1
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Daems S, Stevens H, Dewatripont M, Eichler HG, Goldman M. A novel approach to boost drug development in paediatric oncology. Nat Rev Drug Discov 2023; 22:769-770. [PMID: 37607983 DOI: 10.1038/d41573-023-00136-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
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2
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Hogervorst M, Vreman R, Heikkinen I, Bagchi I, Gutierrez-Ibarluzea I, Ryll B, Eichler HG, Petelos E, Tunis S, Sapede C, Goettsch W, Janssens R, Huys I, Barbier L, DeJean D, Strammiello V, Lingri D, Goodall M, Papadaki M, Toussi M, Voulgaraki D, Mitan A, Oortwijn W. UNCERTAINTY MANAGEMENT IN REGULATORY AND HEALTH TECHNOLOGY ASSESSMENT DECISION-MAKING ON DRUGS: GUIDANCE OF THE HTAi-DIA WORKING GROUP. Int J Technol Assess Health Care 2023:1-25. [PMID: 37325997 DOI: 10.1017/s0266462323000375] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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3
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Cavaller-Bellaubi M, Hughes-Wilson W, Kubinová Š, Van de Casteele M, Van Lente EJ, Degortes E, Pontén J, Eichler HG, Le Cam Y, Boselli S, Bucsics A. Patients, payers and developers of Orphan Medicinal Products: lessons learned from 10 years' multi-stakeholder dialogue on improving access in Europe via MoCA. Orphanet J Rare Dis 2023; 18:144. [PMID: 37308991 DOI: 10.1186/s13023-023-02774-7] [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] [Received: 03/16/2023] [Accepted: 06/04/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND The Mechanism of Coordinated Access to Orphan Medicinal Products (MoCA) was established in 2013 with the intention of developing a coordinated mechanism between volunteering EU stakeholders and developers of Orphan Medicinal Products (OMPs) to support the exchange of information aimed at enabling informed decisions on pricing and reimbursement at Member State level and to evaluate the value of an OMP based on a Transparent Value Framework. The objective of the collaborative approach was to support more equitable access to authorised therapies for people living with rare diseases, rational prices for payers and more predictable market conditions for OMP developers. Over the past 10 years, the MoCA has conducted a series of pilot projects, examining a variety of different products and technologies at different stages of development; and with contributions from a variety of patient representatives, participation from EU payers from a range of Member States and, recently, with EUnetHTA members and the European Medicines Agency participating in the meetings as observers. RESULTS 10 years on from the establishment of the MoCA, the European landscape has significantly evolved, not only in the field of drug development with increasingly transformative therapies based on novel technologies, but also in terms of larger numbers of approved treatments, increased budget impact and the resulting associated uncertainties; as well as in terms of stakeholder collaboration and interactions. The value of early dialogue with OMP developers, including the EU payer community via their national decision-making authorities, is a key element within this early interaction and contributes to identifying, managing and reducing uncertainties allowing a prospectively planned approach earlier in development and, consequently, to support more timely, sustainable and equitable access to new OMPs, particularly where there is a high unmet medical need. CONCLUSIONS The voluntary, informal nature of the MoCA interactions creates a flexible framework for non-binding dialogue. A forum for such interactions is needed to achieve the aims of the MoCA and both to support healthcare systems in planning as well as to underpin timely, equitable and sustainable access to new therapies for patients with rare diseases within the EU.
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Affiliation(s)
- Maria Cavaller-Bellaubi
- EURORDIS - Rare Diseases Europe, Paris, France.
- MoCA Steering Committee Members, Brussels, Belgium.
| | - Wills Hughes-Wilson
- Mereo BioPharma Plc, London, United Kingdom
- MoCA Steering Committee Members, Brussels, Belgium
| | - Šárka Kubinová
- State Institute for Drug Control, Prague, Czech Republic
- MoCA Steering Committee Members, Brussels, Belgium
| | - Marc Van de Casteele
- Rijksinstituut Voor Ziekte- en Invaliditeitsverzekering (RIZIV-INAMI), Brussels, Belgium
- Medicine Evaluation Committee (MEDEV), Brussels, Belgium
- MoCA Steering Committee Members, Brussels, Belgium
| | - Evert Jan Van Lente
- Medicine Evaluation Committee (MEDEV), Brussels, Belgium
- MoCA Steering Committee Members, Brussels, Belgium
| | | | - Johan Pontén
- Medicine Evaluation Committee (MEDEV), Brussels, Belgium
- MoCA Steering Committee Members, Brussels, Belgium
| | | | - Yann Le Cam
- EURORDIS - Rare Diseases Europe, Paris, France
- MoCA Steering Committee Members, Brussels, Belgium
| | - Simone Boselli
- EURORDIS - Rare Diseases Europe, Paris, France
- MoCA Steering Committee Members, Brussels, Belgium
| | - Anna Bucsics
- MoCA Steering Committee Members, Brussels, Belgium
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4
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Eichler HG, Kossmeier M, Zeitlinger M, Schwarzer-Daum B. Orphan drugs' clinical uncertainty and prices: Addressing allocative and technical inefficiencies in orphan drug reimbursement. Front Pharmacol 2023; 14:1074512. [PMID: 36778019 PMCID: PMC9909264 DOI: 10.3389/fphar.2023.1074512] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/09/2023] [Indexed: 01/27/2023] Open
Abstract
Legislations incentivising orphan drug development and scientific advances have made orphan drugs pharma's high-end favourite for the past two decades. Currently, around 50% of new marketing authorizations are for orphan drugs. For third-party healthcare payers ("payers") the rise of orphan drugs presents new challenges, including a high degree of uncertainty around clinical benefits and harms, a moderate effect size (for many orphan drugs), and a high price tag. The association of high clinical uncertainty and moderate effect sizes is not surprising in small target populations but in combination with high prices creates the risk of allocative and technical inefficiencies for payers. We here discuss and illustrate these risks. A combination of policies is needed for mitigation of allocative inefficiency: while there may be a rationale for higher prices for orphan than non-orphan drugs, a focus of pricing and reimbursement negotiations should include considerations of product profitability and of the consequences of orphan drug costs on the distribution inequality of medication costs for individual insured persons, coupled to knowledge generation from reimbursement contracts covering high-price orphan drugs that would benefit the wider patient community. Performance-based managed entry agreements could help to de-risk the economic consequences of clinical uncertainty and to mitigate technical inefficiency.
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Affiliation(s)
| | | | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Brigitte Schwarzer-Daum
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria,*Correspondence: Brigitte Schwarzer-Daum,
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5
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Eichler HG, Trusheim M, Schwarzer-Daum B, Larholt K, Zeitlinger M, Brunninger M, Sherman M, Strutton D, Hirsch G. Precision Reimbursement for Precision Medicine: Using Real-World Evidence to Evolve From Trial-and-Project to Track-and-Pay to Learn-and-Predict. Clin Pharmacol Ther 2021; 111:52-62. [PMID: 34716918 PMCID: PMC9299639 DOI: 10.1002/cpt.2471] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 10/22/2021] [Indexed: 02/03/2023]
Abstract
Basic scientists and drug developers are accelerating innovations toward the goal of precision medicine. Regulators create pathways for timely patient access to precision medicines, including individualized therapies. Healthcare payors acknowledge the need for change but downstream innovation for coverage and reimbursement is only haltingly occurring. Performance uncertainty, high price‐tags, payment timing, and actuarial risk issues associated with precision medicines present novel financial challenges for payors. With traditional drug reimbursement frameworks, payment is based on an assumed randomized controlled trial (RCT) projection of real‐world effectiveness, a “trial‐and‐project” strategy; the clinical benefit realized for patients is not usually ascertained ex post by collection of real‐world data (RWD). To mitigate financial risks resulting from clinical performance uncertainty, manufacturers and payors devised “track‐and‐pay” frameworks (i.e., the tracking of a pre‐agreed treatment outcome which is linked to financial consequences). Whereas some track‐and‐pay arrangements have been successful, inherent weaknesses include the potential for misalignment of incentives, the risk of channeling of patients, and a failure to use the RWD generated to enable continuous learning about treatments. “Precision reimbursement” (PR) intends to overcome inherent weaknesses of simple track‐and‐pay schemes. In combining the collection of RWD with advanced analytics (e.g., artificial intelligence and machine learning) to generate actionable real‐world evidence, with prospective alignment of incentives across all stakeholders (including providers and patients), and with pre‐agreed use and dissemination of information generated, PR becomes a “learn‐and‐predict” model of payment for performance. We here describe in detail the concept of PR and lay out the next steps to make it a reality.
