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Volume 4 - Issue 1

U CLINICAL STUDIES Your Resource for Multisite Studies & Emerging Markets PEER REVIEWED

Clinical Trial Approval Process in Brazil Clearing the Road Block to International Studies DSUR: A Review of this New Aggregate Safety Report And The Risk Management Perspectives The Importance of Remote Data Access and Analysis In Clinical Trials Special Feature: Translational Cardiovascular Safety A Primer of Nonclinical Investigations for Clinical Scientists


U CLINICAL STUDIES Your Resource for Multisite Studies & Emerging Markets

MANAGING DIRECTOR Martin Wright PUBLISHER Mark A. Barker MANAGING EDITOR Mark A. Barker EDITORIAL COORDINATOR Jaypreet Dhillon EDITORIAL ASSISTANTS Nick Love, Kevin Cross, Lanny McEnzie DESIGN DIRECTOR Ricky Elizabeth RESEARCH & CIRCULATION MANAGER Dorothy Brooks BUSINESS DEVELOPMENT Kristine Saunders ADMINISTRATOR Barbara Lasco FRONT COVER © istockphoto PUBLISHED BY Pharma Publications Unit 7a, Evelyn Court Grinstead Road London SE8 5AD Tel: +44 0208 6922878 Fax: +0014802475316 Email: The Journal for Clinical Studies – ISSN 1758-5678 is published by-monthly by PHARMAPUBS.

The opinions and views expressed by the authors in this magazine are not necessarily those of the Editor or the Publisher. Please note that although care is taken in preparation of this publication, the Editor and the Publisher are not responsible for opinions, views and inaccuracies in the articles. Great care is taken with regards to artwork supplied, the Publisher cannot be held responsible for any loss or damage incurred. This publication is protected by copyright. Volume 4 Issue 1 January 2012 PHARMA PUBLICATIONS



Watch Pages 8 Improving Clinical Studies in Women A draft guidance issued last December by the US Food and Drug Administration (FDA) aims to help generate more clinical trial data in women. The draft guidance focuses on potential differences in study design, conduct, outcomes, and interpretation that should be considered to ensure sex-specific issues are sufficiently addressed in clinical studies. By: Deborah A. Komlos of Thomson Reuters 10 Clinical Trials in Baltic States – Latvia and Lithuania Latvia – The Stable Environment for Clinical Research 2010 saw the 20th anniversary of Latvia’s independence, and the re-establishment of clinical research in medicinal product development. An inevitable milestone in this process was the year 2004, when Latvia became an EU member state, and its regulatory and legislative environment was stepwise synchronised with European legislation. Overview of 2011 Clinical Trials in Lithuania Lithuania is the largest of the three Baltic countries, covering an area of 65,300km2, and having a population of 3.2 million. Lithuania is an open economy with a small domestic market; the World Bank has placed it in the “above average” group in terms of the level of income. After joining the European Union in 2004, Lithuania harmonised the legislation on clinical trials with the EU, implemented Directives 2001/20/EC and 2005/28/EC into the local regulations, and also follows the applicable EU guidelines. By: Dr Janis Skards, Dr Indra Aboltina & Ieva Polenenaite of Dokumeds 14 Troubleshooting GMP on Storage Deviations of Investigational Products at Investigational Sites Temperature-sensitive investigational products (IPs) - such as monoclonal antibodies and other biotechnologically produced compounds - need close temperature control during transport and storage. As long as they are handled under the control of the manufacturer, the temperature during storage and transport is usually well controlled within validated and alerted systems. What are the facts to be considered by a qualified person and the sponsor in case of storage or handling deviation at the investigational site? By: Dr Claudio Alexander Lorck of Temmler AG Regulatory 16 Maximising the Value of a Registry Programme Clinical trials conducted for regulatory approval of new pharmaceutical, biotech, device, and diagnostic products frequently do not provide the comprehensive market intelligence required for successful product launch, in-market brand management, and, most importantly, long-term product growth. Queries about the proper use of a new product, expectations of treatment response, key drivers of market uptake, and performance against competitors often multiply after regulatory approval. The answers to these questions require real-world data on a broad spectrum of patients and physician prescribing patterns. Neal Journal for Clinical Studies 1

Contents Mantick of Parexel explains why many managers are increasingly recognising registries as a flexible and cost-effective strategy for filling in the informational gaps left by clinical trials to obtain the intelligence needed to support clinical and marketing strategies. 22 DSUR: A Review of this New Aggregate Safety Report and the Risk Management Perspectives Periodic analysis of safety information is crucial to the ongoing assessment of risk to trial subjects, as well as to understand the benefit-risk of any medicinal product. A Periodic Safety Update Report (PSUR) fulfils national and regional requirements for periodic reporting on the safety of approved drugs. The Development Safety Update Report (DSUR) has been created to be the common standard for periodic reporting on drugs under development among the ICH region. Dr Hemendra Misra of PRA International verifies that the main objective of a DSUR is to present a comprehensive, thoughtful annual review and evaluation of pertinent safety information collected during the reporting period, related to a drug under investigation, whether or not it is marketed. Market Report 26 Indian Clinical Research – Becoming a Global Player Currently drug discovery and development outsourcing are growing rapidly worldwide, with many pharmaceutical companies choosing to outsource to Asia-Pacific due to lower costs and operational efficiencies, as well as the availability of advanced IT and data systems, high quality physicians and high levels of English literacy. India currently has around 150 contract research organisations (CROs) with revenues of $485 million. While India has experienced a growth rate of 15% in the last five years, the forecasted growth rate for the next five years has leaped to 20-25%, with the highest growth expected in late phase trials. By: Apurva Shah of Veeda Clinical Research & Lindsay Baldry of Scott PR. 28 Clinical Trial Approval Process in Brazil – Clearing the Roadblock to International Studies The regulation of clinical research in Brazil started to be regulated at the national level in 1996, with the publication of Resolution number 196 from the National Health Council (CNS). The CNS provides statutory regulation of all research involving human beings, including ethical evaluation, which is performed by Local Ethics Committees (CEPs) and, in certain cases, by the National Ethics Committee (CONEP). Further regulatory assessment is the responsibility of the National Health Surveillance Agency (ANVISA) and is required for trials with drugs and medical devices aimed at future marketing applications. John Andrews & Eduardo Pizolato of Chiltern International discusses Brazil’s health statutes and the clinical trial approval process in Brazil. Therapeutics 32 Standardised Equipment & Centralised Spirometry Approximately 15% of the world‘s population currently suffer from respiratory diseases, with chronic lower respiratory disease listed as the number four cause of death in the United States. In the study of respiratory drugs, the parameters FEV1 and FVC are the important spirometry values used to determine efficacy and 2 Journal for Clinical Studies

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Contents safety of an experimental drug. James Sowash, Director at ERT Inc, explains how, like all other pulmonary function values, these parameters are subject to the great amount of variability inherent in the nature of the testing. 36 Effectiveness of CDDP and CV247 Combination, in Colon and Breast Carcinomas The two most common types of cancer that have spread worldwide are colorectal and breast cancer. Many chemotherapeutic agents have been discovered and one of the most widely used is cis-platinum (CDDP). Dr Ioannis Papasotiriou and his team at Research Genetic Cancer Center Ltd demonstrate the present research attempts to support the hypothesis that the combination of two already known substances, CDDP and CV247 agent, have great efficacy in human colon and breast carcinomas. IT & Logistics 44 Bringing Proven Clinical Trial Electronic Payment Solutions to Emerging Markets The different emerging markets that are being identified as huge potential growth areas each have unique benefits with regard to regulatory landscapes, potential patient population, patient access, recruitment and retention and treatment naivety. However, the emerging markets also present substantial challenges that can impede clinical trial progress and sometimes even threaten the overall success of a trial. Clinical trial payments represent one of the challenges CROs, investigators and sites face in both traditional and emerging markets. Samuel Whitaker of Greenphire discusses how electronic payment solutions and communication technologies present a cost-effective and efficient alternative to traditional payment methods.

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46 The Importance of Remote Data Access and Analysis in Clinical Trials The migration from paper-based data collection to electronic data capture (EDC) systems makes it possible to analyse trial data from any location as soon as it is collected. If leveraged properly, advanced data access and analysis methods can speed up the trial, make it safer, and even unlock substantial cost and time savings. Rick Morrison of Comprehend Systems discusses the potential considerations that must be addressed when choosing remote data access and analysis platforms. Special Feature 50 Translational Cardiovascular Safety. A Primer of Nonclinical Investigations for Clinical Scientists Assessment of cardiovascular safety has become a central component of life-cycle drug development and integrated pharmaceutical medicine. Such assessments are conducted in several stages of this cycle: drug discovery and ‘drug design’, a process involving computer simulation, medicinal chemistry, and structural molecular engineering; in vitro, in vivo, and ex vivo nonclinical studies; pre-approval clinical trials; and post-marketing surveillance once the drug is marketed and is being used in clinical practice. Integration of information gained in different phases is critical to optimising the transition from information alone to knowledge, understanding, and rational decision-making. J. Rick Turner, Senior Director, Integrated & Translational Cardiovascular Safety at Quintiles, provides a broad overview of the work conducted in non-clinical and translational cardiovascular safety. 62 Exhibition Previews & Reviews

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Foreword Industry-sponsored clinical research has traditionally been carried out in relatively wealthy locations in North America, Western Europe and Oceania. However, in recent years, a shift in clinical trials sponsored by the biopharma industry to so-called emerging regions, especially in Eastern European, Latin American and Asian countries, has been noted. Reasons cited for this shift include the ability to reduce operational costs while recruiting a large number of patients in a timely manner; the establishment of contract research organisations focused on global clinical trials; the rapid pace of growth of market size, research capacity and regulatory authority in emerging regions; and the harmonisation of guidelines for clinical practice and research. It seems that these factors will continue to be prominent drivers of the globalisation process, resulting in the solidification of trends and increased geographic dispersion of drug development operations. Country-specific data on trial participation reveals considerable heterogeneity across geographical regions. The US dominates by a large margin, having more than eight times the number of trial sites than second-place Germany. The top five countries are all in traditional regions (North America, Western Europe and Oceania), and together host 66% of all trial sites. Countries in emerging regions (Eastern Europe, Latin America, Asia, Middle East and Africa) are mostly small players when analysed individually (each with less than 2% global share), but as a group they host 17% of actively recruiting sites. Eastern Europe and Latin America generally currently host more sites than Asia. Not only do traditional countries tend to have more trial sites, but their trial capacity is generally larger than in emerging economies. Notably, a substantial number of Eastern European, Latin American and Asian nations have capacity approaching that of the traditional regions. Although trial density is greatest

in the US, Canada and several Western European countries, it is becoming quite substantial in some Eastern European countries such as the Czech Republic, Hungary and Estonia, but is still low in the more populous emerging countries. The fact that countries of emerging regions are reaching an average number of sites per trial capacity comparable to that in traditional nations suggests that they are increasingly able to offer a competitive number of sites suitable to participate in large global clinical trials. These trends have numerous public health, regulatory, economic and medical training implications. The globalisation of clinical trials can bring both health benefits and hazards to research subjects and the general population. Potential benefits include diffusion of medical knowledge and effective medical practice, and greater patient access to high quality medical care. In this first issue of 2012, we have brought you for the first time an evaluation of the Latvian and Lithuanian market, courtesy of Janis Skards, Indra Aboltina & Ieva Polenenaite (Page 10). The Clinical Trial Approval Process in Brazil is explained by John Andrews and Eduardo Pizolato of Chiltern (Page 28). Deborah A. Komlos of Thomson Reuters reports on Improving Clinical Studies in Women (page 8) In this issue we have a special feature by Rick Turner, Senior Director, Integrated & Translational Cardiovascular Safety, Quintiles, entitled Translational Cardiovascular Safety - A Primer of Non-clinical Investigations for Clinical Scientists (page 52). I think this is a must-read for all. I hope you enjoy the first issue of the year. We have a fantastic line-up of editorials for the future issues. Have a Happy and Successful 2012. Mark Barker Publisher

Editorial Advisory Board Andrew King, Managing Director, Biocair International. Art Gertel, VP, Clinical Services, Regulatory & Medical writing, Beardsworth Consulting Group Inc.

