those leading to study withdrawal. In adult treatment trials, oseltamivir did not significantly reduce those complications classified as serious or those which led to study withdrawal (RD 0.07%, 95% CI -0.78 to 0.44), nor in child treatment trials; neither did zanamivir in the treatment of adults or in prophylaxis. There were insufficient events to compare this outcome for oseltamivir in prophylaxis or zanamivir in the treatment of children. Pneumonia. Oseltamivir significantly reduced self reported, investigator-mediated, unverified pneumonia (RD 1.00%, 95% CI 0.22 to 1.49); number needed to treat to benefit (NNTB) = 100 (95% CI 67 to 451) in the treated population. The effect was not significant in the five trials that used a more detailed diagnostic form for pneumonia. There were no definitions of pneumonia (or other complications) in any trial. No oseltamivir treatment studies reported effects on radiologically confirmed pneumonia. There was no significant effect on unverified pneumonia in children. There was no significant effect of zanamivir on either self reported or radiologically confirmed pneumonia. In prophylaxis, zanamivir significantly reduced the risk of self reported, investigator-mediated, unverified pneumonia in adults (RD 0.32%, 95% CI 0.09 to 0.41); NNTB = 311 (95% CI 244 to 1086), but not oseltamivir. Bronchitis, sinusitis and otitis media. Zanamivir significantly reduced the risk of bronchitis in adult treatment trials (RD 1.80%, 95% CI 0.65 to 2.80); NNTB = 56 (36 to 155), but not oseltamivir. Neither NI significantly reduced the risk of otitis media and sinusitis in both adults and children. Harms of treatment. Oseltamivir in the treatment of adults increased the risk of nausea (RD 3.66%, 95% CI 0.90 to 7.39); number needed to treat to harm (NNTH) = 28 (95% CI 14 to 112) and vomiting (RD 4.56%, 95% CI 2.39 to 7.58); NNTH = 22 (14 to 42). The proportion of participants with four-fold increases in antibody titre was significantly lower in the treated group compared to the control group (RR 0.92, 95% CI 0.86 to 0.97, I(2) statistic = 0%) (5% absolute difference between arms). Oseltamivir significantly decreased the risk of diarrhoea (RD 2.33%, 95% CI 0.14 to 3.81); NNTB = 43 (95% CI 27 to 709) and cardiac events (RD 0.68%, 95% CI 0.04 to 1.0); NNTB = 148 (101 to 2509) compared to placebo during the on-treatment period. There was a dose-response effect on psychiatric events in the two oseltamivir "pivotal" treatment trials, WV15670 and WV15671, at 150 mg (standard dose) and 300 mg daily (high dose) (P = 0.038). In the treatment of children, oseltamivir induced vomiting (RD 5.34%, 95% CI 1.75 to 10.29); NNTH = 19 (95% CI 10 to 57). There was a significantly lower proportion of children on oseltamivir with a four-fold increase in antibodies (RR 0.90, 95% CI 0.80 to 1.00, I(2) = 0%). Prophylaxis. In prophylaxis trials, oseltamivir and zanamivir reduced the risk of symptomatic influenza in individuals (oseltamivir: RD 3.05% (95% CI 1.83 to 3.88); NNTB = 33 (26 to 55); zanamivir: RD 1.98% (95% CI 0.98 to 2.54); NNTB = 51 (40 to 103)) and in households (oseltamivir: RD 13.6% (95% CI 9.52 to 15.47); NNTB = 7 (6 to 11); zanamivir: RD 14.84% (95% CI 12.18 to 16.55); NNTB = 7 (7 to 9)). There was no significant effect on asymptomatic influenza (oseltamivir: RR 1.14 (95% CI 0.39 to 3.33); zanamivir: RR 0.97 (95% CI 0.76 to 1.24)). Non-influenza, influenza-like illness could not be assessed due to data not being fully reported. In oseltamivir prophylaxis studies, psychiatric adverse events were increased in the combined on- and off-treatment periods (RD 1.06%, 95% CI 0.07 to 2.76); NNTH = 94 (95% CI 36 to 1538) in the study treatment population. Oseltamivir increased the risk of headaches whilst on treatment (RD 3.15%, 95% CI 0.88 to 5.78); NNTH = 32 (95% CI 18 to 115), renal events whilst on treatment (RD 0.67%, 95% CI -2.93 to 0.01); NNTH = 150 (NNTH 35 to NNTB > 1000) and nausea whilst on treatment (RD 4.15%, 95% CI 0.86 to 9.51); NNTH = 25 (95% CI 11 to 116). AUTHORS' CONCLUSIONS Oseltamivir and zanamivir have small, non-specific effects on reducing the time to alleviation of influenza symptoms in adults, but not in asthmatic children. Using either drug as prophylaxis reduces the risk of developing symptomatic influenza. Treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced, because of a lack of diagnostic definitions. The use of oseltamivir increases the risk of adverse effects, such as nausea, vomiting, psychiatric effects and renal events in adults and vomiting in children. The lower bioavailability may explain the lower toxicity of zanamivir compared to oseltamivir. The balance between benefits and harms should be considered when making decisions about use of both NIs for either the prophylaxis or treatment of influenza. The influenza virus-specific mechanism of action proposed by the producers does not fit the clinical evidence.
