Phase 3 adaptive trial design options in treatment of complicated urinary tract infection.

New antimicrobial drugs for treatment of complicated urinary tract infection (cUTI) are generally assessed in randomized, double-blind, noninferiority clinical trials. Robust historical data for the active comparator inform on treatment effect estimation, yet typically do not substitute for the active comparator data in the proposed trial. We report design options for a phase 3 trial of cUTI using a Bayesian hierarchical model and historical data from 2 well-executed phase 3 registrational trials of doripenem. The methodology is directly applicable to other phase 3 noninferiority settings. In addition to the research design application, we provide a novel methodology for assessing the robustness of type I error control. The model borrows heavily from the prior data when the current active comparator parameter estimate approximated the historical estimate. In contrast, the model had restricted borrowing when the 2 estimates were very different. The alternative trial design, with or without the inclusion of futility stopping criteria, provides a framework for future cUTI phase 3 trials.

Challenges and solutions for clinical development of new antibacterial agents: results of a survey among pharmaceutical industry professionals.

As the number of antibacterial medicines in the pipeline remains low, we anonymously surveyed pharmaceutical industry professionals on challenges and solutions for clinical development of these agents. Challenges were reported primarily as financial and regulatory. For multidrug-resistant organisms, there are needs for rapid diagnostic tests, new regulatory guidance, and adaptation of endpoints/trial designs. Regulators and public/private initiatives are addressing these challenges to help ensure that proposed solutions have the support of all involved stakeholders.

Statistical considerations associated with a comprehensive regulatory framework to address the unmet need for new antibacterial therapies.

At present, there are situations in antibiotic drug development where the low number of enrollable patients with key problem pathogens makes it impossible to conduct fully powered non-inferiority trials in the traditional way. Recent regulatory changes have begun to address this situation. In parallel, statistical issues regarding the application of alternative techniques, balancing the unmet need with the level of certainty in the approval process, and the use of additional sources of data are critical areas to increase development feasibility. Although such approaches increase uncertainty compared with a traditional development program, this will be necessary to allow new agents to be made available. Identification of these risks and explicit discussion around requirements in these areas should help clarify the situation, and hence, the feasibility of developing drugs to treat the most concerning pathogens before the unmet need becomes even more acute than at present.

Systematic review and meta-analysis of antimicrobial treatment effect estimation in complicated urinary tract infection.

Noninferiority trial design and analyses are commonly used to establish the effectiveness of a new antimicrobial drug for treatment of serious infections such as complicated urinary tract infection (cUTI). A systematic review and meta-analysis were conducted to estimate the treatment effects of three potential active comparator drugs for the design of a noninferiority trial. The systematic review identified no placebo trials of cUTI, four clinical trials of cUTI with uncomplicated urinary tract infection as a proxy for placebo, and nine trials with reports of treatment effect estimates for doripenem, levofloxacin, or imipenem-cilastatin. In the meta-analysis, the primary efficacy endpoint of interest was the microbiological eradication rate at the test-of-cure visit in the microbiological intent-to-treat population. The estimated eradication rates and corresponding 95% confidence intervals (CI) were 31.8% (26.5% to 37.2%) for placebo, 81% (77.7% to 84.2%) for doripenem, 79% (75.9% to 82.2%) for levofloxacin, and 80.5% (71.9% to 89.1%) for imipenem-cilastatin. The treatment effect estimates were 40.5% for doripenem, 38.7% for levofloxacin, 34.7% for imipenem-cilastatin, and 40.8% overall. These treatment effect estimates can be used to inform the design and analysis of future noninferiority trials in cUTI study populations.

Pharmacokinetics, safety, and tolerability of BMS-986263, a lipid nanoparticle containing HSP47 siRNA, in participants with hepatic impairment.