Francis Crawley. Executive Director of the Good Clinical Practice Alliance – Europe (GCPA) and a World Health Organization (WHO) Expert in ethics Georg Mathis Founder and Managing Director, Appletree AG

Maha Al-Farhan, Vice President, ClinArt International, Chair of the GCC Chapter of the ACRP Nermeen Varawala, President & CEO, ECCRO – The Pan Emerging Country Contract Research Organisation Patricia Lobo, Managing Director, Life Sciences Business Consulting

Bakhyt Sarymsakova - Head of Department of International Cooperation, National Research Center of MCH, Astana, Kazakhstan

Heinrich Klech, Professor of Medicine, CEO and Executive Vice President, Vienna School of Clinical Research

Caroline Brooks - Associate Director, Logistics, ICON Central Laboratories

Hermann Schulz, MD, CEO, INTERLAB central lab services – worldwide GmbH

Catherine Lund, Vice Chairman, OnQ Consulting

Janet Jones, Senior Director, ICON Clinical Research

Chris Tierney, Business Development Manager, EMEA Business Development, DHL Exel Supply Chain, DHL Global

Jerry Boxall, Managing Director, ACM Global Central Laboratory

Rick Turner, Senior Scientific Director, Quintiles Cardiac Safety Services & Affiliate Clinical Associate Professor, University of Florida College of Pharmacy

Chris Tait, Life Science Account Manager, CHUBB Insurance Company of Europe

Jeffrey Litwin, M.D., F.A.C.C. Executive Vice President and Chief Medical Officer of ERT

Rob Nichols, Director of Commercial Development, PHASE Forward

Charles Horth – Senior Life Sciences Consultant

Jeffrey W. Sherman, Chief Medical Officer and Senior Vice President, IDM Pharma.

Robert Reekie, Snr. Executive Vice President Operations, Europe, Asia-Pacific at PharmaNet Development Group

Jim James DeSantihas, Chief Executive Officer, PharmaVigilant

Sanjiv Kanwar, Managing Director, Polaris BioPharma Consulting

Kamal Shahani, Managing Director of Cliniminds - Unit of Teneth Health Edutech Pvt. Ltd.

Stanley Tam, General Manager, Eurofins MEDINET (Singapore, Shanghai)

Eileen Harvey, Senior VP/General Partner, PRA International

Karl M Eckl, Co-founder, Executive and Medical Director, InnoPhaR Innovative Pharma Research Eastern Europe GmbH

Stefan Astrom, Founder and CEO of Astrom Research International HB

Franz Buchholzer, Director Regulatory Operations worldwide, PharmaNet development Group

Mark Goldberg, Chief Operating Officer, PAREXEL International Corporation

Deborah A. Komlos, Senior Medical & Regulatory Writer, Thomson Reuters Diana L. Anderson, Ph.D president and CEO of D. Anderson & Company

Patrice Hugo, Chief Scientific Officer, Clearstone Central Laboratories Rabinder Buttar – President & Chief Executive Officer of ClinTec International

Elizabeth Moench, President and CEO of Medici Global

Steve Heath, Head of EMEA - Medidata Solutions, Inc

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T S Jaishankar, Managing Director, QUEST Life Sciences Volume 4 Issue 1

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Improving Clinical Studies in Women A draft guidance issued last December by the US Food and Drug Administration (FDA) aims to help generate more clinical trial data in women. The FDA notes in Evaluation of Sex Differences in Medical Device Clinical Studies1 that the historic underrepresentation of women in clinical studies has resulted in limited information available for women and their physicians on the risks and benefits of many medical treatments and diagnostic procedures. The draft guidance focuses on potential differences in study design, conduct, outcomes, and interpretation that should be considered to ensure sex-specific issues are sufficiently addressed in clinical studies. The FDA explains that the terms sex and gender have distinct definitions for research purposes. The differences of greatest interest to its Center for Devices and Radiological Health (CDRH) are those associated with biological factors (sex); however, the majority of medical device studies use patient self-reported values for this variable (gender). Thus, for the purposes of the draft guidance, the FDA uses the term sex, with the understanding that gender is used as a surrogate for sex for most medical device studies. Contributing to the lack of data in women is the fact that women may be less likely to enrol in clinical studies. This may be due to various reasons such as the fear of fetal consequences from drug treatment if the woman becomes pregnant, avoidance of female patients by investigators and sponsors due to the perception that it takes more time and money to recruit them, and family responsibilities that limit ability for time commitment to study follow-up. In providing its recommendations, the FDA advises according to study type: new or ongoing studies, completed studies (marketing application stage), and post-marketing studies. For instance, for new or ongoing studies as well as post-marketing studies, the agency advises sponsors to consider tailored communication strategies (as used in the Women’s Health Initiative study) for study recruitment, informed consent documents, and patient labelling, and also to consider flexibility in follow-up visit scheduling with provision of child care or elder care services during appointments, as ways to increase enrolment of women. Not only should clinical studies enrol a sufficient number of women, they must also include women that reflect the underlying disease distribution in the affected population. To consider potential sex differences, the FDA recommends sponsors to provide background information on the following regarding the disease or condition that the device is intended to treat or diagnose: sex-specific prevalence; sexspecific diagnosis and treatment patterns; identification of proportions of women included in past studies for the target indication; and identification of any known clinically significant sex differences in outcomes related to either safety or effectiveness. Additional recommendations in the draft guidance pertain to specific statistical analysis and reporting sex-specific information in summaries and labelling. The FDA notes that differences between men and women in the incidence and 8 Journal for Clinical Studies

severity of certain diseases may be related to differences in exposures, routes of entry and processing of a foreign agent, and cellular responses. For these and other reasons, the agency advises that differences in study outcomes of treatment be investigated and reported by sex. Methods to use include subgroup analyses and tests for interaction or heterogeneity. Another recent effort by the FDA regarding women in clinical studies was a public meeting it hosted through the Office of Women’s Health and the Society for Women’s Health Research in September 20112. The meeting served as a forum for discussion and dissemination of innovative strategies to increase the recruitment and retention of women and minority subpopulations into clinical studies. Much of the content in the December 2011 draft guidance was discussed at that meeting. The FDA welcomes public input on the draft guidance until March 19, 20123. References 1. US Food and Drug Administration. Draft Guidance for Industry and Food and Drug Administration Staff: Evaluation of Sex Differences in Medical Device Clinical Studies, December 19, 2011. Available at: DeviceRegulationandGuidance/GuidanceDocuments/ ucm283453.htm 2. Federal Register: August 18, 2011. Volume 76, Number 160, 51375. 3. Federal Register: December 19, 2011. Volume 76, Number 243, 78670-78671. Deborah A. Komlos, MS, is the Senior Medical & Regulatory Writer for the IDRAC United States (US) Module at Thomson Reuters. Her previous roles have included writing and editing for magazines, newspapers, online venues, and scientific journals, as well as publication layout and graphic design work. Email: Volume 4 Issue 1

Watch pages

Clinical Trials in the Baltic States – Latvia and Lithuania

Latvia – The Stable Environment for Clinical Research

2010 saw the 20th anniversary since Latvia gained independence and clinical research in medicinal product development had been reestablished. The inevitable milestone in this process was in 2004 when Latvia became an EU member state, and its regulatory and legislative environment was stepwise synchronised with European legislation. In 2011 Latvia passed through tight economic and political times related to the recent global crisis. Recovery after the global economic crisis is slow, and the largest losses in the country are related to the decrease of its population by 13%, returning to the level of 1959 (Figure 1)1. Figure 1: Dynamics of population in Latvia, years 1935-2011 (*1000)

The 2011 census results show that today more than half of the Latvian population resides in the capital Riga and its suburbs. Today, 42.5% of the total population are economically inactive (26.6% retired, 7.8% students and pupils, 8.1% others), adversely affecting the economy in the short and the long term. In 2009, taking into account the non-favourable economic situation, the Latvian government issued Cabinet Order No 413, announcing programmes to promote export and attract foreign investment2. In 2011, the State Agency of Medicines of Latvia (SAM) promoted clinical trials as the competitive product for export3. In the meanwhile, statistics of clinical trials in Latvia reveal some stagnation after 2008 (Figure 2)4,5. Figure 2: Statistics of Clinical trials in Latvia [4; 5]

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In 2011, 77 clinical trial applications were filed and 67 approvals issued (eight of them within the voluntary harmonisation procedure). As usual, the Phase III projects prevailed; 11 pediatric studies were performed in 2011 (10 in 2010); in 19 studies medicines of biological origin were investigated; one authorisation was issued for a Phase I study and one for a Phase IV study5. The range of studies according to the therapeutic areas for the most recent two to three years has changed just slightly – studies still prevail in oncology, neurology, pulmonology, dermatology and endocrinology (in descending order). The number of studies in cardiovascular diseases has a tendency to decrease, reflecting the shortage of new medicines in this therapeutic area. SAM also maintains a list of post-marketing observational studies showing that five observations were introduced and three observations registered in 2011 – the number of observations has decreased since 2006, probably due to the frequently changing state reimbursement system of medicines. From 1st January 2012 a new order for the prescribing of reimbursable medicines and medical devices has entered into force. The new order was developed with the aim of promoting the prescribing of lower-cost state reimbursable medicines having equivalent effectiveness6. A sign that the global tendencies in the clinical research field have reached Latvia is the high number of substantial amendments of study documentation: 218 substantial amendments in 2011 (190 in 2010). In recent years the mass media have been used more and more in the field of clinical trials. In the websites of the largest university clinics, up-to-date information about ongoing studies can be found7. Although advertisements for patient recruitment are not used so widely, it is common to invite healthy volunteers to sign up to a Phase I study register7. It is thought that the number of Phase I studies will increase as soon as appropriate infrastructure has been developed. Modern technologies and highly skilled specialists are concentrated in Latvian university clinics, leading to intensive patient flow. However, the quite difficult and prolonged contracting process frequently hinders a quick site initiation after the receipt of study approval8. There is a clinical research organisation/fund directed by one of the most recognisable vascular surgeons in Latvia, Professor Dainis Krievins9. This organisation involves several academic institutions in different Eastern European countries. In the future, the potential of academic research organisations could essentially increase by also growing state grants for the research of new medicines. Some Latvian pharmaceutical companies (Grindeks; Olainfarm) have long-standing traditions in research into new pharmaceuticals, as well as being clinical research sponsors 10,11.