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Affiliation(s)
- Tom Jefferson
- University of OxfordCentre for Evidence Based MedicineOxfordUKOX2 6GG
| | - Mark A Jones
- The University of QueenslandSchool of Public HealthPublic Health BuildingHerston RoadBrisbaneQueenslandAustralia4006
| | - Peter Doshi
- University of Maryland School of PharmacyDepartment of Pharmaceutical Health Services Research220 Arch Street, 12th floor, Room 01‐228BaltimoreMarylandUSA21201
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)University DriveGold CoastQueenslandAustralia4229
| | - Rokuro Hama
- Japan Institute of Pharmacovigilance902 Ueshio 3‐2‐17OsakaJapan543‐0002
| | - Matthew J Thompson
- University of WashingtonDepartment of Family MedicineBox 354696SeattleWAUSA98195‐4696
| | - Elizabeth A Spencer
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterOxfordOxfordshireUKOX2 6GG
| | - Igho J Onakpoya
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterOxfordOxfordshireUKOX2 6GG
| | - Kamal R Mahtani
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterOxfordOxfordshireUKOX2 6GG
| | - David Nunan
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterOxfordOxfordshireUKOX2 6GG
| | - Jeremy Howick
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterOxfordOxfordshireUKOX2 6GG
| | - Carl J Heneghan
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterOxfordOxfordshireUKOX2 6GG
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Abstract
BACKGROUND Health Canada's Summary Basis of Decision (SBD) documents outline the clinical trial information that was considered in approving a new drug. We examined the ability of SBDs to inform clinician decision-making. We asked if SBDs answered three questions that clinicians might have prior to prescribing a new drug: 1) Do the characteristics of patients enrolled in trials match those of patients in their practice? 2) What are the details concerning the drug's risks and benefits? 3) What are the basic characteristics of trials? METHODS 14 items of clinical trial information were identified from all SBDs published on or before April 2012. Each item received a score of 2 (present), 1 (unclear) or 0 (absent). The unit of analysis was the individual SBD, and an overall SBD score was derived based on the sum of points for each item. Scores were expressed as a percentage of the maximum possible points, and then classified into five descriptive categories based on that score. Additionally, three overall 'component' scores were tallied for each SBD: "patient characteristics", "benefit/risk information" and "basic trial characteristics". RESULTS 161 documents, spanning 456 trials, were analyzed. The majority (126/161) were rated as having information sometimes present (score of >33 to 66%). No SBDs had either no information on any item, or 100% of the information. Items in the patient characteristics component scored poorest (mean component score of 40.4%), while items corresponding to basic trial information were most frequently provided (mean component score of 71%). CONCLUSION The significant omissions in the level of clinical trial information in SBDs provide little to aid clinicians in their decision-making. Clinicians' preferred source of information is scientific knowledge, but in Canada, access to such information is limited. Consequently, we believe that clinicians are being denied crucial tools for decision-making.