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Affiliation(s)
| | - Mark Trusheim
- Massachusetts Institute of Technology Center for Biomedical Innovation, Cambridge, Massachusetts, USA
| | | | - Kay Larholt
- Massachusetts Institute of Technology Center for Biomedical Innovation, Cambridge, Massachusetts, USA
| | | | | | - Michael Sherman
- Point32Health, Wellesley, Massachusetts, USA.,Department of Population Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Gigi Hirsch
- Massachusetts Institute of Technology Center for Biomedical Innovation, Cambridge, Massachusetts, USA
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6
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Selker HP, Cohen T, D'Agostino RB, Dere WH, Ghaemi SN, Honig PK, Kaitin KI, Kaplan HC, Kravitz RL, Larholt K, McElwee NE, Oye KA, Palm ME, Perfetto E, Ramanathan C, Schmid CH, Seyfert-Margolis V, Trusheim M, Eichler HG. A Useful and Sustainable Role for N-of-1 Trials in the Healthcare Ecosystem. Clin Pharmacol Ther 2021; 112:224-232. [PMID: 34551122 PMCID: PMC9022728 DOI: 10.1002/cpt.2425] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 05/11/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022]
Abstract
Clinicians and patients often try a treatment for an initial period to inform longer‐term therapeutic decisions. A more rigorous approach involves N‐of‐1 trials. In these single‐patient crossover trials, typically conducted in patients with chronic conditions, individual patients are given candidate treatments in a double‐blinded, random sequence of alternating periods to determine the most effective treatment for that patient. However, to date, these trials are rarely done outside of research settings and have not been integrated into general care where they could offer substantial benefit. Designating this classical, N‐of‐1 trial design as type 1, there also are new and evolving uses of N‐of‐1 trials that we designate as type 2. In these, rather than focusing on optimizing treatment for chronic diseases when multiple approved choices are available, as is typical of type 1, a type 2 N‐of‐1 trial tests treatments designed specifically for a patient with a rare disease, to facilitate personalized medicine. While the aims differ, both types face the challenge of collecting individual‐patient evidence using standard, trusted, widely accepted methods. To fulfill their potential for producing both clinical and research benefits, and to be available for wide use, N‐of‐1 trials will have to fit into the current healthcare ecosystem. This will require generalizable and accepted processes, platforms, methods, and standards. This also will require sustainable value‐based arrangements among key stakeholders. In this article, we review opportunities, stakeholders, issues, and possible approaches that could support general use of N‐of‐1 trials and deliver benefit to patients and the healthcare enterprise. To assess and expand the benefits of N‐of‐1 trials, we propose multistakeholder meetings, workshops, and the generation of methods, standards, and platforms that would support wider availability and the value of N‐of‐1 trials.
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Affiliation(s)
- Harry P Selker
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Theodora Cohen
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Ralph B D'Agostino
- Department of Mathematics and Statistics, Boston University, Boston, Massachusetts, USA.,Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Willard H Dere
- Department of Internal Medicine, Utah Center for Clinical and Translational Science, University of Utah, Salt Lake City, Utah, USA.,University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - S Nassir Ghaemi
- Psychiatry, Tufts University School of Medicine, Boston, Massachusetts, USA.,Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Kenneth I Kaitin
- Tufts Center for the Study of Drug Development, Tufts University, Boston, Massachusetts, USA
| | - Heather C Kaplan
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Richard L Kravitz
- Department of Internal Medicine, University of California, Davis, Davis, California, USA
| | - Kay Larholt
- Center for Biomedical Innovation, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Newell E McElwee
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut, USA
| | - Kenneth A Oye
- Department of Political Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.,Center for Biomedical Innovation, Cambridge, Massachusetts, USA
| | - Marisha E Palm
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Eleanor Perfetto
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA.,National Health Council, Washington, District of Columbia, USA
| | | | | | | | - Mark Trusheim
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Hans-Georg Eichler
- Regulatory Science and Innovation Task Force, European Medicines Agency, Amsterdam, The Netherlands.,Medical University of Vienna, Vienna, Austria
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7
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Jaksa A, Wu J, Jónsson P, Eichler HG, Vititoe S, Gatto NM. Organized structure of real-world evidence best practices: moving from fragmented recommendations to comprehensive guidance. J Comp Eff Res 2021; 10:711-731. [PMID: 33928789 DOI: 10.2217/cer-2020-0228] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 12/28/2022] Open
Abstract
Decision-makers have become increasingly interested in incorporating real-world evidence (RWE) into their decision-making process. Due to concerns regarding the reliability and quality of RWE, stakeholders have issued numerous recommendation documents to assist in setting RWE standards. The fragmented nature of these documents poses a challenge to researchers and decision-makers looking for guidance on what is 'high-quality' RWE and how it can be used in decision-making. We offer researchers and decision-makers a structure to organize the landscape of RWE recommendations and identify consensus and gaps in the current recommendations. To provide researchers with a much needed pathway for generating RWE, we discuss how decision-makers can move from fragmented recommendations to comprehensive guidance.
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Affiliation(s)
- Ashley Jaksa
- Scientific Research, Aetion Inc., 5 Penn Plaza, 7th Fl., New York, NY 10001, USA
| | - James Wu
- Amgen Inc, 1 Amgen Center Drive, Thousand Oaks, CA 91320-1779, USA
| | - Páll Jónsson
- National Institute for Health & Care Excellence, Level 1A, City Tower, Piccadilly Plaza Manchester, M1 4BT, UK
| | - Hans-Georg Eichler
- European Medicines Agency, Domenico Scarlattilaan 6, Amsterdam 1083 HS, Netherlands
| | - Sarah Vititoe
- Scientific Research, Aetion Inc., 5 Penn Plaza, 7th Fl., New York, NY 10001, USA
| | - Nicolle M Gatto
- Scientific Research, Aetion Inc., 5 Penn Plaza, 7th Fl., New York, NY 10001, USA
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8
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Kurz X, Arlett P, Eichler HG, Nolte A, Straus S, Rasi G. Increasing the impact of Post Authorisation Safety Studies: transparency is key. Eur J Intern Med 2021; 83:6-7. [PMID: 33277138 DOI: 10.1016/j.ejim.2020.11.019] [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] [Received: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Xavier Kurz
- European Medicines Agency (EMA), Amsterdam, The Netherlands.
| | - Peter Arlett
- EMA, Amsterdam, The Netherlands and London School of Hygiene and Tropical Medicine, London, UK
| | - Hans-Georg Eichler
- EMA, Amsterdam, The Netherlands, and Medical University of Vienna, Vienna, Austria
| | - Alexis Nolte
- European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Sabine Straus
- Medicines Evaluation Board (MEB), Utrecht, The Netherlands and EMA Pharmacovigilance and Risk Assessment Committee (PRAC), Amsterdam, The Netherlands
| | - Guido Rasi
- EMA, Amsterdam, The Netherlands, and University Tor Vergata, Rome, Italy
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9
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Eichler HG, Pignatti F, Schwarzer-Daum B, Hidalgo-Simon A, Eichler I, Arlett P, Humphreys A, Vamvakas S, Brun N, Rasi G. Randomized Controlled Trials Versus Real World Evidence: Neither Magic Nor Myth. Clin Pharmacol Ther 2020; 109:1212-1218. [PMID: 33063841 PMCID: PMC8246742 DOI: 10.1002/cpt.2083] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/30/2020] [Indexed: 01/02/2023]
Abstract
Compared with drugs from the blockbuster era, recently authorized drugs and those expected in the future present a heterogenous mix of chemicals, biologicals, and cell and gene therapies, a sizable fraction being for rare diseases, and even individualized treatments or individualized combinations. The shift in the nature of products entails secular trends for the definitions of “drugs” and “target population” and for clinical use and evidence generation. We discuss that the lessons learned from evidence generation for 20th century medicines may have limited relevance for 21st century medicines. We explain why the future is not about randomized controlled trials (RCTs) vs. real‐world evidence (RWE) but RCTs and RWE—not just for the assessment of safety but also of effectiveness. Finally, we highlight that, in the era of precision medicine, we may not be able to reliably describe some small treatment effects—either by way of RCTs or RWE.
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Affiliation(s)
- Hans-Georg Eichler
- European Medicines Agency (EMA), Amsterdam, The Netherlands.,Medical University of Vienna, Vienna, Austria
| | | | - Brigitte Schwarzer-Daum
- Medical University of Vienna, Vienna, Austria.,EMA's Committee for Orphan Medical Products (COMP), Amsterdam, The Netherlands
| | | | | | - Peter Arlett
- European Medicines Agency (EMA), Amsterdam, The Netherlands.,London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Guido Rasi
- European Medicines Agency (EMA), Amsterdam, The Netherlands.,University Tor Vergata, Rome, Italy
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10
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Orsini LS, Monz B, Mullins CD, Van Brunt D, Daniel G, Eichler HG, Graff J, Guerino J, Berger M, Lederer NM, Jonsson P, Schneeweiss S, Wang SV, Crown W, Goettsch W, Willke RJ. Improving transparency to build trust in real-world secondary data studies for hypothesis testing-Why, what, and how: recommendations and a road map from the real-world evidence transparency initiative. Pharmacoepidemiol Drug Saf 2020; 29:1504-1513. [PMID: 32924243 DOI: 10.1002/pds.5079] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/12/2020] [Accepted: 06/23/2020] [Indexed: 12/21/2022]
Abstract
Real-world data (RWD) and the derivations of these data into real-world evidence (RWE) are rapidly expanding from informing healthcare decisions at the patient and health system level to influencing major health policy decisions, including regulatory approvals and coverage. Recent examples include the approval of palbociclib in combination with endocrine therapy for male breast cancer and the inclusion of RWE in the label of paliperidone palmitate for schizophrenia. This interest has created an urgency to develop processes that promote trust in the evidence-generation process. Key stakeholders and decision-makers include patients and their healthcare providers; learning health systems; health technology assessment bodies and payers; pharmacoepidemiologists and other clinical reseachers, and policy makers interested in bioethical and regulatory issues. A key to optimal uptake of RWE is transparency of the research process to enable decision-makers to evaluate the quality of the methods used and the applicability of the evidence that results from the RWE studies. Registration of RWE studies-particularly for hypothesis evaluating treatment effectiveness (HETE) studies-has been proposed to improve transparency, trust, and research replicability. Although registration would not guarantee better RWE studies would be conducted, it would encourage the prospective disclosure of study plans, timing, and rationale for modifications. A joint task force of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the International Society for Pharmacoepidemiology (ISPE) recommended that investigators preregister their RWE studies and post their study protocols in a publicly available forum before starting studies to reduce publication bias and improve the transparency of research methods. Recognizing that published recommendations alone are insufficient, especially without accessible registration options and with no incentives, a group of experts gathered on February 25 and 26, 2019, in National Harbor, Maryland, to explore the structural and practical challenges to the successful implementation of the recommendations of the ISPOR/ISPE task force for preregistration. This positioning article describes a plan for making registration of HETE RWE studies routine. The plan includes specifying the rationale for registering HETE RWE studies, the studies that should be registered, where and when these studies should be registered, how and when analytic deviations from protocols should be reported, how and when to publish results, and incentives to encourage registration. Table 1 summarizes the rationale, goals, and potential solutions that increase transparency, in addition to unique concerns about secondary data studies. Definitions of terms used throughout this report are provided in Table 2.