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Conclusions Latvia is a favourable environment for clinical research, with the number of studies performed becoming stable in recent years. Medical care, including pharmaceutical care, is still improving according to European standards. Private practitioners in their private practices, as well as specialists in hospitals (including regional hospitals) willingly participate in clinical research projects, thereby raising their qualifications and economic wellbeing. Availability and know-how of local CROs, and the professionalism of medical persons and state institutions in Latvia, allow the performance of clinical trials according to today’s dynamically changing demands. Overview of 2011 Clinical Trials in Lithuania Lithuania is the largest of the three Baltic countries, covering an area of 65,300 km2, and it has a population of 3.2 million. Lithuania is an open economy with a small domestic market; the World Bank has placed it in the “above average” group in terms of the level of income. After joining the European Union (2004), Lithuania has harmonised the legislation on clinical trials with the EU, has implemented Directives 2001/20/EC and 2005/28/ EC in local regulations, and also follows the applicable EU guidelines. The function of competent authority was given to the State Medicines Control Agency (SMCA) and the function of single opinion adoption was given to the Lithuanian Bioethics Committee (LBC). Clinical trial documents can be submitted simultaneously to both institutions, which makes the approval process much faster. The examination of the application usually takes no longer than 60 days. The other 12 Journal for Clinical Studies

advantage that makes the setup of the clinical trial faster is that permission to conduct a CT received from the SMCA allows the import of IMP and trial-related material from other EU countries (no separate approval is needed). The major principles relating to the conduct of clinical trials are covered by the Law on Pharmacy of Lithuania No. X-709 (22-Jun-2006) and the Law on Ethics of Biomedical Research No. VIII-1679 (11-May-2000). These regulatory documents are available on the homepage of Seimas of the Republic of Lithuania11. Logistics also plays an important role in the performance of clinical trials, as it ensures fast delivery of study-related material and laboratory samples. There is an adequate choice of international courier companies operating in Lithuania, such as DHL, TNT, FedEx, DPD and Venipak, therefore no delays are foreseen. For local shipments, sponsors can choose local courier companies which provide good quality service with lower costs. In Lithuania, sponsors should not face any problems with laboratories, as most of the state hospitals have up-to-date laboratories, and are able to perform high quality and reliable laboratory tests according to the national and EU regulations. Once the approvals from the SMCA and LBC are received, the agreement between the hospital, principal investigator and sponsor to conduct a clinical trial should be signed, which could be an issue that extends the setup of clinical trial, especially at the state-owned hospitals. The agreement review at the private hospitals and practices can take approximately a week, whereas negotiation with the state hospital can take up to one month. Volume 4 Issue 1

Watch pages Statistics of Clinical Trials in Lithuania The SMCA maintains the list of ongoing clinical trials, which shows that currently there are 447 ongoing clinical trials in Lithuania. The SMCA has also announced yearly reports on its homepage since 2004. 84 applications were submitted in 2004 for approval, and the authority has issued 80 approvals (Figure 3). Since then the number of CT applications has been growing, and in 2008 the SMCA received 123 applications. Due to the global economic crisis, this number decreased in 2009 (only 86 applications were made) but, in 2010, it showed a slow growth, and already 96 applications were submitted in 2011. Figure 3: Number of clinical trial applications, 2004-2011 [13]

Already since 2004 the majority of the studies were Phase III, and the situation has remained the same up to now (Figure 4). SMCA reports show that clinical trials in Lithuania cover a broad range of therapeutic areas: oncology, endocrinology, cardiology, rheumatology, hematology, neurology, psychiatry, pulmonology, surgery, dermatology, gastroenterology, pediatric, ophthalmology, nephrology, infectology and urology. In Lithuania there are a relatively high number of people participating in clinical trials of medicinal products because the access to the National Health System is limited and medications are expensive, so with the offer of better medical care, and free medicines and diagnostic procedures, patient recruitment meets the expectations. Large centralised hospitals also play an important role in meeting the recruitment goals. Figure 4: N  umber of submitted applications according to clinical trial Phase, 2004-2011 [13]

Conclusions Summarising the above mentioned criteria, Lithuania has a very friendly environment for clinical trials. The application approval process is similar to other EU countries. The logistics services are well set in place. Also there is a wide choice of advanced laboratories (including state and private) that provide high quality laboratory tests and meet local and EU requirements. Sponsors will meet investigators who are highly motivated and experienced in clinical trials, with good understanding of local and EU regulations, and a high level of patient enthusiasm. All this together creates excellent conditions for clinical research in Lithuania. References 1. 2. 3. 4. 5. State Agency of Medicines of Latvia, 6. 7. 8. 9. 10. 11. 12. 13. State Medicines Control Agency, 14. Seimas of the Republic of Lithuania, 15. WHO, 16. Statistics department of Lithuania, 17. Janis Skards, MD, PhD has more than 20 years of clinical experience, as well as scientific and academic experience gained at Riga Medical Institute and Latvian Medical Academy; has been involved in clinical research since 1996; and has been working for the pharmaindustry since 2001. Email: Indra Aboltina, MD, PhD has more than 20 years of clinical experience, as well as scientific and academic experience gained at Riga Medical Institute and Latvian Medical Academy; and for more than 10 years has run DOKUMEDS as the Managing Director. Email: Ieva Polenenaite graduated from the Kaunas University of Medicine, Lithuania, Pharmacy faculty; has worked as a chief specialist at the Marketing Authorisation Department of the State Medicines Control Agency; and since 2008 has been working as a CRA for CRO DOKUMEDS. Email:

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Troubleshooting Storage Deviations of Investigational Products at Investigational Sites Cold-chain investigational products (IPs) are often subject to deviations during storage at the investigational site due to, for example, defective refrigerators, refrigerators not designed to keep a temperature range of +2-+8°C, or simply having the refrigerator door open for too long. When a deviation has been identified and reported to the sponsor, the Qualified Person (QP; as defined in Directive 2001/20/EC) is often the final addressee to comment on the deviation and its impact on the quality of the IP stored in the refrigerator concerned. 1. General Temperature-sensitive investigational products (IP) such as monoclonal antibodies and other biotechnologicallyproduced compounds need particularly close temperature control during transport and storage. While products are under the control of the manufacturer, the temperature during storage and transport is usually well controlled within validated and alerted systems. For transport of IPs from the manufacturing site to the investigational site, a couple of high level transport/courier companies with validated transport systems offer their services on the market. They are usually contracted by the IP manufacturer, assuring a high level of reliability to keep the IP within its predefined conditions throughout the transport chain. Once the IP is delivered to the investigational site, however, and depending on the availability of a pharmacy and the GMP training of staff at the investigational site, the storage and handling of the IP are more often subject to errors and mishandling. What are the facts to be considered by a Qualified Person and the sponsor in case of storage or handling deviation at the investigational site? 2. Dealing with deviations by a Qualified Person Although it is the ultimate responsibility of the sponsor to assure GMP-compliant handling of the IP, the QP usually receives the request from the investigational site to assess the impact of a storage deviation of an IP. In order to fully understand a deviation which has occurred, the QP should be provided with the following information as a minimum: • Was the IP continuously stored under the required conditions until the deviation occurred? After the (hopefully) documented delivery of the IP to the investigational site, it has to be proven by documented evidence that the required storage conditions were kept throughout the period from delivery until the storage deviation occurred. A complete printout of the monitored temperature should be available. For example, can it be proven that the IP was stored in the fridge immediately after delivery (and did not sit in the entrance area of the investigational site over the weekend)? 14 Journal for Clinical Studies

• Has the refrigerator used been qualified (IQ/ OQ/PQ) and the temperature-measuring system been initially and subsequently calibrated? The temperature measured by the temperature sensor can be considered representative only if the fridge has been qualified and temperature-mapped to demonstrate that the range of 2-8°C is kept at all storage positions within the fridge, and that there are no spots where freezing or temperatures higher than 8°C occur. Additionally, the temperatures measured and documented are only suitable for interpretation if the temperature sensor has been calibrated initially and subsequently at pre-defined intervals. Provided there is documented evidence for the proper transport of the IP to the investigational site, the correct storage under the required conditions until the deviation occurred, and for qualified and calibrated systems used for storage and control, only then can the QP assess the deviation based on stability data available for the IP, and recommend its further treatment. 3. Preventive actions proposed •T  he refrigerator should be alerted, and the alert function should be tested. Alternatively, a close daily monitoring with e.g. calibrated min/max thermometers should be performed and documented. • Staff of the investigational site should be made aware of temperature-sensitive IPs, and trained on proper handling and storage. They must also be aware of the importance of informing the sponsor immediately of any deviations which have occurred. Definitions IQ: Installation Qualification OQ: Operational Qualification PQ: Performance Qualification Dr. Claudio Alexander Lorck has over 23 years experience in the field of Clinical Trial supply management. Having started his pharmaceutical career in Pharmaceutical Development, he held responsible positions in QC and R&D at Fujisawa Deutschland GmbH and Astellas Deutschland GmbH. Claudio now heads the business unit of “Clinical Trial Materials” of Temmler Werke GmbH delivering supply services for clinical trials all over the world. Email:

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Maximising the Value of a Registry Programme Clinical trials conducted for regulatory approval of new pharmaceutical, biotech, device, and diagnostic products frequently do not provide the comprehensive market intelligence required for successful product launch, in-market brand management, and, most importantly, long-term product growth. Queries about the proper use of a new product, expectations of treatment response, key drivers of market uptake, and performance against competitors often multiply after regulatory approval. The answers to these questions require real-world data on a broad spectrum of patients and physician-prescribing patterns – data that clinical trials cannot deliver owing to rigid patient inclusion and exclusion criteria and tightly controlled study methodologies. The information gaps that remain after a clinical trial handicap decision-makers, who must make early choices about clinical messaging based primarily on the product’s approved labelling. By comparison, real-world studies – including disease registries – can provide a sponsor’s medical affairs and marketing managers with an early warning system for possible threats, as well as insight into potential future opportunities as they map a product’s life-cycle. These managers are increasingly recognising registries as a flexible and cost-effective strategy for filling in the informational gaps left by clinical trials to obtain the intelligence needed to support clinical and marketing strategies. Approximately 12 months prior to the anticipated regulatory approval of their new antibiotic for the treatment of severe skin infections, a global pharmaceutical company launched an 1800-patient disease registry to document patient outcomes and to identify treatment gaps in hospitals’ current standards of care for severe skin infections. The registry information was used to better position the clinical results of their product from the pivotal studies as a superior treatment alternative to fill the identified treatment gaps. In order to confirm their positioning, the sponsor continued the registry after market introduction of their new antibiotic.