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Affiliation(s)
- Roojin Habibi
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Joel Lexchin
- School of Health Policy and Management, York University, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Doyle M. The potential value of discordant studies. Cardiovasc Diagn Ther 2014; 4:1-4. [PMID: 24649418 DOI: 10.3978/j.issn.2223-3652.2014.02.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 02/19/2014] [Indexed: 11/14/2022]
Abstract
Many aspects of the clinical application of gated-single photon emission computed tomography (SPECT) have been well established by multiple trials and studies. However, its utility in the elderly (i.e., the Medicare population in the USA) remains unclear. This is an important population due to its rapid growth, coupled with the increasing prevalence of coronary artery disease with age. A paper in this issue, Predictive value of exercise myocardial perfusion imaging in the Medicare population: the impact of the ability to exercise, indicates that while gated-SPECT clearly directs the performance of interventions at the level of the coronary arteries in the elderly, outcomes are worse for those receiving an intervention vs. those receiving medical therapy. While some literature supports this observation, there are also well documented studies that indicate that the opposite is the case. As consumers of discordant studies, we find ourselves in the unenviable position of having to pull at the threads of evidence and follow them through in an attempt to reconcile the conflicting literature. This is reminiscent of the mythical Gregorian knot, a knot that was impossible to unravel by conventional means. However, it was "solved" by cutting it with a sword. In our case, the sword that we have is the removal of bias. It has been said that there are no unbiased studies, since we only measure what we believe and we tend to believe what we measure. This is further compounded in clinical practice since the Hippocratic Oath requires that the physician above all do no harm. Therefore it follows that whatever action is done is at least not detrimental to the patient. These are powerful belief systems that on the one hand allow us to rapidly discard "irrelevant" information and quickly get to the important point, but on the other hand they may inhibit us from seeing what is truly of value. Discordant and negative studies are important disruptors along the path to easy data assimilation, and force us to seek out sources of bias which otherwise may go unnoted. In the case of the above paper we might look past the perfusion data to the more important cardiac functional data which may contribute to changing the focus of diagnosis and treatment strategies, thus slicing through a little more of the knot.
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Affiliation(s)
- Mark Doyle
- Allegheny Health Network, Pittsburgh, PA, USA
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Abstract
The methods and results of health research are documented in study protocols, full study reports (detailing all analyses), journal reports, and participant-level datasets. However, protocols, full study reports, and participant-level datasets are rarely available, and journal reports are available for only half of all studies and are plagued by selective reporting of methods and results. Furthermore, information provided in study protocols and reports varies in quality and is often incomplete. When full information about studies is inaccessible, billions of dollars in investment are wasted, bias is introduced, and research and care of patients are detrimentally affected. To help to improve this situation at a systemic level, three main actions are warranted. First, academic institutions and funders should reward investigators who fully disseminate their research protocols, reports, and participant-level datasets. Second, standards for the content of protocols and full study reports and for data sharing practices should be rigorously developed and adopted for all types of health research. Finally, journals, funders, sponsors, research ethics committees, regulators, and legislators should endorse and enforce policies supporting study registration and wide availability of journal reports, full study reports, and participant-level datasets.
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Affiliation(s)
- An-Wen Chan
- Women's College Research Institute, Department of Medicine, Women's College Hospital, University of Toronto, Toronto, ON, Canada.
| | - Fujian Song
- Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Norwich, UK
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | - Kay Dickersin
- Center for Clinical Trials, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Harlan M Krumholz
- Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA; Department of Health Policy and Management, Yale School of Public Health, Yale University, New Haven, CT, USA; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Davina Ghersi
- Research Translation Branch, National Health and Medical Research Council, Canberra, ACT, Australia
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
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Wieseler B, Wolfram N, McGauran N, Kerekes MF, Vervölgyi V, Kohlepp P, Kamphuis M, Grouven U. Completeness of reporting of patient-relevant clinical trial outcomes: comparison of unpublished clinical study reports with publicly available data. PLoS Med 2013; 10:e1001526. [PMID: 24115912 PMCID: PMC3793003 DOI: 10.1371/journal.pmed.1001526] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 08/29/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Access to unpublished clinical study reports (CSRs) is currently being discussed as a means to allow unbiased evaluation of clinical research. The Institute for Quality and Efficiency in Health Care (IQWiG) routinely requests CSRs from manufacturers for its drug assessments. Our objective was to determine the information gain from CSRs compared to publicly available sources (journal publications and registry reports) for patient-relevant outcomes included in IQWiG health technology assessments (HTAs) of drugs. METHODS AND FINDINGS We used a sample of 101 trials with full CSRs received for 16 HTAs of drugs completed by IQWiG between 15 January 2006 and 14 February 2011, and analyzed the CSRs and the publicly available sources of these trials. For each document type we assessed the completeness of information on all patient-relevant outcomes included in the HTAs (benefit outcomes, e.g., mortality, symptoms, and health-related quality of life; harm outcomes, e.g., adverse events). We dichotomized the outcomes as "completely