BMS-986263 is a retinoid-conjugated lipid nanoparticle delivering small interfering RNA designed to inhibit synthesis of HSP47 protein, a collagen-specific chaperone protein involved in fibrosis development. This is a phase I, open-label, two-part study evaluating pharmacokinetics and safety of BMS-986263 in participants with hepatic impairment (HI). Part 1 (n = 24) of this study enrolled two cohorts with mild and moderate HI and a separate cohort of age- and body mass index (BMI)-matched participants with normal hepatic function. Part 2 enrolled eight participants with severe HI and eight age- and BMI-matched participants with normal hepatic function. All participants received a single intravenous 90 mg BMS-986263 infusion. Compared with normal-matched participants, geometric mean area under the plasma concentration-time curve time zero to the time of the last quantifiable concentration (AUC(0-T) ) and AUC from zero to infinity (AUC(INF) ) of HSP47 siRNA were similar in participants with mild HI and 34% and 163% greater in those with moderate and severe HI, respectively, whereas the maximum plasma concentration was ~25% lower in mild and moderate HI groups but 58% higher in the severe HI group than in the normal group. Adverse events were reported by two of eight, four of eight, and three of eight participants with mild, moderate, or severe HI, respectively; none were reported in the normal-matched group. Overall, single-dose BMS-986263 was generally safe and well-tolerated and dose adjustment is not considered necessary for participants with mild or moderate HI. Although available data do not indicate that dose adjustment should be performed in patients with severe HI; the optimal posology of BMS-986263 in patients with severe HI may be determined later in its clinical development when additional data to establish exposure-safety/efficacy relationship becomes available.

A Mathematical Model for the First-Pass Dynamics of Antibiotics Acting on the Cardiovascular System.

We present a preliminary first-pass dynamic model for delivery of drug compounds to the lungs and heart. We use a compartmental mass balance approach to develop a system of nonlinear differential equations for mass accumulated in the heart as a result of intravenous injection. We discuss sensitivity analysis as well as methodology for minimizing mass in the heart while maximizing mass delivered to the lungs on a first circulatory pass.

An evaluation of logistic regression models for predicting amphipod toxicity from sediment chemistry.

An empirical screening level approach was developed to assess the probability of toxicity to benthic organisms associated with contaminated sediment exposure. The study was based on simple logistic regression models (LRMs) of matching sediment chemistry and toxicity data retrieved from a large database of field-collected sediment samples contaminated with multiple chemicals. Three decisions were made to simplify the application of LRMs to sediment samples contaminated with multiple chemicals. First, percent mortality information associated with each sediment sample was condensed into a dichotomous response (i.e., toxic or nontoxic). Second, each LRM assumed that toxicity was attributable to a single contaminant. Third, individual contaminants present at low concentrations were excluded from toxic sediment samples. Based on an analysis of the National Sediment Inventory database, the LRM approach classified 55% of nontoxic sediments as toxic (i.e., false-positives). Because this approach has been used to assess the probability of benthic toxicity as reported by the U.S. Environmental Protection Agency (U.S. EPA), the resultant estimates of potential toxicity convey a misleading impression of the increased hazard that sediments pose to the health of aquatic organisms at many sites in the United States. This could result in important resources needlessly being diverted from truly contaminated sites to evaluate and possibly remediate sediments at uncontaminated sites.

Model-based drug development: strengths, weaknesses, opportunities, and threats for broad application of pharmacometrics in drug development.

Systematic implementation of model-based drug development (MBDD) to drug discovery and development has the potential to significantly increase the rate of medical breakthroughs and make available new and better treatments to patients. An analysis of the strengths, weaknesses, opportunities, and threats (ie, SWOT) was conducted through focus group discussions that included 24 members representing 8 pharmaceutical companies to systematically assess the challenges to implementing MBDD into the drug development decision-making process. The application of the SWOT analysis to the successful implementation of MBDD yielded 19 strengths, 27 weaknesses, 34 opportunities, and 22 threats, which support the following conclusions. The shift from empirical drug development to MBDD requires a question-based mentality; early, proactive planning; dynamic access to multisource data; quantitative knowledge integration; multidisciplinary collaboration; effective communication and leadership skills; and innovative, impactful application of pharmacometrics focused on enhancing quantitative decision making. The ultimate goal of MBDD is to streamline discovery and development of innovative medicines to benefit patients.

Model-based drug development survey finds pharmacometrics impacting decision making in the pharmaceutical industry.