In the narrowest sense, a disease registry can be defined as a prospective, observational study of patients over time that provides ongoing epidemiological data for analysis and reporting. Registries are less encumbered by many of the regulatory-imposed constraints of a clinical trial, and thus enable healthcare providers, regulators, and sponsors to observe clinical responses over time among a broader patient population from many physician settings and geographical regions. As a result, global regulatory authorities and reimbursement agencies have increased their attention towards registry-like programmes as a means to accomplish several key objectives, such as requiring drug sponsors to conduct post-marketing studies when needed to ensure the safety of drug products after approval to describe reimbursement determinations that include, as a condition of payment, the development and capture of additional patient data to supplement standard claims data. Owing to the growing awareness of the value of post-marketing data, pharmaceutical, biotechnology, device, and diagnostic companies are increasingly sponsoring registry programmes to satisfy the evolving needs of regulatory and reimbursement agencies. 16 Journal for Clinical Studies

This narrow definition of registry programmes, however, does not sufficiently illustrate their importance and value for sponsors seeking to optimise the clinical and commercial value of their products. Registries can be considered powerful, multifaceted tools and integrated programmes of targeted scientific and commercialisation activities and objectives that address specific challenges, both clinical and businessrelated. Registries, when designed effectively and integrated with a sponsor’s market research activities, can provide a steady stream of new information suitable for external communication to physicians and other healthcare providers, private and public payers, and regulatory authorities. At the same time, registries, along with market research findings, can provide early and ongoing feedback on the effectiveness of clinical messaging and brand management strategies for a sponsor’s internal audience. Overview of Registry Design As a starting point for a new registry programme, it is critical to “begin with the end in mind”. That is, what are the communications – i.e. the clinical messages or product positioning – that the sponsor is trying to relay? Who are the target audiences and what is/are the intended use(s) of the data. Are there any challenges linked to physicians’ perceptions about the product that may influence its uptake and adoption? For example, a new product on the market may lead to a gradual change in the current standard of care for a specific patient population. Reimbursement agencies will be interested in how the clinical outcomes (both effectiveness and safety outcomes) of patients treated with the new product compare with the outcomes of patients still receiving the current standard of care. In this case, collecting clinical response and safety data, as well perhaps as patient-reported outcomes, may provide the information needed to demonstrate the value of the new product in the target patient population. Other possible end results of a well-designed registry include establishing the company as a credible player in a new clinical domain that it seeks to enter, contributing to new disease management or treatment guidelines, establishing therapeutic goals in patient subpopulations, and defending an established franchise against new competitors. Communications from a registry can accommodate many different media, including abstracts, posters, podium presentations for scientific meetings and symposia, manuscripts for publication in clinical journals, dossiers for reimbursement authorities, and speaker bureau/ physician-support activities. As a result of reimbursement pressures, a medical device manufacture launched a patient registry to assess 24-month treatment outcomes associated with the use of their new technology in the treatment of urinary incontinence relative to older technologies still available on the market. The registry results confirmed that fewer long-term adverse events, including the need for repeat surgical procedures, were associated with the new technology, resulting in an overall decrease in health care utilisation costs, and supporting the sponsor’s technology as the new standard of care.

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Regulatory Understanding the key messages, the target audiences, and the intended uses of the data will serve as a foundation for designing the operational strategy for the registry. There is a mix of registry operational elements that must be considered in order to maximise the study’s overall execution in the most cost-effective manner. Basic operational elements include, but are not limited to: Data Elements. The data elements that are needed to develop a credible clinical message to the intended audiences could include clinical assessments provided by physicians, patient-reported outcomes, healthcare utilisation information, or other supporting data like market survey data. Once the data elements are defined, careful attention to the sources of the data is also key. For prospective registry programmes, data can be provided by both physicians and patients. In some registries, retrospective data collection from medical records or secondary database sources is also possible. Carefully choosing specific data elements to collect in the registry facilitates the strategy to engage the target physicians in the scientific exploration, which can ultimately provide valuable clinical information to optimise the care of patients. Methods for Data Collection. Once the data elements and sources of the data are defined, the optimal technologies and workflows to collect and process the data can be selected. Similar to a clinical trial, sponsors may select either paper case report forms (CRFs) or CRFs accessed through an internet portal as the foundation of their registry programme. In addition, registries may integrate patient diaries and electronic patient-reported outcomes, mail and telephone surveys with automated communications, and centralised call centres to collect all of the requested information in a timely manner. Finally, an understanding of routine clinical practice and how data collection may vary across countries and individual sites will influence the frequency of data submission to the registry. Target Sites and Physicians. Participation in a registry typically requires a lesser degree of investigator research experience than a clinical trial; therefore, physicians from an array of community practice settings may be included to provide an important window into product use within the context of prevailing treatment algorithms. This may lead to an understanding of how and why new products drive changes in current treatment patterns, or encounter resistance because of established patterns of practice. Target Patient Population and Recruitment Strategy. Registries allow for more generalisable participation of patients in contrast to a clinical trial’s strict inclusion/ exclusion criteria. As a result, a registry may provide a more complete demonstration of how patients respond to a sponsor’s product in a real practice, including adherence or non-adherence to the prescribed treatment regimen. It can also help create an understanding of barriers to, and facilitators of, both use and adherence, in addition to the various factors associated with clinical outcomes. Good Pharmacoepidemiolgy Practices Good Pharmacoepidemiology Practices (GPP) proposes minimum practices and procedures that should be considered to help ensure the quality and integrity of 18 Journal for Clinical Studies

pharmacoepidemiologic research – like registry programmes – and to provide adequate documentation of research methods and results. The GPP do not prescribe specific research methods, nor will adherence to guidelines guarantee valid research or a successful registry. Because of the highly regulated environment in which pharmaceutical products, devices, and diagnostics are developed, approved, and studied after approval for various reasons, many sponsor companies and clinical research organisations have adopted the position that all pharmacoepidemiologic research, regardless of the purpose, should be conducted under the governance of the GPP. Early Phases of a Registry The activities surrounding the launch of a new registry, as well as descriptive statistics of early registry data, can help establish the sponsor as a credible player in a new market. Initial demographic and disease status data collected as patients enrol in a registry can better define the broader, real-world patient population beyond the narrow reach of a clinical study. This increased understanding of affected patients, with their wide range of demographic characteristics, disease severities, and comorbidities, helps to enhance the mapping of the natural course of the disease, as well as to develop evidence-based guidelines for patient diagnosis and monitoring. Through this exchange of early data from the registry, the sponsor can also begin to develop relationships with and demonstrate its support of wider (perhaps global) communication of clinical investigators and physician treatment providers. Indeed, one of the sponsor’s goals may be to enlarge the network of treatment centres at which patients can receive expert care. Finally, as the new product is introduced into a patient’s care plans, early data from the registry can help the sponsor discern whether the product is being used as expected. At first, physicians may be more comfortable staying within the bounds of the approved product labelling, but over time, registry data may suggest more off-label use or experimentation with different doses or dosing regimens in an effort to optimise a product’s prescription to a specific patient’s needs. Early data from the registry can also be effectively combined with market research findings to position a new product in a new or crowded market. Effective positioning tells the physician and patient communities how a sponsor’s product is unique and the benefits it offers to the target market. In a true disease registry, patients are enrolled without regard to the physicians’ treatment choices. As a result, data from the registry represents results from the range of products available to physicians to treat their patients from many different sponsors. In addition, some registry patients may not receive a specific product at all. In this scenario, registry data can guide the application of market research activities that help define the market in which a specific product will compete, as well as identify and assess threats. Several market research questions can supplement the clinical data from the disease registry – for example; who are the sponsor’s competitors and their respective positioning? What are the treatment options available to physicians? What are the market’s unmet needs? What is in the research and development pipeline, and what are the Volume 4 Issue 1

Regulatory market’s expectations of these future products? What, if any, regulatory mandates will affect uptake of the new product? Even with the limited amount of information that is often the result of a registry’s first year of operation, registry data and market research findings in the peri-approval timeframe can help build a solid foundation for future clinical research and brand management activities. Evolving the Registry to Keep Pace with Sponsor’s Needs As the sponsor’s needs change or as the needs of the medical and patient communities adjust to new clinical advances over time, a registry can also evolve to address these new challenges. Clear strategic direction and appropriate planning can ensure that the registry will keep pace with the clinical and commercial information required for successful in-market brand management, providing early warnings for the medical affairs and marketing management teams, and monitoring effective strategy adjustments. Similar to the early phases of the registry, sponsors can begin defining why physicians are exhibiting certain prescribing behaviours based on the analyses of the registry’s clinical data, rather than tracking uptake and market share only. As a result, current (as well as future) gaps between the expected market effect of a product’s labelling and clinical messaging and actual market behaviour can be identified and addressed sooner rather than later, thereby providing opportunities for course corrections to optimise a product’s success in a complex medical marketplace. Questions to ask when addressing these gaps include: is the product meeting the needs and expectations of the patient and physician communities? Does the usage of the product, as described by registry trends, suggest any unanticipated market opportunities or threats? Why is the product generating (or not generating) expected market share? In addition to addressing these gaps, the integration of registry data analyses with market research findings can also help a sponsor defend an established franchise against new competition. Evolving a registry to continually produce data and other

important market information requires a periodic, strategic reassessment of the key registry design and operational elements previously discussed, continually building on the base of registry data and market research findings already gathered. For example: does the data suggest that a broader range of physician specialities should be recruited for registry participation? Do patient subpopulations within the overall registry population pose unique medical challenges, thereby requiring a more focused data collection effort? What data elements should be eliminated from the registry because they have yielded limited information? What data elements should be added to the registry that take into account new technologies or updated treatment guidelines? Should the assessment schedule be revised to better reflect current clinical practice? Can a physician advisory board be utilised to address emerging treatment options or to generate greater publication opportunities? The overall goal of any registry programme is to continually produce reports and other communications that keep the registry output fresh and relevant to the participating physicians and patients, thereby encouraging their continued engagement in the registry programme. Long-term involvement in the registry may directly influence product sales at participating sites. In addition, registry findings encountered through publications, presentations, or word of mouth may sway the prescribing behaviour of clinicians or the formulary decision-making of managed care organisations or reimbursement authorities, which have never had any direct contact with the registry. These effects are not mutually exclusive, though a sponsor can emphasise some effects over others through their specific registry design choices. A global biotechnology company expanded their long-running rare disease registry to include an even more rare subset of patients with difficult-to-treat neurological manifestations. Since well-controlled clinical trials are extremely challenging in rare disease indications, regulatory and reimbursement agencies agreed to utilise this physician-endorsed and credible registry as a source of supportive outcomes data in the development of evidence-based treatment guidelines for patients with this unique disease manifestation.