reported" or "incompletely reported." For each document type, we calculated the proportion of outcomes with complete information per outcome category and overall. We analyzed 101 trials with CSRs; 86 had at least one publicly available source, 65 at least one journal publication, and 50 a registry report. The trials included 1,080 patient-relevant outcomes. The CSRs provided complete information on a considerably higher proportion of outcomes (86%) than the combined publicly available sources (39%). With the exception of health-related quality of life (57%), CSRs provided complete information on 78% to 100% of the various benefit outcomes (combined publicly available sources: 20% to 53%). CSRs also provided considerably more information on harms. The differences in completeness of information for patient-relevant outcomes between CSRs and journal publications or registry reports (or a combination of both) were statistically significant for all types of outcomes. The main limitation of our study is that our sample is not representative because only CSRs provided voluntarily by pharmaceutical companies upon request could be assessed. In addition, the sample covered only a limited number of therapeutic areas and was restricted to randomized controlled trials investigating drugs. CONCLUSIONS In contrast to CSRs, publicly available sources provide insufficient information on patient-relevant outcomes of clinical trials. CSRs should therefore be made publicly available. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Beate Wieseler
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
- * E-mail:
| | - Natalia Wolfram
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Natalie McGauran
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | | | - Volker Vervölgyi
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Petra Kohlepp
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Marloes Kamphuis
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
| | - Ulrich Grouven
- Institute for Quality and Efficiency in Health Care, Cologne, Germany
- Hanover Medical School, Hanover, Germany
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Abstract
Publication bias undermines the integrity of the evidence base by inflating apparent drug efficacy and minimizing drug harms, thus skewing the risk-benefit ratio. This paper reviews the topic of publication bias with a focus on drugs prescribed for psychiatric conditions, especially depression, schizophrenia, bipolar disorder, and autism. Publication bias is pervasive; although psychiatry/psychology may be the most seriously afflicted field, it occurs throughout medicine and science. Responsibility lies with various parties (authors as well as journals, academia as well as industry), so the motives appear to extend beyond the financial interests of drug companies. The desire for success, in combination with cognitive biases, can also influence academic authors and journals. Amid the flood of new medical information coming out each day, the attention of the news media and academic community is more likely to be captured by studies whose results are positive or newsworthy. In the peer review system, a fundamental flaw arises from the fact that authors usually write manuscripts after they know the results. This allows hindsight and other biases to come into play, so data can be "tortured until they confess" (a detailed example is given). If a "publishable" result cannot be achieved, non-publication remains an option. To address publication bias, various measures have been undertaken, including registries of clinical trials. Drug regulatory agencies can provide valuable unpublished data. It is suggested that journals borrow from the FDA review model. Because the significance of study results biases reviewers, results should be excluded from review until after a preliminary judgment of study scientific quality has been rendered, based on the original study protocol. Protocol publication can further enhance the credibility of the published literature.
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Affiliation(s)
- Erick H Turner
- Behavioral Health and Neurosciences Division, Portland Veterans Affairs Medical Center, P3MHDC, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA.
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Abstract
BACKGROUND Authors of systematic reviews have difficulty obtaining unpublished data for their reviews. This project aimed to provide an in-depth description of the experiences of authors in searching for and gaining access to unpublished data for their systematic reviews, and to give guidance on best practices for identifying, obtaining and using unpublished data. METHODS This is a qualitative study analyzing in-depth interviews with authors of systematic reviews who have published Cochrane reviews or published systematic reviews outside of The Cochrane Library. We included participants who 1) were the first or senior author of a published systematic review of a drug intervention, 2) had expertise in conducting systematic reviews, searching for data, and assessing methodological biases, and 3) were able to participate in an interview in English. We used non-random sampling techniques to identify potential participants. Eighteen Cochrane authors were contacted and 16 agreed to be interviewed (89% response rate). Twenty-four non-Cochrane authors were contacted and 16 were interviewed (67% response rate). RESULTS Respondents had different understandings of what was meant by unpublished data, including specific outcomes and methodological details. Contacting study authors was the most common method used to obtain unpublished data and the value of regulatory agencies as a data source was underappreciated. Using the data obtained was time consuming and labor intensive. Respondents described the collaboration with other colleagues and/or students required to organize, manage and use the data in their reviews, generally developing and using templates, spreadsheets and computer programs for data extraction and analysis. Respondents had a shared belief that data should be accessible but some had concerns about sharing their own data. Respondents believed that obtaining unpublished data for reviews has important public health implications. There was widespread support for government intervention to ensure open access to trial data. CONCLUSIONS Respondents uniformly agreed that the benefit of identifying unpublished data was worth the effort and was necessary to identify the true harms and benefits of drugs. Recent actions by government, such as increased availability of trial data from the European Medicines Agency, may make it easier to acquire critical drug trial data.