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Affiliation(s)
| | | | - C Daniel Mullins
- Pharmaceutical Health Services Research Department, University of Maryland, Baltimore, Maryland, USA
| | | | - Gregory Daniel
- Duke-Margolis Center for Health Policy, Washington, District of Columbia, USA
| | | | - Jennifer Graff
- National Pharmaceutical Council, Washington, District of Columbia, USA
| | | | | | - Nirosha M Lederer
- Duke-Margolis Center for Health Policy, Washington, District of Columbia, USA
| | - Pall Jonsson
- National Institute for Health and Care Excellence (NICE), London, UK
| | | | - Shirley V Wang
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Wim Goettsch
- National Health Care Institute (ZIN), Diemen, the Netherlands.,Utrecht University, Utrecht, the Netherlands
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11
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Orsini LS, Berger M, Crown W, Daniel G, Eichler HG, Goettsch W, Graff J, Guerino J, Jonsson P, Lederer NM, Monz B, Mullins CD, Schneeweiss S, Brunt DV, Wang SV, Willke RJ. Improving Transparency to Build Trust in Real-World Secondary Data Studies for Hypothesis Testing-Why, What, and How: Recommendations and a Road Map from the Real-World Evidence Transparency Initiative. Value Health 2020; 23:1128-1136. [PMID: 32940229 DOI: 10.1016/j.jval.2020.04.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/09/2020] [Indexed: 06/11/2023]
Abstract
Real-world data (RWD) and the derivations of these data into real-world evidence (RWE) are rapidly expanding from informing healthcare decisions at the patient and health system level to influencing major health policy decisions, including regulatory approvals and coverage. Recent examples include the approval of palbociclib in combination with endocrine therapy for male breast cancer and the inclusion of RWE in the label of paliperidone palmitate for schizophrenia. This interest has created an urgency to develop processes that promote trust in the evidence-generation process. Key stakeholders and decision-makers include patients and their healthcare providers; learning health systems; health technology assessment bodies and payers; pharmacoepidemiologists and other clinical reseachers, and policy makers interested in bioethical and regulatory issues. A key to optimal uptake of RWE is transparency of the research process to enable decision-makers to evaluate the quality of the methods used and the applicability of the evidence that results from the RWE studies. Registration of RWE studies-particularly for hypothesis evaluating treatment effectiveness (HETE) studies-has been proposed to improve transparency, trust, and research replicability. Although registration would not guarantee better RWE studies would be conducted, it would encourage the prospective disclosure of study plans, timing, and rationale for modifications. A joint task force of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the International Society for Pharmacoepidemiology (ISPE) recommended that investigators preregister their RWE studies and post their study protocols in a publicly available forum before starting studies to reduce publication bias and improve the transparency of research methods. Recognizing that published recommendations alone are insufficient, especially without accessible registration options and with no incentives, a group of experts gathered on February 25 and 26, 2019, in National Harbor, Maryland, to explore the structural and practical challenges to the successful implementation of the recommendations of the ISPOR/ISPE task force for preregistration. This positioning article describes a plan for making registration of HETE RWE studies routine. The plan includes specifying the rationale for registering HETE RWE studies, the studies that should be registered, where and when these studies should be registered, how and when analytic deviations from protocols should be reported, how and when to publish results, and incentives to encourage registration. Table 1 summarizes the rationale, goals, and potential solutions that increase transparency, in addition to unique concerns about secondary data studies. Definitions of terms used throughout this report are provided in Table 2.
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Affiliation(s)
| | | | | | - Gregory Daniel
- Duke-Margolis Center for Health Policy, Washington, DC, USA
| | | | - Wim Goettsch
- National Health Care Institute (ZIN), Diemen, The Netherlands; Utrecht University, Utrecht, The Netherlands
| | | | | | - Pall Jonsson
- National Institute for Health and Care Excellence (NICE), London, England, UK
| | | | | | - C Daniel Mullins
- Pharmaceutical Health Services Research Department, University of Maryland, Baltimore, MD, USA
| | | | | | - Shirley V Wang
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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12
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Eichler HG, Cavaleri M, Enzmann H, Scotti F, Sepodes B, Sweeney F, Vamvakas S, Rasi G. Clinical Trials for COVID-19: Can we Better Use the Short Window of Opportunity? Clin Pharmacol Ther 2020; 108:730-733. [PMID: 32407539 PMCID: PMC7272975 DOI: 10.1002/cpt.1891] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 05/01/2020] [Accepted: 05/13/2020] [Indexed: 11/17/2022]
Abstract
The scientific community has risen to the coronavirus disease 2019 (COVID‐19) challenge, coming up with an impressive list of candidate drugs and vaccines targeting an array of pharmacological and immunological mechanisms. Yet, generating clinical evidence of efficacy and safety of these candidate treatments may be frustrated by the absence of comprehensive trial coordination mechanisms. Many small stand‐alone trials and observational studies of single‐agent interventions are currently running or in planning; many of these will likely not deliver robust results that could support regulatory and patient‐level treatment decisions. In this paper, we discuss actions that all stakeholders in the clinical trial ecosystem need to take to ensure that the window of opportunity during this pandemic will not shut, both for patients in need of treatment and for researchers to conduct decision‐relevant clinical trials.
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Affiliation(s)
- Hans-Georg Eichler
- European Medicines Agency (EMA), Amsterdam, The Netherlands.,Medical University of Vienna, Vienna, Austria
| | - Marco Cavaleri
- European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Harald Enzmann
- BfArM, Bonn, Germany.,EMA's Committee for Medicinal Products for Human Use (CHMP), Amsterdam, The Netherlands
| | | | - Bruno Sepodes
- EMA's Committee for Medicinal Products for Human Use (CHMP), Amsterdam, The Netherlands.,Universidade de Lisboa, Lisbon, Portugal
| | - Fergus Sweeney
- European Medicines Agency (EMA), Amsterdam, The Netherlands
| | | | - Guido Rasi
- European Medicines Agency (EMA), Amsterdam, The Netherlands.,University Tor Vergata, Rome, Italy
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13
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14
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Affiliation(s)
- Hans-Georg Eichler
- European Medicines Agency (EMA), Amsterdam, the Netherlands; Medical University of Vienna, Vienna, Austria
| | - Guido Rasi
- European Medicines Agency (EMA), Amsterdam, the Netherlands; University Tor Vergata, Rome, Italy.
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15
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Abstract
The authors describe key challenges facing the clinical trials community and propose solutions to these issues, including the role the Clinical Trials Transformation Initiative can play in addressing these issues. Specifically, the authors reflect on clinical trial globalization and the harmonization of frameworks and requirements across regions; the challenges associated with balancing the desire for external validity, pragmatic trials, and precision medicine; clinical trial transparency; and operational complexity and the expense of clinical trials. By addressing these challenges, future clinical trials will be more feasible, relevant, and credible, and support both the continuing altruistic contributions of patients and the collection of more meaningful data.
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16
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Selker HP, Eichler HG, Stockbridge NL, McElwee NE, Dere WH, Cohen T, Erban JK, Seyfert-Margolis VL, Honig PK, Kaitin KI, Oye KA, D'Agostino RB. Efficacy and Effectiveness Too Trials: Clinical Trial Designs to Generate Evidence on Efficacy and on Effectiveness in Wide Practice. Clin Pharmacol Ther 2019; 105:857-866. [PMID: 30610746 PMCID: PMC6422692 DOI: 10.1002/cpt.1347] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 12/13/2018] [Indexed: 12/28/2022]
Abstract
Efficacy trials, designed to gain regulatory marketing approval, evaluate drugs in optimally selected patients under advantageous conditions for relatively short time periods. Effectiveness trials, designed to evaluate use in usual practice, assess treatments among more typical patients in real‐world conditions with longer follow‐up periods. In “efficacy‐to‐effectiveness (E2E) trials,” if the initial efficacy trial component is positive, the trial seamlessly transitions to an effectiveness trial component to efficiently yield both types of evidence. Yet more time could be saved by simultaneously addressing efficacy and effectiveness in an “efficacy and effectiveness too (EE2) trial.” Additionally, hybrids of the E2E and EE2 approaches with differing degrees of overlap of the two components could allow flexibility for specific drug development needs. In planning EE2 trials, each stakeholder's current and future needs, incentives, and perspective must be considered. Although challenging, the ultimate benefits to stakeholders, the health system, and the public should justify this effort.