Using Registry Data to Support Communications Many opportunities exist to disseminate information from registry programmes to fill gaps or pursue new opportunities, depending on the target audience. Typically, the primary goal of registry programmes is to publish long-term patient outcomes, including product effectiveness, safety, and patientreported outcomes. When integrated with market research findings, however, regulatory and reimbursement trends, physician and patient satisfaction/ loyalty measures, completive analyses, physician practice patterns, behavioural drivers, and changing practice patterns can also be the topics of reports from the sponsor. Data can be presented in the form of abstracts, posters, podium presentations at scientific meetings

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Regulatory and symposia, and as manuscripts in peer-reviewed clinical journals. In its most applied state, registry data can be the foundation of consensus statements, as well as disease management and treatment guidelines, by groups of key opinion leaders. Once in the public domain, these guidelines are often accessed by regulatory authorities and incorporated into dossiers from reimbursement agencies. Registry Design and Implementation Challenges A discussion of the many strategic benefits for a sponsor of combining registry efforts with market research activities is not complete without acknowledging the design and implementation challenges. Although well-designed registry programmes can address many clinical and commercial questions, it is important to maintain focus over time and to resist the expectation that the registry can be “all things to all people”. This is often particularly true when working with a physician board of advisors, who, in the interest of research, may believe everything about the patient should be collected, because it could be important. Yielding to this temptation may produce a registry programme that is too cumbersome to implement and manage effectively, especially among physicians who are less research-savvy than the board. Electronic data collection (EDC) technologies are often touted as the answer to this dilemma, but a sponsor has a much better chance for success if it defines the research and commercial objectives of the registry first, then selects the EDC system that can help them better achieve these goals, rather than letting technology drive the registry design. Another important registry evolution challenge is the issue of data gaps, especially over time. As noted above, the reports from a registry can facilitate a long-term commitment to the registry and an excitement surrounding its contributions to patient care. Maintaining a high level of engagement is especially important with regulatory postmarketing requirements or for mandated evidence-based reimbursement decisions. However, physicians eventually retire and patients often move to other cities or states, thus becoming lost to follow-up. In addition, it is not uncommon that once a patient reaches a satisfactory plateau in clinical response, it becomes less interesting to both the physician and patient to continue their participation. Therefore, a sponsor should maintain a plan to not only keep current physicians and patients active, but to also identify and recruit new sites with their untapped patient populations. Conclusion Pharmaceutical, biotechnology, device, and diagnostic companies’ clinical studies clear only one, crucial hurdle – gaining the government’s approval to manufacture and distribute their products to patients. The clinical trials conducted to gain regulatory approval of new pharmaceutical, biotech, and device products are not designed to provide the broader market intelligence required for successful product launch and clinical messaging, in market brand management, and long-term product growth. In addition, sponsors are under increasing pressure from different regulatory authorities and reimbursement agencies to confirm the long-term safety and effectiveness of their 20 Journal for Clinical Studies

products, as well as to justify their product’s inclusion on as many product formularies as possible. By designing, implementing, and maintaining a disease registry, a sponsor can illuminate the real-world use of a product. Moreover, when integrated with the sponsor’s market research activities, a registry can assist in detecting possible threats, identifying potential future opportunities, and making strategic corrections throughout the product’s life-cycle. The steady stream of new information that can be communicated to physicians and other healthcare providers, insurers, private and public payers, and regulatory authorities will establish the sponsor as a credible player in the clinical arena it has entered, position a new product in its target market, and help to defend an established product against new competitors. It may even lay the groundwork for future, well-controlled clinical trials to expand the range of indications for the product. Achieving these objectives requires a sponsor to continually evolve its registry programme to keep pace with the development of new standards of medical care, an ever-increasing clinical knowledge base, and the continually evolving needs of the many external stakeholders. Neal Mantick, Senior Director, Global Observational Research, PAREXEL International. Mr. Mantick has over 25 years of experience in the pharmaceutical and biotech industries. Prior to joining PAREXEL, he served as an Executive Director at a specialist late-phase CRO, Inc. where he led the Observational Studies/Registries Business Unit. Previously at Genzyme, he was responsible for ongoing management of four global registries for rare diseases. In that capacity, he participated in groundbreaking advancements in the medical treatment of patients and led the registry programs through growth and evolution to meet a wider range of clinical, regulatory, and commercial expectations. Mr. Mantick holds a B.S. degree in Pharmacy from the University of Kentucky and an M.S. degree in Health Policy and Management from the Harvard University School of Public Health. Email: Volume 4 Issue 1


DSUR: A Review of this New Aggregate Safety Report and the Risk Management Perspectives Introduction to the DSUR Periodic analysis of safety information is crucial to the ongoing assessment of risk to trial subjects, as well as to understand the benefit-risk of any medicinal product. A Periodic Safety Update Report (PSUR) fulfils national and regional requirements for periodic reporting on the safety of approved drugs. For drugs under development, currently, laws and regulations of some ICH (International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use) countries and regions require submission of a periodic safety report to regulatory authorities. However, significant differences in the CONTENT, FORMAT and TIMING of these reports highlight the importance of harmonisation and a common standard report. Based on CIOMS (Council for International Organizations of Medical Sciences) VII recommendations and the ICH E2F guidance1, the Development Safety Update Report (DSUR) has been created to be the common standard for periodic reporting on drugs under development (including marketed drugs that are under further study) among the ICH regions. In the European Union / European Economic Area (EU/EEA), the guideline has become effective from 1 September 20112. The United States (US) and Japan have not yet incorporated the guideline into national law. Nevertheless, the FDA may accept a DSUR when a request for a waiver has been submitted and approved beforehand. Consequently, the DSUR has replaced the EU Annual Safety Report and may replace the US IND Annual Report3. The main objective of a DSUR is to present a comprehensive, thoughtful annual review and evaluation of pertinent safety information collected during the reporting period, related to a drug under investigation, whether or not it is marketed, by: (1) examining whether the information obtained by the sponsor during the reporting period is in accordance with previous knowledge of the investigational drug’s safety; (2) describing new safety issues that could have an impact on the protection of clinical trial subjects; (3) summarising the current understanding and management of identified and potential risks; and (4) providing an update on the status of the clinical investigation/development programme and study results. A DSUR should be concise and provide information to assure regulators that sponsors are adequately monitoring and evaluating the evolving safety profile of the investigational drug.

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Operational Aspects A single DSUR should be prepared for an investigational drug encompassing: • All strengths • All formulations • All indications • All patient populations under study This includes sponsors with multiple clinical trials, multiple sponsors in formal agreements as well as sponsors of combination products. The focus is on clinical trials of investigational drugs (including vaccines and biologics) for the period under review. Comparator information may be provided if relevant to the safety of trial participants. The DSUR should also include significant safety findings arising out of other sources such as non-clinical studies, epidemiological studies, manufacturing changes and others. When a single DSUR cannot be prepared, the rationale for separate DSURs should be provided in each report. The Development International Birth Date (DIBD) is used to determine the start of the annual period for the DSUR. This date is the sponsor’s first authorisation to conduct a clinical trial in any country worldwide. The data lock point (DLP) of the DSUR should be the last day of the one-year reporting period. The DSUR should be submitted to all concerned regulatory authorities no later than 60 calendar days after the DSUR data lock point. Where national or regional laws or regulations require submission of an annual safety report on an investigational drug to ethics committees/institutional review boards, the DSUR Executive Summary might be appropriate, supplemented with line listings of serious adverse reactions (SARs) as warranted. DSURs should continue to be submitted for as long as indicated by national or regional laws or regulations. For example, in the US, sponsors might keep an IND open even if no clinical trials are ongoing or planned. Annual reports are submitted for as long as the IND remains open. Sponsors should indicate that the final DSUR serves as the last annual report for the investigational drug in that country or region and also indicate whether or not clinical trials are continuing elsewhere. The sponsor of a clinical trial is considered responsible for the preparation, content and submission of a DSUR. The sponsor can delegate the preparation of the DSUR to a third party (e.g., a contract research organisation). The investigator’s brochure (IB) in effect at the start of the reporting period should be used as the reference safety information. If the IB has been revised during the reporting period, a copy of the current version of the IB should be provided as an attachment to the DSUR. The Local Product Label can be used when an IB is not required as per national or local laws. Volume 4 Issue 1

Regulatory EU-ASR vs. DSUR – The Differences The differences between the former EU-ASR and the new DSUR could be summarised as follows:

DSUR and Risk Management A Tool for Risk Identification Regular and timely review, appraisal and communication of safety information are critical to risk management during the clinical development of drugs. The DSUR provides an opportunity to review • Individual case assessments • Non-clinical data • Literature (e.g. issues relating to pharmacological class) • Cumulative data

Strategies for Success The challenges to producing and submitting a complete, comprehensive and high quality DSUR are quite varied. Time, resources, planning, project leadership and teamwork are some of the general constraints, whereas data acquisition and issues related to the DIBD and waiver from the FDA are challenges specific to a DSUR. If a company decides to prepare the DSURs internally, the first strategy would be to plan early. It is advisable to set up a yearly calendar, identifying the number of reports to be written per year and the complexity of each report. Once the tasks are detailed out, the next step would be to identify the resources, both actual and potential, and the training required. Lead authors require significant training on regulatory documents, internal processes and procedures, access and user training in the various technologies employed to gather, collect, and present data. In addition, project management is a key to success, and effective project managers can help define roles and responsibilities, ensure close interdisciplinary cooperation and obtain senior management support when needed. Outsourcing, whether offshoring or nearshoring, has become a part and parcel of today’s working world. Apart from the obvious financial considerations, there is also the availability of highly skilled professionals and experience in the vendor staff, who are possibly already trained or can be easily trained on sponsors’ procedures and technology. These professionals complete defined tasks only and can be available as and when required. As careful planning internally minimises effort and maximises outcomes, outsourcing also requires careful planning. The following steps, if employed, could ensure a high quality deliverable from an outsource partner:

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DSURs help formally review data that have been received in the period of the report, in addition to a cumulative review of certain data, such as SUSARs, and are, therefore, an important tool of a sponsor’s signal detection system. A Tool for Risk Evaluation & Communication By conducting an overall appraisal of safety data at regular intervals, RISKS can be:

The DSUR allows us to discuss what was learnt about the safety of the product in the last year, how risk was managed, what actions were taken and changes made, as well as any potential issues that need to be addressed. The following sections of the DSUR help us in presenting this data: • Overall safety assessment • Evaluation of the risks • Benefit-risk considerations • Summary of important risks A Tool for Risk Minimisation No, the DSUR is not a tool for risk minimisation, but findings from the DSUR can lead to: • Protocol modifications for safety or efficacy concerns • Restrictions in study population or indications • Changes to informed consent for safety issues • Formulation changes for safety • Addition of special reporting requirements • Plans for new safety trials Interface with the EU Risk Management Plan The Summary of Important Risks section in the DSUR can provide the basis for the SAFETY SPECIFICATION OF A RISK MANAGEMENT PLAN. The following example, taken from the guidance document, illustrates how potential and identified risks can be presented in a DSUR.

