Practical approaches to dose selection for first-in-human clinical trials with novel biopharmaceuticals

Recent advances in our understanding of disease biology, biomarkers, new therapeutic targets, and innovative modalities have each fueled a dramatic expansion in the development of novel human therapeutics. Many are biotechnology-derived biologics possessing high selectivity and affinity for their intended target; as such they often pose challenges in the development path to approval. One challenge is the selection of the first-in-human (FIH) dose. This process has come under increased scrutiny as a result of a FIH trial with a super-agonist monoclonal antibody (TGN1412), which resulted in significant injury to healthy volunteers. Regulatory agencies have responded with supplemental guidance for the development of novel therapeutics. The intent of this paper is to provide experience-based insight, with relevant examples, for those planning the first administration of novel biopharmaceuticals in humans.     

对健康成人志愿者进行临床试验的药物安全起始剂量估计

推荐一种确定在健康成人志愿者进行新药临床试验的最大推荐起始剂量(MRSD)的方法.将相关动物研究得到的不良反应未明显增加的最高剂量(NOAEL)用标准系数换算成人等效剂量(HED),根据科学判断,从最合适动物得到的HED除以安全系数(SF)得到MRSD.这种计算方法可用于已做动物研究的新药或新的生物制剂确定MRSD,但不包括预防性疫苗和用生理浓度的内生蛋白.     

美国食品和药物管理局对临床试验中学术行为不端的监管

临床试验中的行为不端不仅仅是学术腐败,它使得临床试验的受试者安全受到威胁,临床试验的过程失去可信度;使得申办者提交数据的有效性和公正性大打折扣,失去公信力。美国食品和药物管理局对临床试验中的欺诈行为实施零容忍,研究者将面临取消研究资格和执业资格,甚至涉及罚款、监禁和法律诉讼。必须对药物临床试验中的行为不端,采取积极预防措施,实施严厉行政监管。     

美国FDA对新药临床试验申办者和合同研究组织的监管模式

申办者或受其委托的合同研究组织(CRO)是药物临床试验的发起者和管理者,是保证药物临床试验质量的关键责任方。对其实施有效监管应当是药物临床试验监管的重要环节。而我国目前对药物临床试验申办者和CRO的监管措施及监督检查机制尚未健全。本文介绍了美国食品和药物管理局(FDA)对新药临床试验申办者和CRO的监管模式,并总结其中有益的监管经验,以供借鉴。     

United States Food and Drug Administration approach to risk evaluation and risk management for foods

The Food and Drug Administration (FDA) is developing a comprehensive program on risk evaluation and risk management related to foods and food ingredients. Various groups view the FDA differently in terms of potential food hazards, but the regulatory agency is required to follow the laws that reflect a set of social judgments about permissible risks and benefits. The traditional agency approaches to risk management are reviewed and recent plins to consider structural changes in the basic food statute that could lead to greater administrative flexibility are presented. The proposed tentative suggestions discussed embody basic principles that the public health and trust remain the focus of food safety laws. Public confidence in the present system must be retained, it must be a credible system, embody valid scientific data, and the regulatory actions must be taken by FDA scientists who are recognized for their scientific competence. All the proposed actions need to be taken without placing unnecessary economic burdens on industry. The scope of this program is reviewed.     

人体耐受性试验中体重因素对人体等效剂量转换计算的影响

临床健康人体耐受性试验最大推荐起始剂量(maximumrecommended starting dose,MRSD)一般是将相关动物研究得到的无明显不良反应的最高剂量(no observed adverse effect level,NOAEL)用标准系数换算成人体等效剂量(human equivalent dose,HED),根据科学判断,从最合适动物得到的HED除以安全系数(safetyfactor,SF)得到MRSD。本文论述了体重因素对HED转换计算的影响。     

Implementation of a Reference-Scaled Average Bioequivalence Approach for Highly Variable Generic Drug Products by the US Food and Drug Administration

Highly variable (HV) drugs are defined as those for which within-subject variability (%CV) in bioequivalence (BE) measures is 30% or greater. Because of this high variability, studies designed to show whether generic HV drugs are bioequivalent to their corresponding HV reference drugs may need to enroll large numbers of subjects even when the products have no significant mean differences. To avoid unnecessary human testing, the US Food and Drug Administration’s Office of Generic Drugs developed a reference-scaled average bioequivalence (RSABE) approach, whereby the BE acceptance limits are scaled to the variability of the reference product. For an acceptable RSABE study, an HV generic drug product must meet the scaled BE limit and a point estimate constraint. The approach has been implemented successfully. To date, the RSABE approach has supported four full approvals and one tentative approval of HV generic drug products.     

