interpretation of low-incidence findings in developmental and reproductive toxicity studies
TRANSCRIPT
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Interpretation of Low-Incidence Findings in Developmental and Reproductive Toxicity Studies
Joseph F. Holson, Ph.D.WIL Research Laboratories, Inc.
Acknowledgements:Bennett J. VarshoJeffrey A. PittLewis E. Kaufman
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ADExperience (formerly ADR, Adverse Drug Reports)
Based on assumptions that rare, latent or long-term effects that the premarketing testing regimen does not reveal will eventually show themselves given a wide enough distribution
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FDA’s View
A serious Adverse Drug Experience is one that kills someone, has been shown to pose a threat to life, is seen to cause persistent or significant disability or incapacity, requires inpatient hospitalization or is diagnosed as a congenital anomaly, cancer or overdose.
“Serious” can also mean occasions in which a reaction to a product prolongs an existing hospitalization or causes other medical events doctors deem important.
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Products deemed likeliest to have unexpected serious medical problem if they fail to produce their expected outcomes: FDA considers likeliest to fall in this category formulations approved within last 3 years
(with emphasis on lack-of-effect reports) new molecular entities products known/suspected of having
bioavailability or bioequivalence problems.
FDA’s View (continued)
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Human Epidemiology Studies vs. Experimental Animal Assessments
Less rigorously monitoredGreater phenotypic heterogeneityLess amenable to dose-response
evaluationsRamifications of endpoints better
ascertainedRetrospective studies plagued with recall
bias
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Observational Determinants of Anatomical/Functional Deviations
Degree of deviation from average
Incidence (prevalence)*Impact on salubrityCosmetic significance
*In humans convention of <4%; no medical or surgical significance has been used
*In experimental studies, no convention used – statistical
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Animal:Human Concordance Studiesfor Prenatal Toxicity
Nisbet & Karch, 1983 Many chemicalsRelied on authors’ conclusionsEmphasis on fertilityNo measures of internal dose
Attributes
Interdisciplinary team Criteria for acceptance of data/conclusionsConcept of multiple developmental toxicology endpoints No measures of internal dose
Authors
Holson et al., 1981 (Tox Forum)Kimmel et al., 1984 (NCTR Report)
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Attributes
Interspecies inhalatory doses adjustedRelied on authors’ conclusions23 occupational chemicals and mixtures No measures of internal dose
Provided detailed informationOnly 4 drugsEmphasis on morphologyFocus on NOAELsNo measures of internal dose
Many chemicalsRelied on authors’ conclusionsNo measures of internal dose
Authors
Hemminki & Vineis, 1985
Newman et al., 1993
Schardein, 1995
Animal:Human Concordance Studiesfor Prenatal Toxicity
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Awareness of Developmental Toxicity of Selected Agents
Agent Year First Reported Species*
Alcohol(ism)
Aminopterin
Cigarette Smoking
Diethylstilbestrol
Heroin/Morphine
Ionizing Radiation
Methylmercury
Polychlorinated Biphenyls
Steroidal Hormones
Thalidomide
1957
1950
1941
1940
1969
1950
1953
1969
1943
1961
(gp), ch, hu, mo, rat
(mo & rat), ch, hu
(rab), hu, rat
(rat), hu, mi, mo
(rat), ha, hu, rab
(mo), ha, hu, rat, rab
(rat), ca, hu, mo
(hu), rat
(monk), ha, hu, mo, rat, rab
(hu), mo, monk, rab
*ca - cat, ch - chicken, ha - hamster, gp - guinea pig, hu - human, mi - mink, mo - mouse, monk - monkey, rat - rat, rab - rabbit
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Effect-Levels for Teratogensin Humans and Test Species
Aminopterin Death/Malformations
Death/Malformations
Agent ResponseHuman
Rat
Species Dose0.1 mg/kg/da
0.1 mg/kg
Diethylstilbestrol Genital Tract Abnormalities/Death
Genital Tract Abnormalities/Death
Human
Mouse
0.8-1.0 mg/kg
1 mg/kg
Ionizing Radiation Malformations
Malformations
Human
Rat/Mouse
20 rads/da
10-20 rads/da
Cigarette Smoking Growth Retardation
Growth Retardation
Human
Rats
>20 cigarettes/da
>20 cigarettes/da
Thalidomide Malformations
Malformations
Malformations
Human
Monkey
Rabbit
0.8-1.7 mg/kg
5.0-45 mg/kg
150 mg/kg
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Possible Inter-relationships of Developmental Toxicity Endpoints
Toxic Stimulus
Malformations
Functional Impairments
Growth Retardation
Death
Toxic Stimulus GrowthRetardation Death
Malformation
Functional Impairment
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Maldevelopment vs. Tumorigenesis
Not more frequent with timeMyriad possible underlying mechanisms
Amniotic banding, oligohydramnios-skull dysgenesis Interference with signaling pathways (TGF-) Mutation
Maternal influences possibleMultiple endpoints interrelated
Weight alterations causing cleft palate and NTDsOccur early in life & hence greater
economic/social impact
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A Ventral view illustrates:
the stomodeum (primitive oral
cavity), the heart in the
pericardial cavity,
the anterior intestinal portal leading to the
foregut,and the
posterior intestinal portal leading to the
hindgut.Kathleen Sulik (http://www.med.unc.edu/embryo_images/unit-welcome/welcome_htms/akgs.htm)
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Selected Differences in Developmental vs. Oncogenic Endpoint Ascertainment
Smaller group sizes (25 vs. minimum 100/group) Macroscopic – histopathology very rare Physical constraints/difficulty Less standardized nomenclature No certification, controls over training, etc.
