Sequential research-related biopsies in phase I trials: acceptance, feasibility and safety.

BACKGROUND: Sequential tumour biopsies are of potential interest for the rational development of molecular targeted therapies. PATIENTS AND METHODS: From June 2004 to July 2009, 186 patients participated in 14 phase I clinical trials in which sequential tumour biopsies (13 trials) and/or sequential normal skin biopsies (6 trials) were optional. All patients had to sign an independent informed consent for the biopsies. RESULTS: Tumour biopsies were proposed to 155 patients and 130 (84%) signed the consent while normal skin biopsies were proposed to 70 patients and 57 (81%) signed the consent. Tumour biopsies could not be carried out in 41 (31%) of the 130 consenting patients. Tumour biopsies were collected at baseline in 33 patients, at baseline and under treatment in 56 patients. Tumour biopsies were obtained using an 18-gauge needle, under ultrasound or computed tomography guidance. Only nine minor complications were recorded. Most tumour biopsy samples collected were intended for ancillary molecular studies including protein or gene expression analysis, comparative genomic hybridization array or DNA sequencing. According to the results available, 70% of the biopsy samples met the quality criteria of each study and were suitable for ancillary studies. CONCLUSIONS: In our experience, the majority of the patients accepted skin biopsies as well as tumour biopsies. Sequential tumour and skin biopsies are feasible and safe during early-phase clinical trials, even when patients are exposed to anti-angiogenic agents. The real scientific value of such biopsies for dose selection in phase I trials has yet to be established.

Acute left ventricular dysfunction induced by a panHER and VEGFR tyrosine kinase inhibitor in a phase I trial.

Tyrosine kinase inhibitors (TKI) or monoclonal antibodies targeting EGFR, HER2 or VEGFR receptors have demonstrated substantial clinical benefit in patients with advanced breast cancer, colon cancer, head and neck cancer, non-small cell lung cancer, and renal cell carcinoma. Nevertheless, these drugs have some target related adverse effects, particularly cardiovascular toxicities. We report here the case of a patient included in a phase I trial of a new compound, a tyrosine kinase inhibitor targeting HER1, HER2, HER4 and VEGFR2. The patient developed during this treatment an acute and transient left ventricular systolic dysfunction. Careful management of this adverse effect allowed the patient to continue therapy and to achieve a major partial response.

A safety grading scale to support dose escalation and define stopping rules for healthy subject first-entry-into-man studies: some points to consider from the French Club Phase I working group.

AIM: To propose a relevant grading scale for clinical adverse events or laboratory results, electrocardiogram (ECG) and vital sign findings supporting both dose escalation and stopping decisions in first-entry-into-man (FIM) studies conducted in young healthy subjects. METHODS: A three-level scale was used for the proposed grading system. The grading is directly derived from the observed severity of discontinuous variables, as are most of clinical adverse events. A 'combined method' based on normal ranges and spontaneous variation is suggested for grading the findings which are continuous variables mainly numerical in nature. One grade, at the subject level, and one algorithm, at the cohort level, support the proposed decision rules. This work was managed by a Club Phase I working group. RESULTS: Examples of grade 1, 2 and 3 limits are given for the most frequent clinical adverse events and laboratory tests, ECG and vital sign findings. When available, the proposed NIH and FDA limits are also provided. The safety recommendation is to use the grade 2 at least as an alert for caution and the grade 3 as a maximum for stopping, applying the algorithm at the cohort level. CONCLUSIONS: This paper proposes a safety grading system based on relevant criteria which might be used by investigators and sponsors to support and rationalize dose escalation decisions in healthy young subject FIM studies. These proposals are designed not to be a guideline but some 'points to consider' helping the dose escalation process. This paper supports the recent reinforcement of the safety requirements for FIM studies by European authorities.

The safety of healthy volunteers in First-in-Man trials - an analysis of studies conducted at the Bayer in-house ward from 2000 to 2005.