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Affiliation(s)
- Harry P Selker
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, USA.,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Norman L Stockbridge
- US Food and Drug Administration Center for Drug Evaluation and Research, Silver Spring, Maryland, USA
| | | | - Willard H Dere
- Department of Internal Medicine, Utah Center for Clinical and Translational Science, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Theodora Cohen
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, USA.,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
| | - John K Erban
- Cancer Center, Tufts Medical Center, Boston, Massachusetts, USA
| | | | | | - Kenneth I Kaitin
- Tufts Center for the Study of Drug Development, Tufts University, Boston, Massachusetts, USA
| | - Kenneth A Oye
- Massachusetts Institute of Technology Political Science and Center for Biomedical Innovation, Cambridge, Massachusetts, USA
| | - Ralph B D'Agostino
- Department of Mathematics and Statistics, Boston University, Boston, Massachusetts, USA.,Baim Institute for Clinical Research, Boston, Massachusetts, USA
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17
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Lim R, Lee DK, Sabourin P, Ferguson J, Metcalf M, Smith M, Corriol-Rohou S, Eichler HG, Lumpkin M, Hirsch G, Chen IM, O'Rourke B, Schiel A, Crabb N, Aronson N, Pezalla E, Boutin M, Binder L, Wilhelm L. Recognizing that Evidence is Made, not Born. Clin Pharmacol Ther 2018; 105:844-856. [PMID: 30472743 PMCID: PMC6590384 DOI: 10.1002/cpt.1317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 11/14/2018] [Indexed: 01/26/2023]
Abstract
Therapeutic product development, licensing and reimbursement may seem a well-oiled machine, but continuing high attrition rates, regulatory refusals, and patients' access issues suggest otherwise; despite serious efforts, gaps persist between stakeholders' stated evidence requirements and actual evidence supplied. Evidentiary deficiencies and/or human tendencies resulting in avoidable inefficiencies might be further reduced with fresh institutional cultures/mindsets, combined with a context-adaptable practices framework that integrates emerging innovations. Here, Structured Evidence Planning, Production, and Evaluation (SEPPE) posits that evidence be treated as something produced, much like other manufactured goods, for which "built-in quality" (i.e., "people" and "process") approaches have been successfully implemented globally. Incorporating proactive, iterative feedback-and-adjust loops involving key decision-makers at critical points could curtail avoidable evidence quality and decision hazards-pulling needed therapeutic products with high quality evidence of beneficial performance through to approvals. Critical for success, however, is dedicated, long-term commitment to systemic transformation.
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Affiliation(s)
- Robyn Lim
- Health Products and Food Branch, Health Canada, Ottawa, Ontario, Canada
| | - David K Lee
- Health Products and Food Branch, Health Canada, Ottawa, Ontario, Canada
| | - Pierre Sabourin
- Health Products and Food Branch, Health Canada, Ottawa, Ontario, Canada
| | | | - Marilyn Metcalf
- GlaxoSmithKline (GSK), Research Triangle Park, North Carolina, USA
| | | | | | | | - Murray Lumpkin
- Bill and Melinda Gates Foundation, Seattle, Washington, USA
| | - Gigi Hirsch
- MIT Center for Biomedical Innovation, NEWDIGS, Cambridge, Massachusetts, USA
| | | | - Brian O'Rourke
- Canadian Agency for Drugs and Technologies in Health, Ottawa, Ontario, Canada
| | - Anja Schiel
- HTA Division, Norwegian Medicines Agency, Oslo, Norway
| | | | - Naomi Aronson
- Blue Cross Blue Shield Association, Chicago, Illinois, USA
| | - Edmund Pezalla
- Enlightenment Bioconsult LLC, Wethersfield, Connecticut, USA
| | - Marc Boutin
- National Health Council, Washington, District of Columbia, USA
| | - Louise Binder
- Save Your Skin Foundation, North Vancouver, British Columbia, Canada
| | - Linda Wilhelm
- Canadian Arthritis Patient Alliance, Midland, New Brunswick, Canada
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18
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Eichler HG, Bloechl-Daum B, Broich K, Kyrle PA, Oderkirk J, Rasi G, Santos Ivo R, Schuurman A, Senderovitz T, Slawomirski L, Wenzl M, Paris V. Data Rich, Information Poor: Can We Use Electronic Health Records to Create a Learning Healthcare System for Pharmaceuticals? Clin Pharmacol Ther 2018; 105:912-922. [PMID: 30178490 PMCID: PMC6587701 DOI: 10.1002/cpt.1226] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 08/14/2018] [Indexed: 12/16/2022]
Abstract
Judicious use of real‐world data (RWD) is expected to make all steps in the development and use of pharmaceuticals more effective and efficient, including research and development, regulatory decision making, health technology assessment, pricing, and reimbursement decisions and treatment. A “learning healthcare system” based on electronic health records and other routinely collected data will be required to harness the full potential of RWD to complement evidence based on randomized controlled trials. We describe and illustrate with examples the growing demand for a learning healthcare system; we contrast the exigencies of an efficient pharmaceutical ecosystem in the future with current deficiencies highlighted in recently published Organisation for Economic Co‐operation and Development (OECD) reports; and we reflect on the steps necessary to enable the transition from healthcare data to actionable information. A coordinated effort from all stakeholders and international cooperation will be required to increase the speed of implementation of the learning healthcare system, to everybody's benefit.
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Affiliation(s)
| | | | - Karl Broich
- Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | | | - Jillian Oderkirk
- Organisation for Economic Co-operation and Development, Paris, France
| | | | - Rui Santos Ivo
- National Authority of Medicines and Health Products, Lisbon, Portugal
| | - Ad Schuurman
- National Health Care Institute, Diemen, The Netherlands
| | | | - Luke Slawomirski
- Organisation for Economic Co-operation and Development, Paris, France
| | - Martin Wenzl
- Organisation for Economic Co-operation and Development, Paris, France
| | - Valerie Paris
- Organisation for Economic Co-operation and Development, Paris, France
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19
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Eichler HG, Bedlington N, Boudes M, Bouvy JC, Broekmans AW, Cerreta F, Faulkner SD, Forda SR, Joos A, Le Cam Y, Mayer MH, Pirard V, Corriol-Rohou S. Medicines Adaptive Pathways to Patients: Why, When, and How to Engage? Clin Pharmacol Ther 2018; 105:1148-1155. [PMID: 29901216 PMCID: PMC6585618 DOI: 10.1002/cpt.1121] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 05/01/2018] [Indexed: 12/30/2022]
Abstract
Medicines Adaptive Pathways to Patients (MAPPs) seeks to foster access to novel beneficial treatments for the right patient groups at the earliest appropriate time in the product life-span, in a sustainable fashion. We summarize the MAPPs engagement process and critical questions to be asked at each milestone of the product life-span. These considerations are of relevance for regulatory and access pathways that strive to address the "evidence vs. access" conundrum.
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Affiliation(s)
| | | | | | - Jacoline C Bouvy
- National Institute for Health and Care Excellence (NICE), London, UK
| | | | | | - Stuart D Faulkner
- Centre for the Advancement of Sustainable Medical Innovation (CASMI), Headington Oxford, UK
| | | | | | - Yann Le Cam
- EURORDIS-Rare Diseases Europe, Paris, France
| | - Mark H Mayer
- Eli Lilly and Company, Indianapolis, Indiana, USA
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20
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Kyrle PA, Minar E, Brenner B, Eichler HG, Heistinger M, Marosi L, Lechner K. Thromboxane A2 and Prostacyclin Generation in the Microvasculature of Patients with Atherosclerosis – Effect of Low-Dose Aspirin. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1646599] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryGeneration of thromboxane A2 (TxA2) and prostacyclin (PGI2) at the site of platelet-vessel wall interaction, i.e. in blood emerging from a standardized injury of the microvasculature made to determine skin bleeding time was investigated in 7 patients with atherosclerosis (angiographically verified obstructions of the femoral arteries) and in 7 normal control subjects apparently free of atherosclerotic lesions. Similar amounts of TxA2 (measured as thromboxane B2, TxB2) were generated at the site of plug formation in the patients with peripheral vascular disease (PVD) and in the control subjects. Significantly lower levels of PGI2 (measured as 6-keto-prostaglandin F1α, 6-keto- PGF1α) were found in blood from an injury of the microvasculature in the patients compared with the controls. These data do not suggest a major role of the platelet prostaglandin metabolism in the development of atherosclerosis. However, decreased synthesis of PGI2 by endothelial cells might contribute to the development and/or progression of atherosclerotic lesions. In the patients with PVD, low-dose aspirin (50 mg/day for 7 days) resulted in a >90% inhibition of the TxB2 production at the site of plug formation. Following low-dose aspirin 6-keto-PcF1α levels were below 20 pg/ml (limit of sensitivity of our radioimmunoassay procedure) in the majority of the samples.We therefore conclude that in patients with PVD a decreased synthesis of PGI2 by endothelial cells might contribute to the progression of atherosclerosis. Furthermore, low-dose aspirin treatment results in a similar inhibition of the platelet prostaglandin generation as recently observed in healthy subjects.