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Affiliation(s)
- Nicole Wolfe
- Department of Social and Behavioral Sciences, University of California, San Francisco, CA 94118, USA
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Abstract
OBJECTIVE To describe the experiences of authors of Cochrane reviews in searching for, getting access to, and using unpublished data. DESIGN Cross sectional study. SETTING Cochrane reviews. PARTICIPANTS 2184 corresponding authors of Cochrane reviews as of May 2012. MAIN OUTCOME MEASURE Frequencies of responses to open ended and closed questions in an online survey. RESULTS Of 5915 authors contacted by email, 2184 replied (36.9% response rate). Of those, 1656 (75.8%) had searched for unpublished data. In 913 cases (55.1% of 1656), new data were obtained and we received details about these data for 794 data sources. The most common data source was "trialists/investigators," accounting for 73.9% (n=587) of the 794 data sources. Most of the data were used in the review (82.0%, 651/794) and in 53.4% (424/794) of cases data were provided in less than a month. Summary data were most common, provided by 50.8% (403/794) of the data sources, whereas 20.5% (163/794) provided individual patient data. In only 6.3% (50/794) of cases were data reported to have been obtained from the manufacturers, and this group waited longer and had to make more contacts to get the data. The data from manufacturers were less likely to be for individual patients and less likely to be used in the review. Data from regulatory agencies accounted for 3.0% (24/794) of the obtained data. CONCLUSIONS Most authors of Cochrane reviews who searched for unpublished data received useful information, primarily from trialists. Our response rate was low and the authors who did not respond were probably less likely to have searched for unpublished data. Manufacturers and regulatory agencies were uncommon sources of unpublished data.
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Affiliation(s)
- Jeppe Bennekou Schroll
- The Nordic Cochrane Centre, Rigshospitalet, Dept 7810, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark.
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Chan AW, Tetzlaff JM, Gøtzsche PC, Altman DG, Mann H, Berlin JA, Dickersin K, Hróbjartsson A, Schulz KF, Parulekar WR, Krleza-Jeric K, Laupacis A, Moher D. SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials. BMJ 2013; 346:e7586. [PMID: 23303884 PMCID: PMC3541470 DOI: 10.1136/bmj.e7586] [Citation(s) in RCA: 3152] [Impact Index Per Article: 286.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2012] [Indexed: 02/06/2023]
Abstract
High quality protocols facilitate proper conduct, reporting, and external review of clinical trials. However, the completeness of trial protocols is often inadequate. To help improve the content and quality of protocols, an international group of stakeholders developed the SPIRIT 2013 Statement (Standard Protocol Items: Recommendations for Interventional Trials). The SPIRIT Statement provides guidance in the form of a checklist of recommended items to include in a clinical trial protocol. This SPIRIT 2013 Explanation and Elaboration paper provides important information to promote full understanding of the checklist recommendations. For each checklist item, we provide a rationale and detailed description; a model example from an actual protocol; and relevant references supporting its importance. We strongly recommend that this explanatory paper be used in conjunction with the SPIRIT Statement. A website of resources is also available (www.spirit-statement.org). The SPIRIT 2013 Explanation and Elaboration paper, together with the Statement, should help with the drafting of trial protocols. Complete documentation of key trial elements can facilitate transparency and protocol review for the benefit of all stakeholders.
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Affiliation(s)
- An-Wen Chan
- Women's College Research Institute at Women's College Hospital, Department of Medicine, University of Toronto, Toronto, Canada M5G 1N8
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Abstract
OBJECTIVE To explore the structure and content of a non-random sample of clinical study reports (CSRs) to guide clinicians and systematic reviewers. SEARCH STRATEGY We searched public sources and lodged Freedom of Information requests for previously confidential CSRs primarily written by the industry for regulators. SELECTION CRITERIA CSRs reporting sufficient information for extraction ('adequate'). PRIMARY OUTCOME MEASURES Presence and length of essential elements of trial design and reporting and compression factor (ratio of page length for CSRs compared to its published counterpart in a scientific journal). DATA EXTRACTION Data were extracted on standard forms and crosschecked for accuracy. RESULTS We assembled a population of 78 CSRs (covering 90 randomised controlled trials; 144 610 pages total) dated 1991-2011 of 14 pharmaceuticals. Report synopses had a median length of 5 pages, efficacy evaluation 13.5 pages, safety evaluation 17 pages, attached tables 337 pages, trial protocol 62 pages, statistical analysis plan 15 pages and individual efficacy and safety listings had a median length of 447 and 109.5 pages, respectively. While 16 (21%) of CSRs contained completed case report forms, these were accessible to us in only one case (765 pages representing 16 individuals). Compression factors ranged between 1 and 8805. CONCLUSIONS Clinical study reports represent a hitherto mostly hidden and untapped source of detailed and exhaustive data on each trial. They should be consulted by independent parties interested in a detailed record of a clinical trial, and should form the basic unit for evidence synthesis as their use is likely to minimise the problem of reporting bias. We cannot say whether our sample is representative and whether our conclusions are generalisable to an undefined and undefinable population of CSRs.
