Science-Based Approach to Harmonize Contraception Recommendations in Clinical Trials and Pharmaceutical Labels

This review presents a European Federation of Pharmaceutical Industries and Association/PreClinical Development Expert Group (EFPIA-PDEG) topic group consensus on a data-driven approach to harmonized contraception recommendations for clinical trial protocols and product labeling. There is no international agreement in pharmaceutical clinical trial protocols or product labeling on when/if female and/or male contraception is warranted and for how long after the last dose. This absence of consensus has resulted in different recommendations among regions. For most pharmaceuticals, contraception recommendations are generally based exclusively on nonclinical data and/or mechanism. For clinical trials, contraception is the default position and is maintained for women throughout clinical development, whereas appropriate information can justify removing male contraception. Conversely, contraception is only recommended in product labeling when warranted. A base case rationale is proposed for whether or not female and/or male contraception is/are warranted, using available genotoxicity and developmental toxicity data. Contraception is generally warranted for both male and female subjects treated with mutagenic pharmaceuticals. We propose as a starting point that contraception is not typically warranted when the margin is 10-fold or greater between clinical exposure at the maximum recommended human dose and exposure at the no observed adverse effect level (NOAEL) for purely aneugenic pharmaceuticals and for pharmaceuticals that induce fetal malformations or embryo-fetal lethality. Other factors are discussed, including contraception methods, pregnancy testing, drug clearance, options for managing the absence of a developmental toxicity NOAEL, drug-drug interactions, radiopharmaceuticals, and other drug modalities. Overall, we present a data-driven rationale that can serve as a basis for consistent contraception recommendations in clinical trials and in product labeling across regions.

Retinal Optical Coherence Tomography Metrics Are Unchanged in Verubecestat Alzheimer's Disease Clinical Trial but Correlate with Baseline Regional Brain Atrophy

BACKGROUND

We performed exploratory analyses of retinal thickness data from a clinical trial of the AβPP cleaving enzyme (BACE) inhibitor verubecestat in patients with Alzheimer's disease (AD).

OBJECTIVE

To evaluate: 1) possible retinal thickness changes following BACE inhibition; and 2) possible association between retinal thickness and brain atrophy.

METHODS

Retinal thickness was measured using spectral-domain optical coherence tomography in a 78-week randomized placebo-controlled trial of verubecestat in 1,785 patients with mild-to-moderate AD. Changes from baseline in retinal pigment epithelium, macular grid retinal nerve fiber layer, central subfield retinal thickness, and macular grid volume were evaluated for verubecestat versus placebo. Correlation analyses were performed to investigate the potential association between macular grid retinal nerve fiber layer and central subfield retinal thickness with brain volumetric magnetic resonance imaging (vMRI) data at baseline, as well as correlations for changes from baseline at Week 78 in patients receiving placebo.

RESULTS

Verubecestat did not significantly alter retinal thickness during the trial compared with placebo. At baseline, mean macular grid retinal nerve fiber layer and central subfield retinal thickness were weakly but significantly correlated (Pearson's r values≤0.23, p-values < 0.01) with vMRI of several brain regions including whole brain, hippocampus, and thalamus. At Week 78, correlations between retinal thickness and brain vMRI changes from baseline in the placebo group were small and mostly not statistically significant.

CONCLUSION

BACE inhibition by verubecestat was not associated with adverse effects on retinal thickness in patients with mild-to-moderate AD. Correlations between retinal thickness and brain volume were observed at baseline.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01739348 (registered December 3, 2012; https://clinicaltrials.gov/ct2/show/NCT01739348).

Development of aprepitant, the first neurokinin-1 receptor antagonist for the prevention of chemotherapy-induced nausea and vomiting

Chemotherapy can be a life-prolonging treatment for many cancer patients, but it is often associated with profound nausea and vomiting that is so distressing that patients may delay or decline treatment to avoid these side effects. EMEND (aprepitant) is the first and only neurokinin-1 (NK-1) receptor antagonist available on the market for the prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV). Aprepitant acts centrally at NK-1 receptors in vomiting centers within the central nervous system to block their activation by substance P released as an unwanted consequence of chemotherapy. By controlling nausea and vomiting, EMEND helps improve patients' daily living and their ability to complete multiple cycles of chemotherapy. The development of aprepitant included a novel nanoparticle formulation to optimize oral absorption and innovative chemistry to discover a prodrug form suitable for intravenous administration to improve compliance and convenience for healthcare professionals and cancer patients.

Health, attitude to care and pattern of attendance among gypsy women-a general practice perspective

BACKGROUND

There is a lack of knowledge about health and attitude to care among gypsies.

OBJECTIVES

The aim of this study was to explore the reasons for and patterns of attendance among gypsy women in primary health care and to shed light on health problems of gypsies.

METHODS

Four gypsy women, frequently attending a primary health care centre, were interviewed in depth. Data were analysed according to grounded theory. Additional facts were received from record files.

RESULTS AND CONCLUSIONS

The gypsy women seldom approached the health centre alone but paid a visit together with relatives or friends. The women usually presented the same type of symptoms, often pain, headache and depression, and obtained the same type of diagnosis and treatment. The symptoms had an acute character and the women wanted immediate access. A collective pattern, a hierarchical order and a strict rule system characterized the gypsy life and coloured the relation to health and illness. Young women were especially vulnerable and could easily end up outside the collective and display symptoms.