OBJECTIVE: The Northwick Park incident has focused the attention on the risk of healthy volunteers participating in Phase I First-in-Man (FiM) studies irrespective of biologicals or small molecules being applied. However, only few data on the safety of healthy volunteers receiving small molecules in FiM trials are available. This study reports on the safety of healthy volunteers participating in single dose FiM studies performed with small molecules at the Bayer in-house study ward in Wuppertal from 2000 to 2005. METHODS: From 2000 to 2005, 24 FiM dose escalation studies with small molecules were performed. Twenty studies were performed with oral formulations and four studies with intravenous formulations. 1,094 young healthy male subjects were included into the studies. 77 subjects dropped out before receiving any study medication. The remaining 1,017 study participants (mean age 31.8 ± 6.5 years (range: 18 - 46 years)) received 1,160 treatments, 792 with active drug and 368 with placebo. RESULTS: In total, 586 adverse events (AE) occurred equaling 0.51 AE/treatment and 0.58 AE/ subject. 128 AEs occurred under placebo (0.35/treatment) and 458 under active drug (0.58/treatment). 98.3% of AEs were of mild or moderate intensity. Adverse events with a frequency > 2% were headache (17.1%), nasopharyngitis (7.3%), flushing (7.0%), feeling hot (5.5%), nausea (4.1%), nasal congestion (3.9%), dizziness (3.4%), diarrhea (3.24%), Alanine aminotransferase (ALT) increase (2.6%) and orthostatic hypotension (2.4%). In only 5 out of 1,160 treatments (0.4%) a serious adverse event occurred. Two cases of hypotension were related to the mode of action of CNS compounds and judged to be drug-related while the other three events (muscle enzyme elevation (2 ×), prolonged orthostatic reaction (1 ×) were not drug-related. None of the serious adverse events was medically worrying or required hospitalization. CONCLUSION: The incidence of adverse events in FiM trials with small molecules in our center between 2000 and 2005 and the severity of AEs is comparable to what has been reported previously for Phase I trials with small molecules [3, 4]. It reflects our experience with FiM trials of more than 25 years in which no medically worrying or hospitalization requiring serious adverse event occurred.

Adverse non-drug-related complaints by healthy volunteers in Phase I studies compared to the healthy general population.

OBJECTIVE: Some complaints that are reported as adverse drug reactions by healthy subjects during participation in Phase I studies are common complaints in healthy individuals from the normal population. The objective of this study was to compare the incidence of complaints in a group of 192 healthy volunteers in Phase I studies with a control group of 112 healthy subjects who matched the Phase I group participants in terms of demographic and socioeconomic characteristics, and to investigate the relationship between some psychological factors and the incidence of complaints. METHODS: Both groups completed a questionnaire on the incidence of complaints during the previous 2 - 4 weeks. Trait anxiety was assessed by the trait scale of the State-Trait Anxiety Inventory (STAI-T), depressive mood by the Beck's Depression Inventory-II (BDI-II) and perceived self-efficacy by the Self-Efficacy Scale (SES). RESULTS: Compared to the control group, Phase I volunteers presented a significantly lower incidence of stomach pain, back pain, limb or joint pain, headaches, fainting spells, palpitations, shortness of breath, constipation, loose stools or diarrhea, nausea, gas or indigestion, feeling nervous or anxious, feeling restless, getting tired very easily, muscle tension, aches, or soreness, and concentration difficulties. Significant positive correlations were found between the STAI-T and BDI-II scores and the incidence of several complaints; inversely, the SES score correlated negatively with several complaints. CONCLUSION: The incidence of complaints in healthy subjects is not of a random character and depends on psychological characteristics. Volunteers in Phase I studies are a self-selected sample with a lower tendency to report non-drug-related adverse events than their peers from the general population. The impact of this self-selection bias on the assessment of tolerability during Phase I studies deserves further evaluation.

Microdosing: the new pharmacokinetic paradigm?

Numerous market factors have converged to create a need for change in the drug development process. Public scrutiny, high failure rates for investigational agents, and concern about the use of animals in research, are just a few. In response, some changes in this process are being made. Microdosing--administering very small, radiolabeled doses of investigational agents to humans--is one change that has the potential to save time and money. It is used to elucidate the pharmacokinetic profile of agents. Not all experts agree that it will live up to its promise, but the potential is great.

Monitoring participant safety in phase I and II interventional trials: options and controversies.

BACKGROUND: The need for phase I and II clinical trials to have a data and safety monitoring plan (DSMP) is widely accepted; however, whether and/or when these trials should also have oversight by a data and safety monitoring board (DSMB) is controversial. Monitoring requirements also depend on whether the study is funded by the National Institutes of Health, funded and/or monitored by the US Food and Drug Administration (FDA), or funded by industry. However, there is little guidance about when and how to constitute a DSMB for phase I and II clinical trials. OBJECTIVES: The objectives of this article are to suggest guidelines for when and how to constitute a DSMB for phase I and II studies and to highlight the similarities and differences between DSMBs monitoring phase I and II versus phase III clinical studies. We highlight the utility of these guidelines in the safety monitoring of a mechanism of disease-based study of inhaled nitric oxide for acute vaso-occlusive crisis in pediatric patients with sickle cell disease that was funded and regulated by the FDA. CONCLUSION: The goal of DSMPs regardless of the phase of the clinical trial is to protect participant safety and ensure the integrity and validity of the data. A DSMB can ensure that risks and data are evaluated in a timely, efficient, and unbiased manner. We describe "risk-based" guidelines to determine situations in which a DSMB may be an appropriate addition to a DSMP for phase I and II clinical trials. We also address the roles and responsibilities of the DSMB for these studies.