More impact because earlier in development due to women in clinical trials
Involves coapt organisms (dam & fetuses) Always potential for maternal influence, but goes both ways
Dynamic morphology & function ACE example
Animals evaluated in the midst of changing morphology No two points in development are the same
Exposure hourly and daily key to outcome An important aspect of human studies
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A B C D E F
Premating to Conception
Conception to Implantation
Implantation to Closure of Hard Palate
Hard-Palate Closure to End of Pregnancy
Birth to Weaning Weaning to Sexual Maturity
Parturition Litter Size Landmarks of Sexual DevelopmentGestation Length Pup Viability Neurobehavioral Assessment F1 Mating and Fertility Pup Weight Acoustic Startle Response
Organ Weights Motor Activity Learning & Memory
ParturitionGestation Length Pup Viability Litter SizeLandmarks of Sexual Development Pup WeightNeurobehavioral Assessment Organ Weights Acoustic Startle Response F1 Mating and Fertility Motor Activity Hormonal Analyses Learning & Memory Ovarian QuantificationHistopathology Premature Senescence
Postimplantation Loss
Postimplantation LossViable FetusesMalformations & VariationsFetal Weight
Postimplantation LossViable FetusesMalformationsVariationsFetal Weight
Estrous Cyclicity Mating Corpora Lutea Fertility Implantation SitesPre-Implantation Loss Spermatogenesis
Estrous CyclicityMatingFertilityCorpora LuteaImplantation SitesPre-Implantation LossSpermatogenesis
Denotes Dosing Period
Single- and Multigenerational
Satellite Phase
OECD 415, OECD 416, OPPTS 870.3800, FDA Redbook I, NTP RACB
F1
F2 ????????????????
????????????????
Pre- and Postnatal Development
F1
ICH 4.1.2F0
????????????????
Prenatal DevelopmentICH 4.1.3 OECD 414
OPPTS 870.3600 870.3700
Fertility StudyICH 4.1.12W4W
CMAX
AUC
CMAX
AUC
10W
Standard Study Designs
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Comparison of Study Scale/Size
0
500
1000
1500
2000
2500
3000
Acute OralToxicity
SubchronicToxicity
2-Year CancerBioassay
DevelopmentalToxicity
2-GenerationReproduction
No
. o
f A
nim
als/
Stu
dy
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MARTA/MTA Database Fetal Abnormalities
Examination Type Individual Descriptors
External 123
Visceral 277
Skeletal 467
Combined 867
www.hcd.org
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Freehand Section
Whole-Body Microdissection
½ Skeletal ½ Visceral 100%
Guideline minimum = 25%, 175 + 175 vs. 1400
4 Groups
(of 25 Dams)X
350 Fetuses =1400 Fetuses
½ & ½ Control and High Group (per guideline)
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Size Comparison at Near Term
CR Length 75 mmCR Length 35 mm
3.6 grams 47 grams
CR Length 19 mm
1.3 grams
RabbitRatMouse
Taylor, 1986
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FDA Definition
Rare Event – “an endpoint that occurs in less than 1 percent of the control animals in a study and in historical control animals”
Reviewer Guidance(Draft)
Integration of Study Results to AssessConcerns About Human Reproductive
And Developmental Toxicities
CDER, 10/2001Pharmacology/Toxicity
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Rare Events (Low-Incidence Findings): Typical Reaction to, and Subsequent Scenario
Disbelief, rely on statistical insignificanceComparison to concurrent controlComparison to historical control (HC)Comparison to other HC databasesAsk experience/opinions of othersConstruct explanation to negateAgency rejectsRe-do study or label appropriately
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Classes of Reproductive and Developmental Toxicity
Reproductive Developmental
Fertility Mortality
Parturition Dysmorphogenesis
Lactation Alterations to Growth
Functional Toxicities
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Selected Reproductive Endpoints Exhibiting Strong Signals from Rare Events/Low Incidence
EndpointExamples from WIL Research Historical Control in Crl:CD(SD)IGS BR
Mean Viable Litter Size