During the past decade, the pharmaceutical industry has seen the increasing application of pharmacometrics approaches in drug development. However, the full potential of incorporating model-based approaches in drug development and its impact on decision making has not been fully realized to date. In 2009, a survey on model-based drug development (MBDD) was conducted (1) to further understand the current state of MBDD in the pharmaceutical industry and (2) to identify opportunities to realize the full potential of MBDD. Ten large and mid-sized pharmaceutical companies provided responses to this survey. The results indicate that MBDD is achieving broad application in early and late development and is positively affecting both internal and regulatory decisions. Senior leadership (vice president and higher) within the companies indicated widely accepted utility for dose selection and gaining acceptance for study design and regulatory interactions but limited acceptance in discovery and commercial/pipeline decisions. Mounting appreciation for the impact of MBDD on internal and regulatory decision-making bodes well for the future of the pharmacometric discipline and the growth of opportunities to realize the full potential of MBDD.

A TEST OF THE SPONTANEOUS HETEROSIS HYPOTHESIS FOR UNISEXUAL VERTEBRATES.

The coupling between clonal modes of reproduction and hybridization in unisexual vertebrates has led to the hypothesis that heterosis accounts for their ecological success (the "spontaneous heterosis" hypothesis). High levels of genic heterozygosity characteristic of unisexual-hybrid vertebrates are believed to result in enhanced growth, survivorship, and fertility relative to their sexual ancestors. To test this hypothesis, we synthesized 33 new unisexual-hybrid strains of fishes in the genus Poeciliopsis (Atheriniformes: Poeciliidae). On average, the synthetic unisexuals had lower survivorship and a higher incidence of birth defects than either of the sexual ancestors or two natural strains of unisexuals. However, a subset of these synthetic unisexuals exhibited characteristics within the range of the sexual ancestors and natural unisexual strains. These results support the alternative hypothesis that the ecological success of natural unisexuals results from selection of the most fit clones from a broad spectrum of genotypes that arose via multiple hybrid events. We propose that the coupling between unisexuality and hybridization in the vertebrates exists because hybridization is a dysgenic process that can disrupt normal gametogenesis and thus lead to clonal reproduction.

BALANCING SELECTION IN A DESERT STREAM-DWELLING FISH, POECILIOPSIS MONACHA.

The desert stream-dwelling fish Poeciliopsis monacha is exposed to extreme seasonal and spatial variation in physical stresses. We examined four diallelic gene loci (Ldh-1, Idh-2, Pgd, and Ck-A) in P. monacha and tested whether genotypes were associated with differential survival of individuals exposed to acute stress. For each locus, the common allele was associated with higher survival during heat and hypoxic stress, whereas the alternate allele was associated with higher survival during cold stress. In most cases, survival of heterozygotes was intermediate and they exhibited less variance in survival than corresponding homozygotes. Identification of substantial linkage disequilibrium in these fish confounds our ability to discern whether the allozymes are the direct targets of selection, or if they just mark chromosomal regions that contain the true modifiers of survival. Nevertheless, the present results clearly identified balancing processes that can serve to stabilize genetic polymorphism in this species.

GENOTYPIC AND ENVIRONMENTAL COMPONENTS OF VARIATION IN GROWTH AND REPRODUCTION OF FISH HEMICLONES (POECILIOPSIS: POECILIIDAE).

The frozen-niche-variation model was proposed to account for the coexistence of genetically related clones in naturally occurring unisexual populations. This model is based on two assumptions: 1) ecologically different clones have multiple independent origins from sexual ancestors; and 2) the population of sexual ancestors contains genetic variability for ecologically relevant traits. To test these assumptions, we produced 14 new "hemiclones" (nonrecombining haploid genotypes) of fish (Poeciliopsis: Poeciliidae). Our ability to synthesize many new hemiclones demonstrates the feasibility of multiple independent origins of nonrecombining genotypes. A substantial proportion (10-50%) of the phenotypic variation among hemiclones in size at birth, juvenile growth rate, and fecundity had a genetic basis. Thus, we conclude that multiple origins can give rise to an assemblage of genetically distinct hemiclones, each with a unique combination of life-history traits. Additionally, a comparative analysis of two natural hemiclones revealed that the synthetic strains represent a broad field of variation from which natural hemiclones can be selected.