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Regulatory Conclusions The ICH E2F guideline recommended Development Safety Update Report (DSUR) will become the common standard for periodic reporting of drugs under development (including marketed drugs that are under further study) in the ICH regions. In the EEA, this guideline is effective as of 1 September 2011. It is also acceptable in many other countries outside the ICH region which used to accept the EU-ASR previously. DSURs provide an opportunity for sponsors to formally review data from various sources and to assess them for their relevance to the safety profile of the drug. This periodic review and analysis of relevant cumulative data is a useful tool for identifying and assessing risks during the clinical drug development process, and for the understanding of the benefit-risk balance of the investigational medicinal product. Additionally, the DSUR acts as a tool for communication of safety information to health authorities, ethics committees and other stakeholders. References 1. development-safety-update-report.html, visited on 15 Oct 2011. 2. guideline/2010/09/WC500097061.pdf, visited on 15 Oct 2011. 3. GuidanceComplianceRegulatoryInformation/Guidances/ ucm073109.pdf, visited on 15 Oct 2011.

Hemendra Misra, MD, MPH, MSc, Director, Safety and Risk Management. Dr. Hemendra Misra is a pharmacovigilance physician with more than 15 years of international work experience. His medical practice includes positions at hospitals in India and with Medecines Sans Frontieres (Doctors Without Borders). He gained public health experience as a Consultant for a WHO Anti-Malaria program in India, being part of the STB SARS Containment Team in Singapore as well as working for the Health Promotion Board in Singapore. He has more than seven years of experience in the Industry (both Pharma and CRO) as a medical monitor, drug safety physician and also leading the Medical/Safety unit in the Asia-Pacific region. Focused drug safety experience includes safety-surveillance of marketed drugs as well as drugs in development: case assessments, signal detection and evaluation, risk management activities, aggregate safety reports as well as regulatory expertise and support. Dr. Misra studied Medicine in India and has a Masters degree in Public Health and an additional Masters degree in Clinical Science both from Singapore. He is experienced in a broad range of therapeutic areas including endocrinology, CVD, infectious diseases, oncology and CNS. Email:

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Market Report

Indian Clinical Research – Becoming a Global Player

Currently drug discovery and development outsourcing are growing rapidly worldwide, with many pharmaceutical companies choosing to outsource to Asia-Pacific due to lower costs and operational efficiencies, as well as the availability of advanced IT and data systems, high quality physicians and high levels of English literacy. In addition, as Asia accounts for 60% of the world’s population, this results in greater access to patients, offering advantages in terms of logistics, therapeutic areas, genetics and demographics. India currently has around 150 contract research organisations (CROs) with revenues of $485 million. While India has experienced a growth rate of 15% in the last five years, the forecasted growth rate for the next five years has leaped to 20-25%, with the highest growth expected in late phase trials (see Figure 1).1 Figure 1: Total number of clinical trials in India by phase

During 2005-2009, India’s clinical research industry grew by 17.7%, which is well above the world average of 2.60% (see Figure 2). The growth of clinical research in India has many socio-economic advantages, offering employment opportunities to the educated youth, enabling the provision of cost-effective healthcare, developing drugs and finding cures for local diseases such as TB and malaria and strengthening the infrastructure of India’s hospital network. Indian pharmaceutical companies are currently developing drugs for diseases including cancer, CVS, malaria and TB (see Figure 3). Figure 2: India versus other mature and emerging markets

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Figure 3: New drug development: India pharmaceutical companies

However, the Indian clinical research market did experience a fall in 2008-2009, dropping by 9.6%, while China and Korea grew by 15.03% and 20.70% respectively. In addition, the Indian market was expected to grow to $2 billion by 2010/11. This has not happened as the forces that were driving this growth were not working in tandem with respect to infrastructure, the regulatory environment, manpower and efficiency. As the Indian government will need to take a number of steps to eliminate the issues and regulatory hurdles that slow down the growth of the Indian clinical trial market, CROs are both optimistic and slightly sceptical as to whether the forecasted 20-25% growth figure will be achieved. India must learn from countries such as Korea, which has invested in infrastructure to ensure clinical research happens in an organised manner, and has established a robust regulatory framework that allows good clinical practice (GCP) compliant trials across the country. This article will review current obstacles and recommendations to improve clinical research processes in India and ensure future growth. Obstacles to Clinical Research Growth In Indian bio-availability/bio-equivalence studies, regulatory timelines can result in significant delays to clinical research. The Drug Controller General of India (DCGI) is responsible for approval of licenses of specified categories of drugs such as blood and blood products, IV fluids, vaccine and sera. It currently takes six to eight weeks to get an initial response from the DCGI, resulting in significant delays to drug development. In addition, the process of handling amendments to an application is timely as each amendment is considered as a new application. Linking amendments to the original application is recommended to reduce the review time. Regulatory timelines are also increased as clinical trial January 2011

Market Report

applications (CTAs) are reviewed by DCGI during a 45day process, followed by an expert panel review taking an additional six weeks. To save time and resource, it is recommended that the expert review period is avoided for clinical trials with key country approvals. In some cases, CTAs are also not being referred to the correct experts and instead should be channelised in an organised manner. There is also a need to improve clinical research infrastructure in India. Steps have already been taken towards this, with the Drugs Technical Advisory Board (DTAB) making it mandatory for all ethics committees attached to clinical trial organisations to register themselves with the DCGI. This is in line with India’s efforts to build a sound regulatory framework, and is predicted to help increase transparency in relation to patient recruitment, consent process, independence of the ethics committee and its review and decision-making process. Developments have also been made in terms of CRO registration, in which CROs should be graded as per their capabilities and expertise, and a draft guideline is currently under review. As well as challenges relating to regulatory frameworks and inadequate infrastructure, lack of adequate funds from Indian pharmaceutical companies is hindering the growth of Indian clinical research. The government has began to offer incentives to domestic and multinational drug makers to encourage new drug discovery and transform India into one of the top five pharma innovation hubs by 2020.2 To conclude, the Indian clinical research market is buoyant and many of the world’s major pharmaceutical companies are looking to India for outsourcing partners thanks to its large patient population, disease demographics and significantly lower costs. In order to achieve aggressive growth targets, CROs and pharmaceutical companies must work with the Indian government to streamline regulatory framework, address ethical issues and establish new mechanisms for private-public partnership (PPP), enabling India to offer scientifically-driven, value-added research. This way India

can lead the way in drug discovery and research innovation, while also addressing domestic healthcare challenges. References 1. Frost & Sullivan, November 2011 2. Realizing the Promise of Asia Pacific: The Region’s Strategic Shift from Outsourcing to Innovation, Quintiles India. Apurva Shah is the Founder & Group Managing Director of Veeda Clinical Research. He has an MBA in International Finance & Entrepreneurship from Babson College in Boston USA. Apurva has strong entrepreneurial and organizational skills and as a founder & MD is responsible for set up and running of Veeda’s operations. As a member of the Board he gives strategic and financial direction to all Group Companies. Veeda has grown globally in the last 8years to have more than 400 employees worldwide in 5 offices in 4 countries. Frost & Sullivan awarded Veeda the coveted “CRO of the Year” in 2009. Apurva Shah was awarded “Entrepreneur of the Year” by the prestigious Bio Spectrum Magazine in 2009 and SME CEO of the year by Business India and Yes Bank in 2010 Apurva is the current Chairman of Association of CROs in India (www. where he wishes to develop India as a premier centre for clinical research. Apurva believes very strongly in giving back to the society and hence as a Managing Committee member of Each One Teach One ( a 26 year old NGO based in Mumbai he helps in furthering the cause of education and development of under privileged children. Lindsay Baldry is an Account Manager at The Scott Partnership (www.scottpr. com), a specialist B2B marketing communications agency delivering global communications within the clinical trials industry. Email: Journal for Clinical Studies 27

Market Report

Clinical Trial Approval Process in Brazil – Clearing the Roadblock to International Studies The regulation of clinical research in Brazil started at the national level in 1996, with the publication of Resolution number 196 from the National Health Council (CNS). The CNS provides statutory regulation of all research involving human beings, including ethical evaluation, which is performed by Local Ethics Committees (CEPs) and, in certain cases, by the National Ethics Committee (CONEP). Further regulatory assessment is the responsibility of the National Health Surveillance Agency (ANVISA), and is required for trials with drugs and medical devices aimed at future marketing applications. Brazil’s health statutes have grown over the years since inception and now include approximately 20 regulations at the national level from the Brazilian Ministry of Health and the National Ethics Committee, as well as the international requirements included in the International Conference on Harmonization (ICH), principles of Good Clinical Practice (GCP), and the Helsinki Declaration. The complexity of the Brazilian human health regulatory environment originated from the country’s concern for the safety of its people as potential participants in international studies. The socioeconomic disparity in certain regions of Brazil relative to the countries of origin of the pharmaceutical sponsors of clinical trials was seen as a potential enticement for study participation that may disguise the risk. As a result, the regulation of clinical research in Brazil ensures a high ethical standard comparable to internationally accepted benchmarks, yet has resulted in a lengthy process, slow to reach its conclusion due to the requirement for several independent and somewhat redundant reviews and approvals.

chemical entities were performed in Brazil compared to about 75, 100, and 150 studies performed in India, Russia and China, respectively (see Figure below).

The origin of the problem and the disparity in the number of clinical trials performed in Brazil is largely due to the period required for the approval of clinical studies by the National Research Ethics Committee, the CONEP. A survey by the University of São Paulo showed that the national average just for ethics approval of a study by the Local Ethics Committee, followed by approval by CONEP, may be as long as 100 to 150 days. According to the Association of Pharmaceutical Research, the national average for the overall approval of a new clinical trial from the time the documents are first submitted by the sponsor to ANVISA and by the investigator to the Ethics Committees, until the full review and approval by all agencies involved is complete and the drug has been imported into Brazil and accepted by Customs, may be as long as 10 to 14 months (see Figure below). In contrast, the US, Canada, Russia, and most other countries around the world range from 3-6 months, with China being the only other country with an approval time of at least a year.