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Affiliation(s)
- P A Kyrle
- The Department of Internal Medicine I, University of Vienna, Vienna, Austria
| | - E Minar
- The Department of Internal Medicine I, University of Vienna, Vienna, Austria
| | - B Brenner
- The Department of Internal Medicine I, University of Vienna, Vienna, Austria
| | - H G Eichler
- The Department of Internal Medicine I, University of Vienna, Vienna, Austria
| | - M Heistinger
- The Department of Internal Medicine I, University of Vienna, Vienna, Austria
| | - L Marosi
- The Department of Internal Medicine I, University of Vienna, Vienna, Austria
| | - K Lechner
- The Department of Internal Medicine I, University of Vienna, Vienna, Austria
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21
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Wolzt M, Eder M, Weltermann A, Entlicher J, Eichler HG, Kyrle PA. Comparison of the Effects of Different Low Molecular Weight Heparins on the Hemostatic System Activation In Vivo in Man. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1657645] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryIn a double-blind, randomized, cross-over study the effects of single subcutaneous doses of 120 anti-Xa units/kg body wt. of three different low molecular weight heparin (LMWH) preparations were investigated in 15 healthy subjects by determination of thrombin-antithrombin El complex (TAT), prothrombin fragment 1.2 (fl.2), and β-thromboglobin (β-TG) in shed blood and in venous blood.Certoparin, dalteparin, and enoxaparin significantly inhibited coagulation activation marker formation in shed blood. The substantial inhibition of TAT and fl.2 formation was slightly more pronounced in response to certoparin. β-TG was decreased following certoparin and enoxaparin, but not following dalteparin. However, no difference between groups was detectable. A small but consistent decrease of fl.2 formation in venous blood was noted for all LMWHs and dalteparin and enoxaparin, but not certoparin, inhibited TAT formation. Only a minor impact of the three LMWH preparations was noted on β-TG plasma concentrations.Our data indicate that the studied LMWH preparations have a major impact on blood clotting in the activated state and inhibit in vivothe hemostatic system to a comparable extent.
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Affiliation(s)
- Michael Wolzt
- The Department of Clinical Pharmacology, Allgemeines Krankenhaus Wien, Austria
| | - Michaela Eder
- The Department of Clinical Pharmacology, Allgemeines Krankenhaus Wien, Austria
| | - Ansgar Weltermann
- The Department of Internal Medicine I/Division of Hematology and Hemostaseology Vienna University, Allgemeines Krankenhaus Wien, Austria
| | - Jesusa Entlicher
- The Department of Clinical Pharmacology, Allgemeines Krankenhaus Wien, Austria
| | - Hans-Georg Eichler
- The Department of Clinical Pharmacology, Allgemeines Krankenhaus Wien, Austria
| | - Paul A Kyrle
- The Department of Internal Medicine I/Division of Hematology and Hemostaseology Vienna University, Allgemeines Krankenhaus Wien, Austria
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22
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Jilma B, Dirnberger E, Eichler HG, Matulla B, Schmetterer L, Kapiotis S, Speiser W, Wagner OF. Partial Blockade of Nitric Oxide Synthase Blunts the Exercise-induced Increase of von Willebrand Factor Antigen and of Factor VIII in Man. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1657726] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryBackground: Until now the effects of β-adrenergic agonists have largely been ascribed to their ability to induce intracellular formation of cyclic adenosine monophosphate. Recently evidence has been accumulating that at least some β1 and β2-adrenoceptor effects may be mediated by nitric oxide (NO). Based on these studies, we hypothesized that the β-adrenoceptor mediated increase of von Willebrand factor and factor VIII-activity (FVIII:C) in plasma during exercise, is caused by an NO-dependent mechanism. Methods: Thirteen young healthy subjects finished an exhaustive bicycle exercise protocol while they were infused placebo or the NO-synthase inhibitor N-monomethyl-L-arginine (L-NMMA) on two separate days in a randomized, double blind cross-over design. Findings: During exercise systemic haemo-dynamic changes were parallel in both treatment periods, but L-NMMA caused a partial inhibition of NO-synthase as evidenced by a 30% decrease in exhaled NO. The workload capacities were not different during L-NMMA or placebo infusion. However, under placebo treatment exercise increased vWF-Ag by a maximum of 61% (CI: 43-84; p = 0.002) and FVIII:C by 44% (CI: 31-59; p = 0.001), which was significantly attenuated when subjects were treated with L-NMMA (p <0.05): under L-NMMA treatment vWF-Ag increased by only 25% (CI: 5-51; p = 0.001) and FVIII:C by 12% (CI: 6-39; p = 0.001). Interpretation: Partial blockade of NO-synthase with L-NMMA blunts the exercise-induced increase in vWF-Ag and FVIII:C. Our trial points to a role of endogenous NO-generation in the β2-adrenergic increase in vWF/FVIII. Thus, we propose that physiologic processes which are induced by systemic β2-adrenoceptor stimulation may at least partly be mediated by NO.
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Affiliation(s)
- Bernd Jilma
- The Department of Clinical Pharmacology, University of Vienna, Austria
| | - Eva Dirnberger
- The Department of Clinical Pharmacology, University of Vienna, Austria
| | | | - Bettina Matulla
- The Department of Clinical Pharmacology, University of Vienna, Austria
| | - Leopold Schmetterer
- The Department of Clinical Pharmacology, University of Vienna, Austria
- The Institute of Medical Physics, University of Vienna, Austria
| | - Stylianos Kapiotis
- The Clinical Department of Medical and Chemical Laboratory Diagnostics, Vienna University Hospital School of Medicine, Austria
| | - Wolfgang Speiser
- The Clinical Department of Medical and Chemical Laboratory Diagnostics, Vienna University Hospital School of Medicine, Austria
| | - Oswald F Wagner
- The Clinical Department of Medical and Chemical Laboratory Diagnostics, Vienna University Hospital School of Medicine, Austria
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23
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Kyrle PA, Brockmeier J, Weltermann A, Eichinger S, Speiser W, Lechner K, Eichler HG. Inhibition rather than Enhancement of Hemostatic System Activation during Initiation of Oral Anticoagulant Treatment. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1656034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryCoumarin-induced skin necrosis is believed to be due to a transient hypercoagulable state resulting from a more rapid decline of the protein C activity relative to that of coagulation factors (F) II, IX and X during initiation of oral anticoagulant therapy. We studied hemostatic system activation during early oral anticoagulant treatment with a technique that investigates coagulation activation in the microcirculation.We determined in 10 healthy volunteers the concentrations of prothrombin fragment F1+2 (f1.2) and thrombin-antithrombin complex (TAT) in blood emerging from an injury of the microvasculature (bleeding time incision) before and after initiation of both high-inten- sity and low-intensity coumarin therapy. In addition, f1.2, TAT, activated F VII (F Vila) and the activities of FII, F VII, F X and protein C were measured in venous blood.A rapid decline of F VII and protein C was observed in venous blood with activities at 24 h of 7 ± 1% and 43 ± 2%, respectively, during the high-intensity regimen. A 20 to 30% reduction of f1.2 and TAT was seen in venous blood at 72 h with no major difference between the high- and the low-intensity regimen. F Vila levels were substantially affected by anticoagulation with a >90% reduction at 48 h during the high-intensity regimen. Following high-intensity coumarin, a >50% decrease in the fl.2 and TAT levels was found in shed blood at 48 h suggesting substantial inhibition of thrombin generation during early oral anticoagulation. An increase in the f1.2 and TAT levels was seen neither in shed blood nor in venous blood.Our data do not support the concept of a transient imbalance between generation and inhibition of thrombin as the underlying pathomechanism of coumarin-induced skin nekrosis.