A placebo arm is not always necessary in clinical trials of amyotrophic lateral sclerosis.

Riluzole is currently the only approved medication for amyotrophic lateral sclerosis (ALS). While other potential neuroprotective agents have been tested in clinical trials, none has been effective, and few symptomatic treatments have been studied. Randomized placebo-controlled trials are necessary to establish the effectiveness of a drug, but an increasing number of potential therapies combined with limited resources means that only a few drugs at a time can be tested for efficacy in ALS. Therefore, priority must be given to agents that show an advantage in early phase trials before proceeding to Phase III efficacy trials. New strategies are being used to screen different agents, along with their correct dose, in a variety of neurological illnesses, including ALS. Early phase trial designs conducted without a placebo arm improve efficiency, reduce cost, and appeal to patients. Dose-ranging, futility, and selection trials are examples of Phase I and II trial designs that can be conducted without placebo groups.

Laboratory data in healthy volunteers: reference values, reference changes, screening and laboratory adverse event limits in Phase I clinical trials.

OBJECTIVE: Laboratory data are key evaluation procedures for Phase I clinical pharmacology for two reasons. Firstly, laboratory data are used within the screening process to exclude subjects with asymptomatic diseases, which could result in increased danger to themselves or confuse interpretation of the study results. Secondly, during study implementation, safety evaluation and in particular maximum tolerated dose determination have to be done by a case-by-case analysis, sometimes using laboratory adverse events (LAEs). Thus, relevant limits are needed to discriminate between a usual common variation and a significant abnormality, which is considered to be a LAE. This report presents laboratory data distribution, reference values and reference changes and, based on previously published new methods, suggests inclusion limits at screening and laboratory adverse event limits for analysis during study implementation. SUBJECTS AND METHODS: Nine hundred and twenty-seven young healthy male volunteers were recruited in one centre (Association de Recherche Thérapeutique). A standard screening process was carried out. Protocols were approved by the local ethics committee. Blood sampling was performed in the same conditions. Reference values (at screening and at baseline) were determined by a non-parametric procedure selecting 2.5% and 97.5% of the distribution of data. Reference changes were also defined as the 2.5-97.5% interval of distribution of the variations between the end of treatment and baseline. Inclusion limit and LAE limit methods of determination used had been specified in previous articles. RESULTS: Detailed results of laboratory data distribution, reference values at screening and at baseline, reference changes, inclusion limits and LAE limits are presented in tables with number of subjects, mean, median, standard deviation, minimal and maximal values and the 2.5-97.5% interval for each laboratory parameter. CONCLUSION: The key aims of this paper are to provide clinical pharmacologists with data, reference values or changes obtained in the real conditions of Phase I study implementation, and to propose relevant limits, either for screening as inclusion limits, or during studies as LAE limits. Thus, these data, reference values and specific limits improve the capacity to screen healthy volunteers and to analyse LAEs during Phase I studies.

Willingness to participate in HIV-1 vaccine efficacy trials and the effect of media events among gay and bisexual men in New York City: Project ACHIEVE.

Efficacy trials of candidate HIV-1 vaccines require study populations at high risk of infection who adhere to study protocols and who are willing to participate. Data from HIV-1 antibody-negative men (n = 698) enrolled in Project ACHIEVE in New York City were analyzed to assess willingness to participate in efficacy trials, factors influencing willingness, and the effect on willingness of the June 1994 media events about the decision not to proceed with phase III trials and about breakthrough infections during phase I and II vaccine trials. Sixty-eight percent indicated they would definitely or probably be willing to participate. Men enrolled during the time of media events were significantly less willing compared with men enrolled during other periods. These men were also more likely to mention safety of the vaccine, fear or mistrust of research or government, and social risks as important factors in their decision compared with men enrolled during other periods. The most frequently cited motivator for participation was altruism (57%); the most frequently cited barriers were vaccine safety (36%) and vaccine-induced seropositivity (19%). A substantial proportion of this cohort was willing to participate in future vaccine efficacy trials. However, because willingness may be affected by issues of vaccine safety, vaccine-induced seropositivity, and media coverage of these issues, significant efforts are needed for participant and community education, and specific concerns must be addressed in the design and implementation of trials.