The Process “From 2005 until today, there was a 4% decline in the number of recruiting patients for new studies in Brazil,” says Fabio Thiers, founder of ViS Research Institute, whose information is derived from work performed in conjunction with the Massachusetts Institute of Technology and the National Bureau of Economic Research, which evaluates the growth and decline of this economic segment. (See Figure below)

It is widely recognised that a major bottleneck in clinical trials in Brazil is the long timeline for study approval in relation to other countries, resulting in the loss of the country’s competitiveness in the case of international multi-centre trials. Furthermore, considering just clinical trials of new pharmaceutical products conducted in BRIC (the acronym for the four largest emerging markets: Brazil, Russia, India, China), the number of trials performed has decreased in all nations, but the decrease in Brazil was greater than in any of the other three countries. A total of only about 50 trials of new 28 Journal for Clinical Studies

The Cause The President of CONEP, Gyselle Tannous, has stated publicly that the delay in clinical trial approval derives from the arduous national policies which are in place to ensure conformity to the international requirements governing the use of humans in experimental trials. For example, the standard template Volume 4 Issue 1

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required for national approval of any study requiring the patient to give informed consent consists of 30 pages. “Hardly any patient will read it all. We have to make changes,” said Gyselle. Another bottleneck in the arduous process is the need to provide each study subject free access to treatment for the disease under study until the new drug is commercially available. “Clinical research is a field of conflicts of interest. We are rigorous in the defence of the rights of research subjects,” she stated.

The Ministry of Health recognises this issue and is implementing changes quickly in order to shorten the studyapproval timeline to international standards. In the last six years, according to estimates by ABRACRO - Brazilian Association of Clinical Research Organizations - Brazil missed realising investments of over USD 200 billion, although Brazil has more than 300,000 active physicians/investigators and more than 600 Local Ethics Committees installed. If this matter can be successfully addressed, capturing this missed Journal for Clinical Studies 29

Market Report revenue, the impact on the national economy, the viability of Brazil as a participant in international drug development and the resulting improved healthcare that can be offered to its citizens, will be substantial. These issues have been discussed in meetings between investigators, ethicists, the pharmaceutical industry and the Brazil Ministry of Health. The investigators agree with the importance of the Local Ethics Committees’ authority over participating institutions and the coordinated review and approval process through CONEP, which manages and administers the work. The proposal for revision of the process is to create and release five regional CONEPs and require just one ethics review, where the approval process is monitored and timelines standardised as much as possible. Facilitating the Clinical Trial Approval Process in Brazil By 2015, the Brazilian Ministry of Health plans to invest USD 1.5 billion in research into new drugs, treatments, vaccines and devices. The value is almost four times greater than the investment portfolio accumulated in the last four years, about USD 400 million. The regulatory agencies in Brazil are addressing changes in the review and approval process in order to speed up the actual timelines for study start-up. Implementation of the improvements began in 2005 with the publication of Resolution 346. This new regulation facilitates the process of the multi-centre research protocol review by the National Ethics Committee, requiring the dossier to be submitted only once by a single Local Ethics Committee, unlike the previous process when each Ethics Committee from each participating research centre was required to submit the same dossier for individual review and approval. In 2008, the National Health Surveillance Agency (ANVISA) published new regulations for clinical trials in Brazil, Resolution 39. The major importance of this resolution was the establishment of parallel procedures for both regulatory and ethical review, as well as permitting, under certain circumstances, importation of investigational products even before the ethics approvals of the study. Until recently, the ethics approval process was performed using hard paper copies and the national postal system, without taking advantage of the efficiencies of modern communications technologies. According to Reinaldo Guimarães, Secretary of Science and Technology of the Ministry of Health, “In part, industry and investigators are right; the first step will be to put in place a system that will allow the online tracking of protocol assessment.” Consequently, in November 2011 the Brazilian Ministry of Health launched the Platform Brazil and Brazilian Registry of Clinical Trials (REBEC), programmes that will unify data from research involving human subjects. With this platform, researchers can follow the project review via the internet. With REBEC, the first database for registration of clinical trials, the researcher will not have to resort to foreign databases to record the trial and track its progress. The REBEC is endorsed by the World Health Organization (WHO). With the unification of data, the expectation is that time for authorisation of research in Brazil will be decreased by many months, solving one of the main frustrations of the scientific community, research institutes and laboratories. The National Ethics Committee posted a letter on their website, stating: “We 30 Journal for Clinical Studies

advise that after the usual vacation of CONEP, from 15th Dec 2011 to 15th Jan 2012, all studies must only be submitted to ethics review by electronic system named Plataforma Brasil.” We hope that Platform Brazil will help speed up the ethics timelines in Brazil. The expected new ethics approval timeline is now eight weeks (See Figure below).

Platform Brazil is a national and unified electronic database of clinical trial records, which allows for the submission of study-related documents in digital form. It allows studies to be followed through their different stages from submission to final approval by the EC and CONEP, and, when necessary, also allows monitoring of the study progress through approval phases, including the submission of interim and final reports.

John Andrews PhD, Director, Regulatory Affairs, Chiltern. John Andrews PhD serves as the Director of Regulatory Affairs for the Americas for Chiltern International. Dr. Andrews has spent the majority of his career developing antivirals. He has published in the field and has been an invited speaker at FDA advisory panels and has served on expert panels for the evaluation of new surrogate markers for viral diseases. Email:

Eduardo Pizolato, Regulatory Affairs Officer, Chiltern. Eduardo Pizolato serves as the Regulatory Affairs Officer for Brazil for Chiltern Pesquisa Clínica. Eduardo is experienced in all phases of clinical studies including start-up and the regulatory and clinical importation process in Brazil, working with sites and vendors. His main therapeutic areas are oncology, infectious diseases, rheumatoid arthritis, haematology and HIV studies. Email:

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Standardised Equipment & Centralised Spirometry Approximately 15% of the world‘s population currently suffer from respiratory diseases, with chronic lower respiratory disease listed as the number four cause of death in the United States1. Chronic obstructive pulmonary disease (COPD) and asthma are cited as the two most common respiratory diseases, with over 20 million individuals in the United States recorded as suffering from asthma, and over 12 million with COPD2,3. Of the millions of respiratory disease sufferers, 4 million die each year within the United States, with women and children being particularly vulnerable1. Worringly, the rate of individuals with asthma continues to rise, with a 1.2% increase recorded from 2001-2009. Developing treatments to cure, prevent or provide palliative effect to sufferers of respiratory disease involves a significant investment from pharmaceutical companies. In the last four years the industry has spent an estimated $1.2 billion in developing new treatments for asthma alone4 . The investment cost associated with the development of new treatments is a key incentive for pharmaceutical companies to prioritise high quality data during clinical trials. Good quality data can accelerate the chances of compounds being accepted by the FDA and other regulatory bodies in addition to helping companies identify no-go projects at an early stage, thus avoiding further investment into compounds that will ultimately not be progressed successfully. When developing the treatments to treat asthma and COPD, pharmaceutical companies utilise pulmonary function testing (PFT) to determine the compound’s efficacy. Pulmonary function testing indicates the improvements to the respiratory system caused by the treatment being tested. The main pulmonary function test utilised in asthma and COPD research is a basic spirometry test. Why are there Problems with Spirometry? It is important to note that spirometry testing involves the cooperation of the subject to give a maximal exhalation in order to obtain good quality data. An uncooperative subject during the performance of the test can cause the data to be of poor quality and may actually mask a treatment effect. This can heighten the potential for the parameter in most respiratory studies to be overestimated or underestimated, depending on the error5. With this potential for poor quality data there is a need to utilise standards to determine what parameters could be used to determine a good spirometry test from a poor test. In 2005, the American Thoracic Society (ATS) and European Respiratory Society (ERS) released their most recent document with guidelines on how to collect and interpret spirometry data6. The ATS/ERS document outlines criteria that should be used to determine if a spirometry test is of good quality. The application of these standards creates a systematic approach for the review of a spirometry test. The ATS stated in 1991 that, “The largest single source of variation of within-subject variability is improper performance of the test.”5,7. The current 2005 ATS/ERS document states, “If the variability of the results can be diminished and the measurement accuracy improved, the range of normal values for a population can be narrowed and abnormalities more 32 Journal for Clinical Studies

easily detected.”5. In line with these guidelines, it is vital that pharmaceutical companies work to decrease variability in data in order to facilitate the detection of true clinical signals in all treatments being tested. Increased variability can occur for a multitude of reasons, with a lack of standardisation due to the use of a decentralised approach cited as a key cause of heightened variability. A lack of standardisation can impact the following areas: equipment, reference equations, test performance, training, and transcription errors, resulting in increased variability and unreliable data. Problem: Non-Standardised Equipment: Equipment Variability: While the majority of manufacturers produce spirometers that meet the ATS/ERS criteria for devices, there is still a broad range of varying levels of acceptability within the criteria. The accuracy of a spirometer defined by the 2005 ATS/ERS is ± 3% or ± .050 L (50ml) 6. Due to this range, if multiple manufacturers were used in a clinical trial there could be an error of 100ml in the data from just the variability of devices used. Treatment effects of the various drugs used in asthma and COPD vary from as small as 50ml to as high as 120ml8. By utilising multiple manufacturers, the risk of data variability is increased, potentially masking a treatment’s effect and hiding the efficacy of the treatment. Equipment Feedback: During the measurement it is important to provide feedback to the technician about the quality of the measurement, in line with ATS/ERS standards. The feedback can take the form of a simple message on data errors or an elaborate animation, designed to encourage the subject to perform a proper measurement. Problems arise in clinical research when the criteria for feedback are different. For example, Equipment A may use late time to peak expiratory flow to determine subject effort, and Equipment B may not utilise this criterion, resulting in inconsistent assessments. Equipment A may call the data good quality and Equipment B may call it poor quality. As a result, data may be deemed acceptable by Equipment A that is deemed unacceptable by Equipment B. Reference Equations: Inclusion of proper subjects in a clinical trial is sometimes established on a reference value from a prediction equation, with inclusion of improper subjects deemed as a risk to the efficacy of a trial. Subjects who meet a certain percentage of the prediction equation will be allowed to be included within a study. There are multiple prediction equations available for spirometry testing from various authors and years of publication5,9. While a pharmaceutical company may specify a specific prediction equation for their trial, they may not know with 100% certainty that the principal investigator is using the correct author or year of the prediction equation. Without this certainty, a doubt can occur concerning whether all subjects in the trial really qualified for that trial based on the correct prediction equation, leaving the trial vulnerable to decreased efficacy. Volume 4 Issue 1

Therapeutics Non-Standardised Training: Non-standardised studies often utilise multiple measurement techniques depending on the technician training at varying sites. This problem becomes amplified in an international study where technicians will have received different education and techniques for collecting spirometry data depending on their country. The collection of data utilising multiple techniques across sites will significantly increase the variability of the data, and as a result reduce the level of quality. For example, Site A may require subjects to take a deep breath in, put the spirometer in their mouth, exhale forcefully and then stop the measurement. Site B may require subjects to breathe with the spirometer in their mouth, take a deep breath, forcefully exhale, take another deep breath in and then stop the measurement. Both techniques will provide a forced expiratory volume in the first second FEV1, however the ability to determine a quality effort are reduced with site A’s process. The centralised approach ensures all sites are given standardised training, ensuring consistent data collection processes across the board and reducing any variability.

c. Increased cost: Increasing the numbers of subjects will increase the cost of the study. d. Delayed time to market, resulting in delayed revenues. e. Not finding a treatment effect when one exists: With the poor quality data and FEV1 being overestimated or underestimated based on poor quality data, a treatment effect may not be seen even when one exists.