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Affiliation(s)
- Paul A Kyrle
- The Departments of Medicine I (Division of Hematology and Hemostaseology), Clinical Pharmacology and Laboratory Medicine, Vienna University Hospital Vienna, Austria
| | - Johannes Brockmeier
- The Departments of Medicine I (Division of Hematology and Hemostaseology), Clinical Pharmacology and Laboratory Medicine, Vienna University Hospital Vienna, Austria
| | - Ansgar Weltermann
- The Departments of Medicine I (Division of Hematology and Hemostaseology), Clinical Pharmacology and Laboratory Medicine, Vienna University Hospital Vienna, Austria
| | - Sabine Eichinger
- The Departments of Medicine I (Division of Hematology and Hemostaseology), Clinical Pharmacology and Laboratory Medicine, Vienna University Hospital Vienna, Austria
| | - Wolfgang Speiser
- The Departments of Medicine I (Division of Hematology and Hemostaseology), Clinical Pharmacology and Laboratory Medicine, Vienna University Hospital Vienna, Austria
| | - Klaus Lechner
- The Departments of Medicine I (Division of Hematology and Hemostaseology), Clinical Pharmacology and Laboratory Medicine, Vienna University Hospital Vienna, Austria
| | - Hans-Georg Eichler
- The Departments of Medicine I (Division of Hematology and Hemostaseology), Clinical Pharmacology and Laboratory Medicine, Vienna University Hospital Vienna, Austria
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24
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Jilma B, Fasching P, Ruthner C, Rumplmayr A, Ruzicka S, Kapiotis S, Wagner OF, Eichler HG. Elevated Circulating P-Selectin in Insulin Dependent Diabetes Mellitus. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1650578] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryBased on findings that showed increased P-selectin expression on platelets and on choroidal microvessels of patients with insulin dependent diabetes mellitus (IDDM), we hypothesized that also plasma concentrations of circulating (c)P-selectin would be increased in these patients.The aim of this study was to compare the plasma levels of cP-selec-tin between non-smoking patients with IDDM, treated with an intensified insulin therapy, and healthy controls. The study design was prospective, cross-sectional and analyst-blinded. Subjects were matched individually for sex, age and body mass index. Plasma levels of cP-selectin and of von Willebrand antigen (vWF-Ag) were determined by enzyme linked immunoassays.Forty-two pairs were available for intergroup comparison. Median plasma concentrations of cP-selectin in patients with IDDM (285 ng/ml; interquartile range: 233-372) were on average 21% higher than those of controls (236 ng/ml; interquartile range: 175-296; p = 0.004). Also, median plasma levels of vWF-Ag were 10% higher in patients (96 U/dl; interquartile range: 82-127) than controls (87 U/dl; interquartile range: 70-104; p = 0.025). There was no correlation between plasma concentrations of cP-selectin and vWF-Ag levels in either group (p ώ0.05).In conclusion, our results of increased cP-selectin levels are in line with increased P-selectin expression on platelets and on choroidal microvessels found in patients with IDDM. In view of the currently developed small molecule inhibitors of cell adhesion molecules, these independent observations together may provide a sound rationale to select P-selectin as a target for treating or preventing IDDM-associated micro- or macrovascular complications.
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Affiliation(s)
- Bernd Jilma
- The Department of Clinical Pharmacology, Vienna, Austria
| | - Peter Fasching
- The Department of Internal Medicine III, Div. of Endocrinology and Metabolism, Vienna, Austria
| | | | - Anna Rumplmayr
- The Department of Clinical Pharmacology, Vienna, Austria
| | - Sabine Ruzicka
- The Department of Internal Medicine III, Div. of Endocrinology and Metabolism, Vienna, Austria
| | - Stylianos Kapiotis
- The Clinical Institute of Medical and Chemical Laboratory Diagnostics, Vienna, Austria
| | - Oswald F. Wagner
- The Clinical Institute of Medical and Chemical Laboratory Diagnostics, Vienna, Austria
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25
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Wolzt M, Weltermann A, Nieszpaur-Los M, Schneider B, Fassolt A, Lechner K, Eichler HG, Kyrle PA. Studies on the Neutralizing Effects of Protamine on Unfractionated and Low Molecular Weight Heparin (Fragmin®) at the Site of Activation of the Coagulation System in Man. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1653794] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryIn a double-blind, randomized, cross-over study the neutralizing action of protamine towards unfractionated heparin (UFH, 150 U/kg i.v.) and a low molecular weight heparin (LMWH, Fragmin®, 100 anti-Xa U/kg i.v.) was investigated in 15 healthy subjects in vitro by measuring activated partial thromboplastin time (APTT), thrombin time (TT) and anti factor Xa activity (anti-Xa) in venous blood and in vivo by determination of prothrombin fragment 1.2 (f1.2) and thrombin-antithrombin III complexes (TAT) in venous blood and in shed blood. UFH and LMWH caused a prolongation of APTT and TT, an increase in anti-Xa and significantly inhibited f1.2 and TAT formation in shed blood, whereas only a minimal effect on TAT and f1.2 formation in venous blood was noted. Administration of 1 mg protamine/100 U UFH resulted in a near complete reversal of APTT, TT and anti-Xa, whereas lower doses (0.25 and 0.5 mg) were less effective. The effects of UFH on f1.2 and TAT generation in shed blood were partially (60-70%) neutralized only by the high dose (1.0 mg). Application of 1 mg protamine/100 anti-Xa U LMWH caused a near complete reversal of both APTT and TT but had only a weak effect on anti-Xa. In shed blood, the effect of LMWH on TAT and f1.2 formation was reversed by protamine only by 14% and 23% respectively. Our data do not support the concept that to reduce the incidence of protamine’s potential clinical side effects, the administration of a lower dose of protamine than 1 mg protamine/100 U UFH is justified. Furthermore, a significant residual impairment of hemostasis is still detectable after administration of the recommended dose of protamine to neutralize the anticoagulant effects of a LMWH preparation.
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Affiliation(s)
- Michael Wolzt
- The Department of Clinical Pharmacology, Vienna, Austria
| | - Ansgar Weltermann
- Department of Internal Medicine I/Division of Hematology, Blood Clotting, Vienna, Austria
| | | | | | - Anita Fassolt
- The Department of Clinical Pharmacology, Vienna, Austria
| | - Klaus Lechner
- Department of Internal Medicine I/Division of Hematology, Blood Clotting, Vienna, Austria
| | | | - Paul A Kyrle
- Department of Internal Medicine I/Division of Hematology, Blood Clotting, Vienna, Austria
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26
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Elchinger S, Wolzt M, Nieszpaur-Los M, Schneider B, Lechner K, Eichler HG, Kyrle PA. Effects of a Low Molecular Weight Heparin (Fragmin®) and of Unfractionated Heparin on Coagulation Activation at the Site of Plug Formation In Vivo. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1648970] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryThe clinical benefits of unfractionated heparin (UFH) and low molecular weight heparin (LMWH) have been shown in many trials. However, the mode of action of heparin has not been fully elucidated. Thus, we wanted to study the effects of UFH and LMWH in vivo by measuring coagulation activation markers in blood obtained directly from a vascular injury site. In a double-blind, randomized, 3-way, cross-over study 18 healthy volunteers were given UFH (150 U/kg s.c.) and 2 doses of LMWH [35 U/kg s.c. (low dose, Id), 75 U/kg s.c. (high dose, hd)]. Prothrombin fragment 1+2 (F1+2), thrombin-antithrombin complex (TAT) and fibrinopeptide A (FPA) were measured in bleeding time blood and in venous blood before and after drug application. In addition, the effects of UFH and LMWH on in vitro coagulation tests were studied. Compared to base line, UFH and both IdLMWH and hdLMWH caused significant reductions of F1+2, TAT and FPA in bleeding time blood at 2 h. A marked effect of UFH and of hdLMWH was also seen at 5 h. The inhibition of FPA generation was more pronounced after hdLMWH compared to IdLMWH. In venous blood, UFH and LMWH caused reductions of F1+2, but not of TAT and FPA. In vitro, UFH predominantly affected the anti-IIa assays (activated partial thromboplastin time, thrombin time) and LMWH mainly the anti-Xa test system. Using a technique that investigates the activated coagulation system in vivo, a time- and dose dependent inhibitory effect of heparin on coagulation activation was detectable. Therefore, in our experimental setting a preferential inhibition of a particular portion of the coagulation system by one of the two heparin preparations was not detectable.
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Affiliation(s)
- Sabine Elchinger
- The Department of Medicine I, Division of Hematology and Hemostaseology, Department of Clinical Pharmacology, and Institute of Medical Statistics and Documentation, Vienna University Hospital, Vienna, Austria
| | - Michael Wolzt
- The Department of Medicine I, Division of Hematology and Hemostaseology, Department of Clinical Pharmacology, and Institute of Medical Statistics and Documentation, Vienna University Hospital, Vienna, Austria
| | - Malgorzata Nieszpaur-Los
- The Department of Medicine I, Division of Hematology and Hemostaseology, Department of Clinical Pharmacology, and Institute of Medical Statistics and Documentation, Vienna University Hospital, Vienna, Austria
| | - Barbara Schneider
- The Department of Medicine I, Division of Hematology and Hemostaseology, Department of Clinical Pharmacology, and Institute of Medical Statistics and Documentation, Vienna University Hospital, Vienna, Austria
| | - Klaus Lechner
- The Department of Medicine I, Division of Hematology and Hemostaseology, Department of Clinical Pharmacology, and Institute of Medical Statistics and Documentation, Vienna University Hospital, Vienna, Austria
| | - Hans-Georg Eichler
- The Department of Medicine I, Division of Hematology and Hemostaseology, Department of Clinical Pharmacology, and Institute of Medical Statistics and Documentation, Vienna University Hospital, Vienna, Austria
| | - Paul A Kyrle
- The Department of Medicine I, Division of Hematology and Hemostaseology, Department of Clinical Pharmacology, and Institute of Medical Statistics and Documentation, Vienna University Hospital, Vienna, Austria
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Eichler HG, Barker R, Bedlington N, Bouvy JC, Broekmans AW, Bucsics A, Cerreta F, Corriol-Rohou S, Granados A, Le Cam Y, Schuurman A. The evolution of adaptiveness: balancing speed and evidence. Nat Rev Drug Discov 2018; 17:845-846. [PMID: 29977052 DOI: 10.1038/nrd.2018.90] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
| | - Richard Barker
- Centre for the Advancement of Sustainable Medical Innovation (CASMI), Oxford, UK
| | | | - Jacoline C Bouvy
- National Institute for Health and Care Excellence (NICE), London, UK
| | | | - Anna Bucsics
- Mechanism of Coordinated Access to Orphan Medicinal Products (MoCA), Vienna, Austria
| | | | | | | | | | - Ad Schuurman
- National Health Care Institute (ZIN), Diemen, Netherlands
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Abstract
The continued development of new antibacterial drugs is critical to meet patient and public health needs. In this editorial, authors from the US Food and Drug Administration and European Medicines Agency reflect on the role of public-private partnerships and the development of clinical trials networks as agents to guide and perform quality studies of antibacterial drugs.
