1 design of dose response clinical trials boston chapter of asa april 10, 2006 naitee ting, pfizer...
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Design of Dose Response Clinical Trials
Boston Chapter of ASAApril 10, 2006
Naitee Ting, Pfizer Global R&D
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Drug Development Process Drug Discovery Non-clinical Development Clinical Development
Phase I Clinical pharmacology (PK/PD, MTD)
Phase II Drug efficacy/safety, dose ranging Phase III Long-term, large scale,
confirmatory Phase IV Post-market
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Phase I Studies (Drugs developed for non-life-threatening diseases) Healthy normal volunteers Single dose Double-blind, placebo controlled,
randomized, dose escalation Clinical pharmacology – PK/PD, MTD Cross-over studies (BA, BE) Answer the question – how often
should we dose the patient?
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Phase II Studies (Non-life-threatening diseases) Patients with the disease under study Dose ranging, efficacy dose response Double-blind, placebo controlled,
randomized, fixed doses Clinical efficacy and safety endpoints Exploratory, estimation of efficacy,
dose,.. Answer the question – how much should
we dose the patient?
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Phase III, IV Studies Phase III studies are for registration
purposes Confirmatory, hypothesis testing Study for target dose(s) Phase IV studies are for larger scale
safety surveillance, or new indication
Change of labeled dose post market is possible
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Concerns in Developing Drugs for Life-Threatening Diseases May not be ethical to use placebo
control May not be ethical to recruit
normal healthy volunteers Open label, single arm, dose
titration study designs
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Challenges in dose selection Every stage of drug development –
from drug discovery to post market What is the right range of doses Individual dose response curves vs
population curve Exposure-response vs dose-response Other challenges (choice of primary
endpoint, multiple comparison, …)
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WHAT ARE THE ISSUES IN DOSE FINDING? Individual versus global responses What are you looking for? What range of doses should we
consider? How many doses to be tested? What are we measuring? The differences in exploration and
confirmation
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INDIVIDUAL VERSUS GLOBAL RESPONSES In most of drugs, we need to
recommend a few fixed doses For wide Therapeutic Index (TI), it is
possible to use one dose Dose response relationship vs
concentration response relationship
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PHARMACOKINETICS (PK), PHARMACODYNAMICS (PD) PK, PD, PK/PD
PK: body act on drug PD: drug act on body
Concentration response uses PK, but should we consider PD?
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WHAT ARE YOU LOOKING FOR A single dose or a range of doses Fixed dose or titration doses As needed or chronic treatment How many doses a day
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DRUG LABEL (Package Insert) Summary Information of the Drug Agreed with Regulatory Agencies Target Product Profile Competitors on Market Easy for Physicians to prescribe
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Pre-clinical
PhaseI
PhaseII
PhaseIII
DrugLabel
Forward: Accumulating information
Backward: Planning Based on Label
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DETERMINING DOSING FREQUENCYDETERMINING DOSING FREQUENCY
When determining dosing frequency, the pharmacodynamics of a compound should be considered as critical as the pharmacokinetics
In contrast to the pharmacokinetic half-life, the pharmacodynamic half-life will be dose dependent
Will a control release formulation be needed?
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Q day dosing at 2x dose
Bid Dosing at 1x dose
Minimal effective levelby PD marker
12h 24h
Dru
g C
on
cen
tra
tio
n
QD Feasible if high levels are well tolerated, otherwisewill need to default to BID dosing or change shapeof curve with CR.
DETERMINING DOSING FREQUENCY
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WHAT RANGE OF DOSES SHOULD WE CONSIDER In early Phase II, not much information
available (pre-clinical, PK, MTD) We know 0 (Placebo), we know MTD Exploring an Adequate Dose Range Selecting Doses for Early Dose-
ranging Studies
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STUDY 1 - WHAT’S NEXT?