基于美国FDA不良事件报告数据库的贝拉西普不良反应数据挖掘

目的:挖掘贝拉西普相关不良反应风险信号,为其临床安全应用提供参考.方法:采用报告比值比(ROR)法对美国FDA不良事件报告系统(FAERS)中2011年第3季度至2019年第4季度收到的贝拉西普为首要怀疑(PS)药物的不良事件进行挖掘.检测阈值为报告数≥3且ROR的95％置信区间(CI)下限>1的不良事件.采用国际医学...     

New era in drug interaction evaluation: US Food and Drug Administration update on CYP enzymes, transporters, and the guidance process

Predicting clinically significant drug interactions during drug development is a challenge for the pharmaceutical industry and regulatory agencies. Since the publication of the US Food and Drug Administration's (FDA's) first in vitro and in vivo drug interaction guidance documents in 1997 and 1999, researchers and clinicians have gained a better understanding of drug interactions. This knowledge has enabled the FDA and the industry to progress and begin to overcome these challenges. The FDA has continued its efforts to evaluate methodologies to study drug interactions and communicate recommendations regarding the conduct of drug interaction studies, particularly for CYP-based and transporter-based drug interactions, to the pharmaceutical industry. A drug interaction Web site was established to document the FDA's current understanding of drug interactions (http://www.fda.gov/cder/drug/drugInteractions/default.htm). This report provides an overview of the evolution of the drug interaction guidances, includes a synopsis of the steps taken by the FDA to revise the original drug interaction guidance documents, and summarizes and highlights updated sections in the current guidance document, Drug Interaction Studies-Study Design, Data Analysis, and Implications for Dosing and Labeling.     

美国FDA哨点行动及其对我国食品药品监管数据管理的启示

目的：介绍美国FDA哨点行动背景、项目、内容、特点,为我国食品药品监管数据共享利用和管理提供参考。方法：使用文献研究的方法,围绕美国食品药品管理局哨点行动计划收集材料并梳理分析。结果与结论：信息化和大数据时代背景下数据资源共享与食品药品监管业务工作密不可分;顶层支持有助于数据协同共享等工作开展;分布式数据管理模式值得借鉴;产学研结合有助于开展数据分析挖掘;相关方广泛参与有助于从源头保障数据质量。     

Comments on the draft guidance on "adaptive design clinical trials for drugs and biologics" of the U.S. Food and Drug Administration

The U.S. FDA has published a draft guidance on "Adaptive Design Clinical Trials for Drugs and Biologics", which gives regulatory guidance on methodological issues in exploratory and confirmatory clinical trials planned with an adaptive design. This comment summarizes the discussion within the joint working group "Adaptive Designs and Multiple Testing Procedures" of the Austro-Swiss and German regions of the International Biometric Society held at the 90-day public comment period in spring 2010.     

Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: a replication analysis of the Food and Drug Administration Database

The assumption that depressed patients who are assigned to placebo in antidepressant clinical trials are exposed to substantial morbidity and mortality has not been based on research data. Because of worldwide concern about placebo use and the implications of our earlier findings of no increased suicide risk in placebo-treated patients, we conducted a replication study in a new patient sample. We assessed suicide risk and symptom reduction among placebo-treated patients participating in antidepressant clinical trials for two recently approved antidepressants, venlafaxine ER and citalopram, which were unavailable during our previous study. Among 23,201 participant patients, 32 committed suicide and 172 attempted suicide. Rates of suicide and attempted suicide did not differ significantly among the placebo- and drug-treated groups. Based on patient exposure years, annual rates of suicide and attempted suicide were 0.5 and 6.7% with placebo, 0.9% with active comparator (rates for attempted suicide are unavailable), and 0.6 and 6.3% with investigational antidepressants. Symptom reduction was 47.9% with investigational drugs (n = 1172), 47.5% with active comparators (n = 161), and 35.5% with placebo (n = 606). These data may inform discussions about the use of placebo in antidepressant clinical trials.     