13.9 1.02 decrease of 1
Mortality PND 4Mean = 96.2% Min/Max 91-95%
91%
Total Litter LossMean = 0.94% (10/1061)
1 is equivocal 2 is more significant signal
Newborn Pup Weights
Mean = 7.0g 0.23
range 6.5-7.4g n = 1100 litters
6.5g strong signal
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Case Study: Dystocia, Extended Parturition and/or Pregnancy
2-generation with second mating phase of F1, vapor inhalation, used industrially, OTC pharmaceutically
PPM 0 70 300 500 700
F0 0 0 0 2/24 3/26
F1-1st 0 0 0 0 1/17
F1-2nd 0 0 1/21 1/18 0/12
HC then: 2/333 = 0.60% HC now: 4/1100 = 0.36%
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Organogenesis (classically defined) is unaffected
Effects are severe
Risk is low
Caused by ACEinh that cross placenta
ACEinhFetal
Hypotension
RenalCompromise
(Anuria)Oligohydramnios
Calvarial Hypoplasia
Neonatal Anuria
IUGR
Death
Case Study: Functional Alteration Example ACE Inhibition-Induced Fetopathy (Human)
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Case Study: Functional Alteration Example ACE Inhibition in Developing Rats
RAS (renin-angiotensin system) matures around GD17
No ‘apparent’ effect in initial reproductive studies Nonstatistically significant increase in postnatal mortality (~8%)
Subsequent postnatal studies with direct administration to pups Growth retardation
Renal alterations (anatomic and functional)
Mortality increased to more than 30%
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Comparison of Overall Spontaneous Malformation Rates in Different Species
Species Mean % Range (%) N
Rat* 0.33 0-1.6 9643
Mouse 1.2 0-3 5207
Rabbit 3.2 0-10 4708
Dog 5.5 5.3-5.7 167
Human 4.0 3-9 Multiple Surveys
* Actual number in laboratory population ~44,000
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Case Study: Malformation Example Topical Antibiotic for Oral Mucosa
Historical Control Data
Malformation TotalMean% PL
Min Max
Retroesophageal Aortic Arch
2/9643 0.02% 0.0% PL 0.3%PL
Rat Study Data
Malformation 1 2 3 4
Retroesophageal Aortic Arch
0 01
(0.3%PL)1
(0.3%PL)
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Rare Events: Control vs. Treated Groups
3
1
3:1 Probability that spontaneous event will occur in treated group
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Malformations which Have Occurred as Rare Events in Numerous Scenarios
MalformationIncidence (%PL)
Rat Rabbit
Ventricular Septal Defect 0 0.02
Cleft Lip/Palate 0.02 0.04
Abdominal Wall Defect Including Gastroschisis
0.04 0.06
Hydrocephaly 0.03 0.20
Spina Bifida 0 0.17
Renal Agenesis 0.01 0.02
Diaphragmatic Hernia 0 (2/39442) 0.04
Malformations can involve any tissue or structure and may constitute a rare event issue
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Rare Event Manifestation Matrix
Control Low Mid High
0 0 0 1
0 1 0 0
0 0 1 0
0 0 1 1
1 0 0 1
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Paradigm to Evaluate Rare Findings
Comparison to concurrent control Evaluate dose-responsiveness including TK, AUC/Cmax Compare to HC range and mean, consider other statistical tests,
including Monte-Carlo Analysis Evaluate signals of developmental toxicity among dose groups Compare to second species Compare to findings in the combined pre-/postnatal study Perform confirmatory study:
Increasing N Increasing number of concurrent controls Increasing dose (based on TK: AUC/Cmax) Consider unbalanced study design Delimited exposure regime Evaluate pharmacologic action relative to ontogeny of receptors, etc. and
reconcile with modified dosing regime Label and follow-up in birth defects registry
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The Bottom Line
With rare events, the best practice for resolution of the relationship to treatment is through a large historical control database developed at the same laboratory, using consistent methodology and conditions in conjunction with appropriately designed confirmatory study.
Human risk assessment and management may require study in human registries.