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Affiliation(s)
- Edward Cox
- US Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Janet Woodcock
- US Food and Drug Administration, Silver Spring, Maryland
| | - Luciana Borio
- US Food and Drug Administration, Silver Spring, Maryland
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Stohlawetz P, Folman CC, von dem Borne AEGK, Pernerstorfer T, Eichler HG, Panzer S, Jilma B. Effects of Endotoxemia on Thrombopoiesis in Men. Thromb Haemost 2017. [DOI: 10.1055/s-0037-1614534] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Summary
Background. Febrile conditions are often associated with increased platelet turnover and refractoriness to platelet transfusions, although several pyrogenic cytokines enhance thrombopoiesis. This study aimed to characterize the effects of experimental human endotoxemia on platelet turnover and thrombopoiesis. Methods. Endotoxin (4 ng/kg) was infused into 30 healthy men to study the regulation of thrombopoiesis in systemic human inflammation. Platelet counts, plasma thrombopoietin (TPO) and glycocalicin levels, and reticulated platelets (RP) were measured to evaluate the effect of acute endotoxemia on thrombopoiesis. Ten subjects received pretreatment with 1000 mg aspirin po. to evaluate possible effects of aspirin on platelet turnover, and ten subjects received paracetamol to control for effects of anti-pyresis. Results. Platelet counts dropped by about 15% (p <0.001) one hour after LPS infusion, began to recover at 24 h, and exceeded baseline values by 8% (CI: 5-12; p <0.001) at 7 days after LPS iv. Reticulated platelet counts increased from 1.62% (CI: 1.24-2.0) to a maximum of 2.39% (CI: 1.81-2.98; p = 0.003) at 6 h. TPO levels increased from baseline values of 10 A.U/ml (CI: 8.8-11.2) to 15.5 A.U/ml (CI: 13.6-17.3) at 24 h (p <0.001), whereas plasma glycocalicin was not changed (p >0.05). The number of circulating platelet-neutrophil aggregates increased more than 100% at 6 h (p <0.001). Neither aspirin nor paracetamol affected changes in any of the parameters measured. Conclusion. Low grade endotoxemia induces a rapid fall of platelet counts, which is followed by an early increase in reticulated platelets and TPO levels but not of glycocalicin levels. Finally peripheral platelet counts increase several days after LPS infusion.
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Berger ML, Sox H, Willke RJ, Brixner DL, Eichler HG, Goettsch W, Madigan D, Makady A, Schneeweiss S, Tarricone R, Wang SV, Watkins J, Mullins CD. Good Practices for Real-World Data Studies of Treatment and/or Comparative Effectiveness: Recommendations from the Joint ISPOR-ISPE Special Task Force on Real-World Evidence in Health Care Decision Making. Value Health 2017; 20:1003-1008. [PMID: 28964430 DOI: 10.1016/j.jval.2017.08.3019] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE Real-world evidence (RWE) includes data from retrospective or prospective observational studies and observational registries and provides insights beyond those addressed by randomized controlled trials. RWE studies aim to improve health care decision making. METHODS The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the International Society for Pharmacoepidemiology (ISPE) created a task force to make recommendations regarding good procedural practices that would enhance decision makers' confidence in evidence derived from RWD studies. Peer review by ISPOR/ISPE members and task force participants provided a consensus-building iterative process for the topics and framing of recommendations. RESULTS The ISPOR/ISPE Task Force recommendations cover seven topics such as study registration, replicability, and stakeholder involvement in RWE studies. These recommendations, in concert with earlier recommendations about study methodology, provide a trustworthy foundation for the expanded use of RWE in health care decision making. CONCLUSION The focus of these recommendations is good procedural practices for studies that test a specific hypothesis in a specific population. We recognize that some of the recommendations in this report may not be widely adopted without appropriate incentives from decision makers, journal editors, and other key stakeholders.
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Affiliation(s)
| | - Harold Sox
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
| | - Richard J Willke
- International Society for Pharmacoeconomics and Outcomes Research, Lawrenceville, NJ, USA
| | | | | | - Wim Goettsch
- Zorginstituut Nederland and University of Utrecht, Utrecht, The Netherlands
| | | | - Amr Makady
- Zorginstituut Nederland and University of Utrecht, Utrecht, The Netherlands
| | | | | | - Shirley V Wang
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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31
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Medem AV, Seidling HM, Eichler HG, Kaltschmidt J, Metzner M, Hubert CM, Czock D, Haefeli WE. Definition of variables required for comprehensive description of drug dosage and clinical pharmacokinetics. Eur J Clin Pharmacol 2017; 73:633-641. [PMID: 28197684 DOI: 10.1007/s00228-017-2214-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/02/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Electronic clinical decision support systems (CDSS) require drug information that can be processed by computers. The goal of this project was to determine and evaluate a compilation of variables that comprehensively capture the information contained in the summary of product characteristic (SmPC) and unequivocally describe the drug, its dosage options, and clinical pharmacokinetics. METHODS An expert panel defined and structured a set of variables and drafted a guideline to extract and enter information on dosage and clinical pharmacokinetics from textual SmPCs as published by the European Medicines Agency (EMA). The set of variables was iteratively revised and evaluated by data extraction and variable allocation of roughly 7% of all centrally approved drugs. RESULTS The information contained in the SmPC was allocated to three information clusters consisting of 260 variables. The cluster "drug characterization" specifies the nature of the drug. The cluster "dosage" provides information on approved drug dosages and defines corresponding specific conditions. The cluster "clinical pharmacokinetics" includes pharmacokinetic parameters of relevance for dosing in clinical practice. A first evaluation demonstrated that, despite the complexity of the current free text SmPCs, dosage and pharmacokinetic information can be reliably extracted from the SmPCs and comprehensively described by a limited set of variables. CONCLUSION By proposing a compilation of variables well describing drug dosage and clinical pharmacokinetics, the project represents a step forward towards the development of a comprehensive database system serving as information source for sophisticated CDSS.
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Affiliation(s)
- Anna V Medem
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Hans-Georg Eichler
- European Medicines Agency, 30 Churchill Place, Canary Wharf, London, E14 5EU, UK
| | - Jens Kaltschmidt
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Michael Metzner
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Carina M Hubert
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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Spindler P, Bach KF, Schmiegelow M, Bedlington N, Eichler HG. Innovation of Medical Products: The Evolution of Regulatory Science, Research, and Education. Ther Innov Regul Sci 2016; 50:44-48. [PMID: 30236007 DOI: 10.1177/2168479015599810] [Citation(s) in RCA: 8] [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
We present a commentary on the international aspects of the evolution of regulatory science as a multidisciplinary, multistakeholder academic discipline of education and applied research emphasizing the need for seamless interaction between stakeholders such as regulatory authorities, the pharmaceutical industry, universities, payers, and patient organizations. Regulatory science is the science of developing new tools, standards, and approaches to evaluate the efficacy, safety, quality, and performance of medical products in order to assess benefit/risk and facilitate a sound and transparent regulatory decision making throughout development and life cycle management.
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Affiliation(s)
- Per Spindler
- 1 Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,2 Biopeople, University of Copenhagen, Copenhagen, Denmark
| | - Karin F Bach
- 1 Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,3 Copenhagen Centre for Regulatory Science, Copenhagen, Denmark
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33
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Oye KA, Eichler HG, Hoos A, Mori Y, Mullin TM, Pearson M. Pharmaceuticals Licensing and Reimbursement in the European Union, United States, and Japan. Clin Pharmacol Ther 2016; 100:626-632. [DOI: 10.1002/cpt.505] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 08/22/2016] [Accepted: 08/28/2016] [Indexed: 12/26/2022]
Affiliation(s)
- KA Oye
- Massachusetts Institute of Technology; Cambridge Massachusetts USA
| | | | | | - Y Mori
- Ministry of Education, Culture, Sports, Science and Technology (MEXT); Tokyo Japan
| | - TM Mullin
- U.S. Food and Drug Administration; Silver Spring Maryland USA
| | - M Pearson
- Organization for Economic Cooperation and Development; Paris France
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35
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Healy MJ, Tong W, Ostroff S, Eichler HG, Patak A, Neuspiel M, Deluyker H, Slikker W. Regulatory bioinformatics for food and drug safety. Regul Toxicol Pharmacol 2016; 80:342-7. [PMID: 27208439 DOI: 10.1016/j.yrtph.2016.05.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 05/16/2016] [Indexed: 10/21/2022]
Abstract
"Regulatory Bioinformatics" strives to develop and implement a standardized and transparent bioinformatic framework to support the implementation of existing and emerging technologies in regulatory decision-making. It has great potential to improve public health through the development and use of clinically important medical products and tools to manage the safety of the food supply. However, the application of regulatory bioinformatics also poses new challenges and requires new knowledge and skill sets. In the latest Global Coalition on Regulatory Science Research (GCRSR) governed conference, Global Summit on Regulatory Science (GSRS2015), regulatory bioinformatics principles were presented with respect to global trends, initiatives and case studies. The discussion revealed that datasets, analytical tools, skills and expertise are rapidly developing, in many cases via large international collaborative consortia. It also revealed that significant research is still required to realize the potential applications of regulatory bioinformatics. While there is significant excitement in the possibilities offered by precision medicine to enhance treatments of serious and/or complex diseases, there is a clear need for further development of mechanisms to securely store, curate and share data, integrate databases, and standardized quality control and data analysis procedures. A greater understanding of the biological significance of the data is also required to fully exploit vast datasets that are becoming available. The application of bioinformatics in the microbiological risk analysis paradigm is delivering clear benefits both for the investigation of food borne pathogens and for decision making on clinically important treatments. It is recognized that regulatory bioinformatics will have many beneficial applications by ensuring high quality data, validated tools and standardized processes, which will help inform the regulatory science community of the requirements necessary to ensure the safe introduction and effective use of these applications.