Liver injury with novel oral anticoagulants: assessing post-marketing reports in the US Food and Drug Administration adverse event reporting system

Aim

We assessed the hepatic safety of novel oral anticoagulants (NOACs) analyzing the publicly available US-FDA adverse event reporting system (FAERS).

Methods

We extracted reports of drug-induced liver injury (DILI) associated with NOACs, including acute liver failure (ALF) events. Based on US marketing authorizations, we performed disproportionality analyses, calculating reporting odds ratios (RORs) with 95% confidence interval (CI), also to test for event- and drug-related competition bias, and case-by-case evaluation for concomitant medications.

Results

DILI reports represented 3.7% (n = 146) and 1.7% (n = 222) of all reports for rivaroxaban and dabigatran, respectively. No statistically significant association was found for dabigatran, in primary and secondary analyses. Disproportionality signals emerged for rivaroxaban in primary analysis (ALF: n = 25, ROR = 2.08, 95% CI 1.34, 3.08). In a large proportion of DILI reports concomitant hepatotoxic and/or interacting drugs were recorded: 42% and 37% (rivaroxaban and dabigatran, respectively), especially statins, paracetamol and amiodarone. Among ALF reports, fatal outcome occurred in 49% of cases (44% and 51%, rivaroxaban and dabigatran, respectively), whereas rapid onset of the event (<1 week) was detected in 46% of patients (47% and 44%, respectively).

Conclusions

The disproportionality signal for rivaroxaban calls for further comparative population-based studies to characterize and quantify the actual DILI risk of NOACs, taking into account drug- and patient-related risk factors. As DILI is unpredictable, our findings strengthen the role of (a) timely pharmacovigilance to detect post-marketing signals of DILI through FAERS and other data sources, (b) clinicians to assess early, on a case-by-case basis, the potential responsibility of NOACs when they diagnose a liver injury.     

A review of the Food and Drug Administration risk analysis for polychlorinated biphenyls in fish

This paper reviews the Food and Drug Administration (FDA) analysis of the risk to humans from consuming fish contaminated with polychlorinated biphenyls (PCBs). In brief, the FDA methodology employed "high" dose experiments on animals and extrapolated the observed rates of certain types of cancer at these elevated doses to the low doses found in human diets. These extrapolations were then used to define a recommended tolerance level of 5 ppm, and proposed reduction to 2 ppm, for fish sold in interstate commerce. Unfortunately, as is shown here, such a procedure is extremely sensitive to the basis for extrapolation. Important elements of the FDA analysis include the following: (i) FDA assumed a particular form of the dose-response model: the one-hit model. Many other models have been proposed and, on balance, appear equally plausible. These models estimate lower risks than does the one-hit model. (ii) FDA calculated 99% upper confidence bounds on these risks and, moreover, emphasized cases of fish eaters who consume greater amounts of PCB-contaminated fish than do 98.5% of the U.S. population. (iii) FDA based PCB ingestion computations on consumption of raw fish, whereas most fish are cooked before eating, and it is known that PCB levels in cooked fish are lower than PCB levels in raw fish. (iv) FDA based estimates of cancer risk on the assumption that PCB levels in fish would be constant over the nominal 70-year human life span used in the FDA "lifetime risk" computation. Recent data suggest that PCB levels have been declining in fish (particularly in sport fish) and humans as well. Such trends imply significantly lower cumulative lifetime PCB doses than were assumed in the FDA analysis. (v) FDA assumed that humans and test animals are equally sensitive to PCB ingestion when measured on a parts per million in diet basis. Extrapolations on an equivalent consumption per unit of body weight, thought appropriate by most researchers, result in much lower health risks. In short, when confronted with methodological choices, the FDA consistently selected "worst case" or conservative assumptions over other alternatives of at least equal plausibility. This philosophy of choice was explicitly acknowledged by the FDA. What was omitted from the FDA analysis, however, was the possible degree of overstatement of these risks. The results of replicate risk computations using alternative assumptions to examine the possible magnitude of overstatement of health risk are summarized in Table 12. As can be seen, this overstatement could easily account for a discrepancy of several orders of magnitude between actual and calculated risks.(ABSTRACT TRUNCATED AT 400 WORDS)