Effects of porcine growth hormone on pregnancy and fetal/neonatal development in the rat

Porcine growth hormone was given subcutaneously twice daily to two groups of 20 females at dose levels of 0.5 and 2.5 IU/kg (1 and 5 IU/kg/day). A control group of 20 females was similarly treated with vehicle. The females were given either vehicle or porcine growth hormone from gestation day (GD) 6 through GD 21, for 10 females that were cesarean sectioned, or through lactation day (LD) 21, for 10 females scheduled for natural delivery. There were no deaths, abortions, or drug-related physical signs in any treatment group. Drug-related effects during gestation were limited to significant (p < or = 0.05) pharmacologically mediated increases in F0 maternal body weight gain during GD 6-20 in the 2.5-IU/kg group, approximately 24% above controls. During LD 0-21, there were significant (p < or = 0.05) dose-related increases in average maternal body weight gain in the 0.5- and 2.5IU/kg groups (72 and 200% above controls, respectively). Consistent with these findings, there were dose-dependent increases in maternal serum growth hormone and IGF-1 levels noted on GD 21 and LD 21 in both drug-treated groups. There were no drug-related effects on embryonal/fetal survival, GD 21 fetal body weight, placental weight, fetal femur length and width, or fetal morphology as determined by external, visceral, and skeletal examinations. There were no drug-related effects on F1 pup mortality, physical signs, body weight, biparietal diameter, liver weight, and femur length or width. These data suggest that subcutaneous administration of growth hormone to pregnant and lactating rats, at a dose that produces significant (p < or = 0.05) increases in maternal body weight gain and serum IGF-1 levels, has no apparent effect on embryonal/fetal development or preweaning growth.

Cost-utility analysis of group living in dementia care

A cost-utility analysis (CUA) was applied to group living for dementia patients. A Markov-model of an expected life-length of 8 years was used. Forty-six patients in group living were compared to 39 patients living at home by inclusion and 23 institutionalized patients. When the cost per gained quality-adjusted life-year (QALY) was calculated, the group living alternative was the most favorable for the patients, giving a cost per paired QALY of US dollars < 0. In the extensive sensitivity analysis the main result was consistent but methodological problems were indicated.

Predictive validity of factors influencing the institutionalization of elderly people with psycho-geriatric disorders

The predictive validity of certain items was tested with respect to their influence on the institutionalization of elderly people with psycho-geriatric disorders (n = 69). Twelve items measuring both the patient's condition and the exhaustion around the patient were tested. Two outcome measurements were used, the first measuring the number of patients who were institutionalized after the end of 12 months and the second measuring the number of days at an institution during 12 months. The items "Exhaustion of spouse" and "Supervision need" showed the highest correlation with institutionalization and predicted institutionalization, better than items describing the degree of dementia.

Qualitative research and family practice: a marriage made in heaven?

Recent years have seen the development of interest in the usefulness of qualitative methods in family practice research. This paper shows how the underlying concerns of family practice medicine parallel those of the qualitative research tradition. After contrasting the philosophical underpinnings of both quantitative and qualitative methods, we go on to describe the methodological commitments of qualitative research. We relate this emerging debate within family practice to that which has taken place in other disciplines, particularly that of education. We discuss the relative strengths of qualitative and quantitative methods, and argue that these two traditions have complementary contributions to make to the discipline of family practice medicine.

Malignant melanoma: aetiological importance of individual pigmentation and sun exposure

A case-control study of cutaneous malignant melanoma (CMM) was based on 523 incident cases and 505 age- and sex-matched controls selected from the general population. The purpose was to investigate the relative risk of developing CMM associated with different sun habits and indicators of pigmentation, such as skin type, eye colour and hair colour. Compared to people with black hair, blonde subjects had a relative risk of 74.4 (95% confidence interval, 45.8-120.8). Associations with skin type and eye colour were considerably weaker. Relative risks of about 1.5-2.5 were found for certain sun habits. The results suggest that in a population of Caucasian origin with a predominantly fair complexion, pigmentary status characterized by hair colour is a far more important aetiological factor than sun habits.

Tumor induction by 4-(methyl)benzenediazonium sulfate in mice

4-(Methyl)benzenediazonium sulfate (MBD) was administered to Swiss mice by subcutaneous injection at weekly intervals 19 or 16 times at 50 micrograms/g body weight. The treatment gave rise to tumors of the subcutaneous tissue and skin. The tumor incidences in the groups with 19 injections were 12 and 6% in females and 12 and 4% in males, respectively, while in the group with 16 injections were 24 and 14% in females and 50 and 4% in males, respectively. The corresponding tumor incidences in the untreated controls were 2 and 2% in females and 8 and 2% in males, respectively. Histopathologically, the tumors were classified as fibromas, fibrosarcomas, myxosarcomas, fibromyxosarcomas, rhabdomyosarcomas and angiosarcomas in subcutis and squamous cell papillomas and carcinomas of skin. MBD is closely related to 4-(hydroxymethyl)benzenediazonium ion (HMBD), an ingredient of the cultivated mushroom Agaricus bisporus. The conversion of HMBD to MBD appears to be a distinct possibility.