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Affiliation(s)
- Peter Doshi
- Divisions of General Pediatrics and General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
OBJECTIVE To investigate clinical trialists' opinions and experiences of sharing of clinical trial data with investigators who are not directly collaborating with the research team. DESIGN AND SETTING Cross sectional, web based survey. PARTICIPANTS Clinical trialists who were corresponding authors of clinical trials published in 2010 or 2011 in one of six general medical journals with the highest impact factor in 2011. MAIN OUTCOME MEASURES Support for and prevalence of data sharing through data repositories and in response to individual requests, concerns with data sharing through repositories, and reasons for granting or denying requests. RESULTS Of 683 potential respondents, 317 completed the survey (response rate 46%). In principle, 236 (74%) thought that sharing de-identified data through data repositories should be required, and 229 (72%) thought that investigators should be required to share de-identified data in response to individual requests. In practice, only 56 (18%) indicated that they were required by the trial funder to deposit the trial data in a repository; of these 32 (57%) had done so. In all, 149 respondents (47%) had received an individual request to share their clinical trial data; of these, 115 (77%) had granted and 56 (38%) had denied at least one request. Respondents' most common concerns about data sharing were related to appropriate data use, investigator or funder interests, and protection of research subjects. CONCLUSIONS We found strong support for sharing clinical trial data among corresponding authors of recently published trials in high impact general medical journals who responded to our survey, including a willingness to share data, although several practical concerns were identified.
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Affiliation(s)
- Vinay Rathi
- Yale University School of Medicine, New Haven, CT 0520, USA
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Wieseler B, McGauran N, Kerekes MF, Kaiser T. Access to regulatory data from the European Medicines Agency: the times they are a-changing. Syst Rev 2012; 1:50. [PMID: 23110993 PMCID: PMC3495027 DOI: 10.1186/2046-4053-1-50] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 10/29/2012] [Indexed: 11/13/2022] Open
Abstract
Systematic reviewers are increasingly trying to obtain regulatory clinical study reports (CSRs) to correct for publication bias. For instance, our organization, the Institute for Quality and Efficiency in Health Care, routinely asks drug manufacturers to provide full CSRs of studies considered in health technology assessments. However, since cooperation is voluntary, CSRs are available only for a subset of studies analysed. In the case of the inhaled insulin Exubera, the manufacturer refused to cooperate and in 2007 we asked the European Medicines Agency (EMA) to provide the relevant CSRs, but EMA denied access. Other researchers have reported similar experiences.In 2010 EMA introduced a new policy on access to regulatory documents, including CSRs, and has also undertaken further steps. The new policy has already borne fruit: in 2011, by providing additional sections of relevant CSRs, EMA made an important contribution to a review of oseltamivir (Tamiflu).Unfortunately, speedy implementation of the new policy may be endangered. We define a CSR following the International Conference on Harmonisation (ICH) E3 guideline. Although this guideline requires individual patient data listings, it does not necessarily require that these listings be made available in a computer-readable format, as proposed by some regulators from EMA and other agencies. However, access to raw data in a computer-readable format poses additional problems; merging this issue with that of access to CSRs could hamper the relatively simple implementation of the EMA policy. Moreover, EMA plans to release CSRs only on request; we suggest making these documents routinely available on the EMA website.Public access to regulatory data also carries potential risks. In our view, the issue of patient confidentiality has been largely resolved by current European legislation. The risk of other problems, such as conflicts of interest (CoIs) of independent researchers or quality issues can be reduced by transparency measures, such as the implementation of processes to evaluate CoIs and the publication of methods and protocols.In conclusion, regulatory data are an indispensable source for systematic reviews. Because of EMA's policy change, a milestone for data transparency in clinical research is within reach; let's hope it is not unnecessarily delayed.
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Affiliation(s)
- Beate Wieseler
- Institute for Quality and Efficiency in Health Care, Im Mediapark 8 (KölnTurm), Cologne, 50670, Germany.
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