CLINICAL TRAILS

CLINICAL TRAILS

• To collect data on usual and unusual events, conditions, & population groups.
• To test hypotheses formulated from observations.
• To understand better one’s

Three main types are there

Observational Studies:

• Groups are studied & contrasts made between groups
• The observed data collected are analyzed
• 

Analytic Studies:

Also called Experimental

Study the impact of a certain therapy

Ultimately the investigator controls  factor being studied

Clinical Trial:

Considered the “true” experimental study

“Gold Standard” of clinical research

Often a prospective study that compares the effect and value of an intervention against a control in human subjects

The Different Study Designs

• Case-control
• Cohort
• Case Reports
• Case Series
• Outcomes Based:
• Survey Research:

Quality of Life  Questionnaires

Decision analysis   Polls

Economic Analysis  Surveys

• Meta Analyses
• Survival Analysis
• Randomized Clinical Trial

Terminology

• Cross-sectional Study: Presence or absence of exposure to possible risk factor measured at one point in time. Prevalence obtained.
• Prevalence: The # of new cases and existing cases during specified time period.
• Incidence: The # of NEW cases per unit of a population at risk for disease occurring during stated time period.

Historical Highlights of Drug Trials

• 1909: Paul Ehrlich – Arsphenamine
• 1929: Alexander Fleming – Penicillin
• 1935: Gerhard Domagk – Sulfonamide
• 1944: Schatz/Bugie/Waksman – Streptomycin
• By 1950, the British Medical Res. Council developed a systematic methodology for studying & evaluating therapeutic interventions

Components of Clinical Trials

• Involve human subjects
• Move forward in time
• Most have a comparison CONTROL group
• Must have method to measure intervention
• Focus on unknowns: effect of medication
• Must be done before medication is part of standard of care
• Conducted early in the development of therapies

Clinical Trial Designs

• Randomized/blinded trial
• Randomized/double blinded trial
• Non-randomized concurrent controlled trial
• Placebo trial
• Historical controlled trial
• Crossover Trial
• Withdrawal trial

Simplified

• Randomized: Schemes used to assign participant to one group

Ex: Every 3 gets higher dose

• Nonrandomized: All with Hep. C = cases; others = controls
• Protocol: Study design – instructions

Blinded:  Participants do not know if in experimental or control  group

Double Blinded: Participants AND staff do not know group assignment

Placebo:  Inactive pill with no therapeutic value

Components of Clinical Trial Protocols

• Investigating two or more conditions so have two(+) groups
• Ex: drug vs. placebo; medicine vs. surgery; low dose vs. high dose
• Specific inclusion/exclusion criteria
• Sample size & power calculations
• Plan re: potential biases
• Plan re: handling of attrition/loss to follow up

Study Participant Recruitment

• Identify eligible participants
• Explain study
• Provide informed consent
• Reassess eligibility
• Assign to one group

Participants should be told:

• May have side effects (adverse effects)
• Time commitment
• Benefits & risks
• May withdraw at any time
• Enrollment 100% voluntary

Phases of Clinical Trials

• Most trials that involve new drugs go through a series of steps:

–#1: Experiments in the laboratory

–#2: Once deemed safe, go through 1-4 phases

• Phase I: Small group [20-80] for 1st time to evaluate safety, determine safe dosage range & identify SE
• Phase II: Rx/tx given to larger group [100-300] to confirm effectiveness, monitor SE, & further evaluate safety

• Phase III: Rx/tx given to even larger group [1,000-3,000] to fulfill all of Phase II objectives & compare it to other commonly used txs & collect data that will allow it to be used safely
• Phase IV: Done after rx/tx has been marketed – studies continue to test rx/tx to collect data about effects in various populations & SE from long term use.