0
5
10
15
20
25
Placebo 20 mg 30 mg 40 mg
Series1
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STUDY 2
0
5
10
15
20
25
Placebo 5 mg 10 mg 20 mg
Series1
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WHAT RANGE OF DOSES SHOULD WE CONSIDERWHAT RANGE OF DOSES SHOULD WE CONSIDER
Examine a wide dose range in early development and follow this study with a narrower dose range study
Use pharmacological response or biological markers from animal studies and phase I studies to guide the selection in dose range for the early studies
Although not always attainable in early studies, a goal should be to try and define the Maximum Tolerated Dose (MTD), the Maximum Effective Dose (MaxED), and the Minimum Effective Dose (MinED)
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IS THERE A DOSE RESPONSE?
0
5
10
15
20
25
30
35
Low Medium High
Series1
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IMPORTANCE OF PLACEBO RESPONSE
0
5
10
15
20
25
30
35
Placebo Low Medium High
Series1
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ACTIVE CONTROL
0
10
20
30
40
50
60
Placebo Low Medium High Active
Series1
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ACTIVE CONTROL
0
5
10
15
20
25
30
35
Placebo Low Medium High Active
Series1
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ACTIVE CONTROL Active control is not strictly necessary It serves as a useful control in case the
test drug “doesn’t work” or works poorly Active control “worked” or not?
An active comparator may also be critical if there is an effective competitor on the market How appropriate are Phase II comparisons? Statistically valid vs “looks similar”?
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HOW MANY DOSES TO BE TESTED Can we set all possible doses to test Do we include control groups If so, which controls Spacing between doses
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LIMITED NUMBER OF FIXED DOSES Multiple center designs Formulation considerations Placebo and maximum tolerable
dose (MTD) Incorporate active control? Concerns in interpreting titration
dose
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TREATMENT BY CENTER INTERACTION
Placebo
Low Medium
High
Center 1
6 7 6 8
Center 2
1 1 0 1
Center 3
4 2 3 2
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DOES THE DRUG WORK? Test hypothesis - does the drug
work? Null hypothesis (H0) - no difference
between test drug and placebo Alternative hypothesis (Ha) - there
is a difference
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TYPES OF ERRORS
Null True Null FalseAccept Null OK IIReject Null I OK
If there is no true difference, but concluded there is => Type I error
If there is a difference, but concluded there isn’t => Type II error
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TYPES OF ERRORS Regulatory agencies focus on the
control of Type I error Probability of making a Type I error
is not greater than In general, = 0.05; i.e., 1 in 20 Avoid inflation of this error Change method of analysis to fit
data will inflate
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MULTIPLE COMPARISONS For 20 independent variables (clinical
endpoints), one significant at random For 20 independent treatment
comparisons, one significant at random
For 20 small studies, one sig. At random
Multiple comparison adjustment
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MULTIPLE COMPARISONS Consider a dose response study with
high and low dose against placebo 2 comparisons each dose vs placebo Bonferroni is to divide by 2 Step-down Special contrasts Fisher protected LSD
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MULTIPLE COMPARISONS Other types of multiple comparisons
compare test drug with placebo and active control
Multiple endpoints Subset analysis Various statistical methods available to
handle these situations
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INTERIM ANALYSIS Final analysis: LPV -> closed
database -> break blind -> final analysis
Any analysis before final is interim Objectives
claim efficacy stop for no efficacy (for safety, …) help decision making for other studies other
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INTERIM ANALYSIS Randomized Double-Blind study to
control for bias Multiple look at data will inflate Statistical penalty
inflation of -> need adjustment enough efficacy data to help
decision?
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CONTROL OF TYPE I ERROR Experiment-wise Type I error is
controlled by specifying primary endpoint, primary comparison, primary time point for the primary study population
Keep analysis method as stated in the protocol
If interim analysis is needed, we should pre-specify, and plan for it
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WHAT ARE WE MEASURING PD marker, clinical endpoint (hard, soft)
or safety Efficacy can’t be observed from normal
volunteer Early Phase or late phase Time after baseline (short, long) Multiple endpoints
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Effi
cacy
30
20
10
0
Low Medium High
Dose
X
X
X
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EXPLORATION AND CONFIRMATION Phase I, II, III clinical trials Exploratory – estimation Confirmatory – hypothesis testing Learning process
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EXPLORATION AND CONFIRMATION Design considerations for exploratory
and confirmatory are different Analysis method depending on
objective For labeling, may consider the entire
database to select doses