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Affiliation(s)
- Marion J Healy
- Food Standards Australia New Zealand, Barton, Australian Capital Territory, 2905, Australia.
| | - Weida Tong
- National Center for Toxicological Research, US Food and Drug Administration, Jefferson, AR, 72079-9502, USA.
| | - Stephen Ostroff
- US Food and Drug Administration, Silver Spring, MD, 20993-0002, USA.
| | | | - Alex Patak
- European Commission, Joint Research Centre, Ispra, Varese, 21027, Italy.
| | | | | | - William Slikker
- National Center for Toxicological Research, US Food and Drug Administration, Jefferson, AR, 72079-9502, USA.
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Affiliation(s)
- Hans-Georg Eichler
- From the European Medicines Agency, London (H.-G.E., G.R.); European Medicines Agency Management Board, London (H.H., K.B.); Medical University of Vienna, Vienna (H.-G.E.); College ter Beoordeling van Geneesmiddelen, Utrecht, the Netherlands (H.H.); Bundesinstitut für Arzneimittel und Medizinprodukte, Bonn, Germany (K.B.); and the University of Rome Tor Vergata, Rome (G.R.)
| | - Hugo Hurts
- From the European Medicines Agency, London (H.-G.E., G.R.); European Medicines Agency Management Board, London (H.H., K.B.); Medical University of Vienna, Vienna (H.-G.E.); College ter Beoordeling van Geneesmiddelen, Utrecht, the Netherlands (H.H.); Bundesinstitut für Arzneimittel und Medizinprodukte, Bonn, Germany (K.B.); and the University of Rome Tor Vergata, Rome (G.R.)
| | - Karl Broich
- From the European Medicines Agency, London (H.-G.E., G.R.); European Medicines Agency Management Board, London (H.H., K.B.); Medical University of Vienna, Vienna (H.-G.E.); College ter Beoordeling van Geneesmiddelen, Utrecht, the Netherlands (H.H.); Bundesinstitut für Arzneimittel und Medizinprodukte, Bonn, Germany (K.B.); and the University of Rome Tor Vergata, Rome (G.R.)
| | - Guido Rasi
- From the European Medicines Agency, London (H.-G.E., G.R.); European Medicines Agency Management Board, London (H.H., K.B.); Medical University of Vienna, Vienna (H.-G.E.); College ter Beoordeling van Geneesmiddelen, Utrecht, the Netherlands (H.H.); Bundesinstitut für Arzneimittel und Medizinprodukte, Bonn, Germany (K.B.); and the University of Rome Tor Vergata, Rome (G.R.)
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Henshall C, Sansom L, Eichler HG, Lemgruber A, Longson C, O’Rourke B, Tunis S. Understanding the Role and Evidence Expectations of Health Technology Assessment and Coverage/Payer Bodies: What Are They Looking for, and How and Why Does This Differ From What Regulators Require? Ther Innov Regul Sci 2014; 48:341-346. [DOI: 10.1177/2168479013512488] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Affiliation(s)
- Sergio Bonini
- From the European Medicines Agency (S.B., H.-G.E., N.W., G.R.), London; the Second University of Naples, Naples, Italy (S.B.); the Institute of Translational Pharmacology, Italian National Research Council (S.B.), and the University of Rome Tor Vergata (G.R.) - both in Rome; and the Medical University of Vienna, Vienna (H.-G.E.)
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Berntgen M, Gourvil A, Pavlovic M, Goettsch W, Eichler HG, Kristensen FB. Improving the contribution of regulatory assessment reports to health technology assessments--a collaboration between the European Medicines Agency and the European network for Health Technology Assessment. Value Health 2014; 17:634-41. [PMID: 25128058 DOI: 10.1016/j.jval.2014.04.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 03/07/2014] [Accepted: 04/04/2014] [Indexed: 05/22/2023]
Abstract
In response to a recommendation from the Pharmaceutical Forum, the European Medicines Agency and the European network for Health Technology Assessment initiated a collaboration with the aim to improve the contribution regulatory assessment reports can make to the assessment of relative effectiveness of medicinal products by health technology assessment bodies. This collaboration on improving European Public Assessment Reports (EPARs) started in February 2010 and was performed over 2 years. As a result, the templates for preparing EPARs were revised to better address the needs of heath technology organizations. The better understanding of information needs was a key outcome of the collaboration. To ascertain whether these template changes led to the inclusion of relevant information, a review of a small set of EPARs for recently approved medicinal products was carried out in parallel by both the European network for Health Technology Assessment and the European Medicines Agency. This report provides an account of this project on improving EPARs, which is part of the ongoing dialogue between regulators and health technology assessment bodies on a European level to support policymaker decisions in the future.
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Affiliation(s)
| | - Anne Gourvil
- La Haute Autorité de Santé, Saint-Denis La Plaine Cedex, France
| | - Mira Pavlovic
- La Haute Autorité de Santé, Saint-Denis La Plaine Cedex, France
| | - Wim Goettsch
- National Health Care Institute, Diemen, The Netherlands
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Baird LG, Trusheim MR, Eichler HG, Berndt ER, Hirsch G. Comparison of Stakeholder Metrics for Traditional and Adaptive Development and Licensing Approaches to Drug Development. Ther Innov Regul Sci 2013; 47:474-483. [PMID: 30235525 DOI: 10.1177/2168479013487355] [Citation(s) in RCA: 14] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study evaluates whether an adaptive development and licensing approach to drug development, compared with approaches widely used today, might have tangible advantages across stakeholder groups, thereby facilitating the future adoption. Details involving actual and modeled clinical development and licensing programs for 3 case studies were used as inputs into a discounted cash flow spreadsheet model. Outputs included net present value and expected net present value, which are metrics considered as key incentives for pharmaceutical developers, and change in patient access over the product life and numbers of appropriately and inappropriately treated patients, which are metrics considered as key incentives for regulators, patients, and prescribers. Actual and modeled development programs were compared using an "adaptiveness" scoring algorithm. Generally, the more adaptive programs correlated with more favorable stakeholder outcomes. However, favorable outcomes may be overwhelmed in some cases, and the causative conditions and stakeholder reactions need to be defined.
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Affiliation(s)
- Lynn G Baird
- 1 Center for BioMedical Innovation, Massachusetts Institute of Technology, Cambridge, MA, USA.,These authors contributed equally to this work
| | - Mark R Trusheim
- 2 Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA.,These authors contributed equally to this work
| | | | | | - Gigi Hirsch
- 1 Center for BioMedical Innovation, Massachusetts Institute of Technology, Cambridge, MA, USA
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Affiliation(s)
- Alasdair Breckenridge
- UK Emerging Science and Bioethics Advisory Committee, Department of Health, Richmond House, 79 Whitehall, London SW1 2NS, UK.
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Ehmann F, Papaluca Amati M, Salmonson T, Posch M, Vamvakas S, Hemmings R, Eichler HG, Schneider CK. Gatekeepers and Enablers: How Drug Regulators Respond to a Challenging and Changing Environment by Moving Toward a Proactive Attitude. Clin Pharmacol Ther 2013; 93:425-32. [DOI: 10.1038/clpt.2013.14] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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47
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Putzeist M, Mantel-Teeuwisse AK, Aronsson B, Rowland M, Gispen-de Wied CC, Vamvakas S, Hoes AW, Leufkens HGM, Eichler HG. Factors influencing non-approval of new drugs in Europe. Nat Rev Drug Discov 2012. [DOI: 10.1038/nrd3894] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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49
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Abstract
Hans-Georg Eichler from the European Medicines Agency and colleagues provide a view from regulators on access to clinical trial data.
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50
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Maxwell S, Eichler HG, Bucsics A, Haefeli WE, Gustafsson LL. e-SPC - delivering drug information in the 21st century: developing new approaches to deliver drug information to prescribers. Br J Clin Pharmacol 2012; 73:12-5. [PMID: 21470290 DOI: 10.1111/j.1365-2125.2011.03981.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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