Clinical trails at a glance

	# Subs.	Length	Purpose	% Drugs Successfully Tested
Phase I	20 – 100	Several months	Mainly Safety	70%
Phase II	Up to several 100	Several months- 2 yrs.	Short term safety; mainly effectiveness	33%
Phase III	100s – several 1000	1-4 yrs.	Safety, dosage & effectiveness	25-30%

Ethics of Clinical Trials:
Protection of Participants

3 ethical principles guide clinical research:

• Respect for Persons: Treatment of person as autonomous
• Beneficence: Issue re: potential conflict between good of society vs. individual
• Justice: Treatment of all fairly & all equally share benefits & risks

Ethical Norms of Clinical Trials

Sound study designs take into account:

• Randomization or sharing of risks
• Proper use of placebo
• Processes to monitor safety of rx/tx
• Competent investigators
• Informed consent
• Equitable selection of participants
• Compensation for study related injuries

Ethical Issues: Protection of Human Subjects

• Rely on integrity of Investigator but outside groups also have oversight
• Participants’ rights protected by Institutional Review Boards [IRBs]

An IRB is defined as:  “any board, committee or other group formally designated by an institution to review, to approve the initiation of, and to conduct periodic review of biomedical research involving human subjects”

Human Subjects’ Protection

IRB responsible for such tasks:

• Review research to ensure that potential benefits outweigh risks
• Develop and issue written procedures
• Review research for risk/benefit analysis & proper protection of subjects
• Issue written notice of approval/disapproval to the Investigator
• Review and respond to proposed protocol changes submitted by the Investigator
• Review reports of deaths, and serious and unexpected adverse events received from the Investigator.
• Conduct periodic continuing review of the study, study risks, selection of subjects, privacy of subjects, confidentiality of data, and the consent process.

10 Key Points to be Noted

• Voluntary informed consent
• Experiment must be for the good of society, & results not obtainable by other means
• Experiment should be based upon prior animal studies
• Physical & mental suffering & injury should be avoided
• No expectation that death/disabling injury will occur from the experiment
• Risk vs. benefit
• Protect subjects against injury, disability, or death
• Only scientifically qualified persons to be involved
• Subject can terminate her/his involvement

Informed Consent:
A Part of Human Subject Protection

Objectives of Informed Consent

To Ensure:

• Voluntariness
• Comprehension
• Information

To Demonstrate That:

• Person freely gave consent to participate
• Consent given by a competent person
• Person has been given all information
• Person knows this is research – not treatment

Components of Informed Consent

Must Include the Following Information:

• Why research being done?
• What researchers want to accomplish
• What will be done and for how long
• Risks & benefits of trial
• Other treatments available
• Can withdraw from trial whenever desire
• Compensation for unexpected injuries

Vulnerable Populations

Groups thought not to have autonomy to give informed consent:

• children
• mentally impaired, individuals with dementia
• Prisoners

OR

Who may be unduly influenced to participate:

• students
• subordinates
• pregnant women (actually, the fetuses)
• patients (care-giver vs. researcher)

Inclusion in Clinical Trials

• Historically women were excluded if of reproductive age (ages 18-45)
• Fear of harm to potential unborn child
• In essence, excluded MAJORITY of women
• New guidelines eliminates this stipulation

Participation in Clinical Trials

Why Some Participate:

Give back to society

Exhausted all other txs

Health care services

Payment & incentives

Support

Others?

Why Some Do Not?

• Mistrust of studies
• Do not want to be “guinea pig”
• Do not meet criteria
• Cannot give up time for study visits
• Barriers: lang., distance

Taking Part in Research Studies:
Questions to Ask

• What is study about?
• What are the goals?
• Study sponsor?
• Participant input into protocols?
• Inclusion criteria?
• Benefits & risks

Is there an incentive?

How protected from harm?

What is required: # study visit & what occurs?

What happens after study is over?

How results will be disseminated?

The Impact of Studies

• Some clinical trials have been critical to patient health & provision of health care
• For instance:

Protocol 076:  HIV perinatal transmission

1st trial of AZT

Various cancer treatments

Development of other HIV related medications like PIs

Other clinical trials have not been as

successful for a variety of reasons:

• Medications did not work as in laboratory
• Loss to Follow-Up of too many patients
• Harmful substance
• Unethical & poorly conducted study (Ex: Tuskegee Study & recent Gene Replacement Study)

CONCLUSION

• Clinical trails are a valuable part in drug discovery & development.
• Huge costs are involved in conducting clinical trails, so a careful planning is necessary to avoid mistakes and risk involved with clinical trails.
• And a successful trail leads to launch of new drug to people & profits to company.

 

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