Problem: Non-Centralised Spirometry

Step 1: Standardised Equipment

Data Collection: Difference in feedback from the equipment may also lead to variations in how a test is performed. For example, feedback from Manufacturer A may state a measurement is poor quality based on time to peak expiratory being >120ms. However, Manufacturer B may use >160ms. This difference may have the same data point being excluded from Manufacturer A and used for Manufacturer B. As a result, further measurements will need to be collected, depending on what feedback the technician receives, requiring further time and cost, and reducing efficiency.

Reduced Equipment Variability: Sourcing equipment from the same manufacturer to ensure standardisation can reduce the risk of variability caused from different equipment, which could be as high as 100ml difference in FEV1 from just the equipment differences. In addition, when the same manufacturer’s equipment is utilised, study protocol workflows can be programmed into the spirometry devices. Equipment which controls the workflow of data collection will reduce protocol violations using criteria that restrict the user to specific time points for data collection. When outside of these time points, data collection is not allowed or a message is entered to explain the reason why the data point is outside the allowed time point. Also, the same subject inclusion prediction equations can be programmed into the devices, eliminating the possibility of different equations being utilised. This includes subjects resulting in erroneous subject inclusion or exclusion due to different prediction equations.

Data Review: In most non-centralised studies the data is not reviewed for quality, or it is reviewed at the end of the study, both of which can be problematic. Without continuous data quality review throughout the course of the study, no indications of variability or compromised quality can be detected and solved. Data Quality: When using the non-centralised approach, data is manually entered into an ECRF application without data quality statements. Manual data entry poses a significant risk for transcription errors. A 2.51 L FEV1 could easily become a 5.51 L FEV1. Transcription errors will increase the variability of data and may hide a treatment effect by causing outliers to happen by inputting the wrong values. Due to a lack of standard quality statements followed by constant feedback to the sites, site performance can potentially be decreased during the course of the trial. All of these issues could lead to: a. Decreased statistical power: The variance for FEV1 and forced vital capacity FVC will increase, which could cause a reduction in the power of a study. b. Increased number of subjects: With the power reduced, a sponsor will need to add additional subjects to increase the study power. 34 Journal for Clinical Studies

Solution: Standardisation and Centralisation As awareness of the potential shortcomings associated with the decentralised model increases, pharmaceutical companies are moving towards a new centralised model of data collection. A centralised respiratory model is defined by two elements: standardised equipment and centralised spirometry. In order to standardise on equipment, each site receives identical equipment with the same protocol-specific software. To ensure centralised spirometry, an electronic transfer of the spirometry data is automatically made to a centralised database for review by a centralised OverRead service.

Consistent Equipment Feedback: Utilising the same equipment manufacturer also allows for consistent feedback while performing the spirometry measurement. This helps to ensure consistency of measurement and to reduce variability. Standardised Training: Standardisation of equipment allows for standardised training and test performance, thus ensuring that all the data is collected utilising the same techniques and reducing variability. Step 2: Centralised Spirometry Electronic Data Transfer: After the data has been collected it is electronically transferred to a central database. This step eliminates any transcriptional errors that may occur when entering data manually into an eCRF.

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Therapeutics variability. As a result, a greater percentage of acceptable data is collected, resulting in fewer patients, increased statistical power and reduced costs. To ensure the cleanest and most accurate results, standardised equipment and centralised spirometry should be standard operating procedure for sponsors developing new compounds for the treatment of respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD) and cystic fibrosis.

Ongoing Data Review: Another significant benefit associated with the centralised approach is the centralised review of data by a team of expert reviewers. The reviewers assess the measurement and data quality based on the current ATS/ERS standards. Throughout the centralised data review process the data will be graded according to a combination of the ATS/ ERS standards and pharmaceutical company specifications. This grade can be used for multiple functions, in particular for indicating which sites may need retraining due to a large percentage of poor quality tests. Proactive reviewing of sites can help to reduce large volumes of poor quality data by indicating poor performance and highlighting the need for improvement. Consistent Site Feedback: Feedback is provided directly to the investigational site or to the sponsor for each measurement performed. This feedback explains what errors were found on the data and how to prevent these errors in the future. A grade is applied to the data during this review process. This grade can be summarised for a particular investigator site to determine if they are performing the measurement properly and collecting good quality data. Identify Poor Performing Sites: Centralised OverRead occurs during the course of a study allowing for the data quality to be reviewed proactively. With a proactive review of data quality a site with a large amount of poor quality data can be targeted during the trial for retraining. This proactive review of the data quality will benefit the pharmaceutical company at the end of their study. A poorly performing site will be identified during the study and be retrained to improve the quality of their data. Without this intervention, the site would be collecting poor quality data throughout the study, which would have to be eliminated from the overall analysis. The pharmaceutical company will know during the trial and in real time how sites are performing, and act accordingly. Conclusion In the study of respiratory drugs, the parameters FEV1 and FVC are the important spirometry values used to determine efficacy and safety of an experimental drug. However, like all other pulmonary function values, these parameters are subject to the great amount of variability inherent in the nature of the testing. Poor data quality produces inconclusive results, which wastes stakeholders’ time and money and ultimately may prevent the release of a promising compound or, in the worst case, release a compound that is harmful to patients. By using centralised spirometry services, sponsors can benefit from increased consistency of processes and reduced

Sources: 1. Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. Deaths: Final data for 2007. National vital statistics reports; vol 58 no 19. Hyattsville, MD: National Center for Health Statistics. 2010. 2. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2009 Series 10: No. 249 Data From the National Health Interview Survey U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics Hyattsville, Maryland August 2010 DHHS Publication No. (PHS) 2011-1577 3. Akinbami LJ, Moorman JE, Liu X. Asthma prevalence, health care use, and mortality: United States, 2005–2009. National health statistics reports; no 32. Hyattsville, MD: National Center for Health Statistics. 2011 4. Parexel Biopharmaceutical R&D Statistical Sourcebook 2011/2012 5. Townsend M, Eschenbacher W, Beckett W et al. Spirometry in the Occupational Health Setting-2011 Update, Journal of Occupational & Environmental Medicine. 2011:53:569-584. 6. Miller MR, Hankinson J, Brusasco V et al. Standardization of Spirometry, Eur respr J, 2005:26:319-38. 7. American Thoracic Society. Lung function testing: selection of reference values and interpretive strategies. AM Rev Respir Dis 1991: 144:1202-1218 8. Jensen et al. Sources of Long-term variability in measurements of lung function implications for interpretations and clinical trial design. Chest, 2007:132:396-402. 9. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eurr Respir J, 2005:26:948-968. For further press information please contact Fiona Robinson, The Scott Partnership, 1 Whiteside, Station Road, Holmes Chapel, Cheshire CW4 8AA, United Kingdom. Phone +44 1477 539539, Fax +44 1477 539540, Email Jim Sowash, Director Respiratory OverRead, ERT. Jim Sowash has a Bachelor of Science degree in Exercise Science with a concentration in Exercise Physiology from the University of Toledo, Toledo Ohio. He also has a Master’s Degree in Exercise Science with a concentration in Cardiac and Pulmonary Rehabilitation from Adelphi University in Garden City New York. Sowash has worked for ERT for ten years and is currently working as a Director of the Respiratory CorLab , overseeing the review of pulmonary function data collected for COPD, Asthma and IPF clinical trials. Professional experiences include co-authoring over 15 professional posters, presentations, abstracts and articles in organizations such as the American College of Sports Medicine, American College of Chest Physicians, and the American Thoracic Society. Email: Journal for Clinical Studies 35


Effectiveness of CDDP and CV247 Combination, in Colon and Breast Carcinomas The present research attempts to support the hypothesis that the combination of two already known substances, CDDP and CV247 agent, have great efficacy in human colon and breast carcinomas. Currently, many studies have evaluated their positive effect in patients suffering from colon and breast cancer. In order to prove the above statement, chemo-sensitivity (viability and cytotoxiccytostatic) assays have been used over a period of ten days and using several different concentrations. The exported results showed a decreased number of viable cancer cells, especially in colon carcinomas, when compared with untreated cancer cells. Key words: CDDP, CV247 agent, colon cancer, breast cancer, viability assays Introduction The two most common types of cancer that have spread worldwide are colorectal and breast cancer. According to the information given by the National Cancer Institute, during 2010 in the UK, from the 207,090 women diagnosed with breast cancer, 39,840 died, and of the 142,570 men and women diagnosed with colorectal cancer, 51,370 died. From the above we understand that the need to find new ways to treat and/or to improve the standard of living for people who suffer from such carcinomas has been dramatically increased. Many chemotherapeutic agents have been discovered, and one of the most widely used is cis-platinum. Cis-platinum (cisplatin or cis-diamminedichloroplatinum (II) (CDDP)) was the first substance of a group of platinum-containing anti-cancer drugs, which now also includes carboplatin and oxaliplatin. These platinum complexes react in vivo, bind to and generate intrastrand bond between DNA and cis-platin, which ultimately triggers apoptosis (programmed cell death). Concerning CDDP, it has been proven to be effective for treating various types of cancer, including colon and breast carcinomas. The CV247 component is also a cytotoxic-cytostatic agent which is a combination of already known substances, and has been proved to be effective against colon and breast cancer. In order to investigate the effect from the combination of these two drugs, both colon and breast cancer cells were separately treated with CDDP and CV247, as well as with the combination of these two. For this reason, viability assays such as MTT (methyl-tetrazolium dye), SRB (Sulforodhamine B assay) and CV (crystal violet dye elution assay) were used. Materials and Methods In order to test the effect of the combination of the two substances (CV247 (Ivy Biochemicals Ltd) and CDDP (P4394, Sigma)) in comparison with the effect of each of them separately, three human colon cancer cell lines and three 36 Journal for Clinical Studies

human breast cancer cell lines, which have been obtained from the European Collection of Cell Culture (ECACC), have been used. The studied cell lines that represented colon carcinomas were LoVo, HCT-8 and HT55 cell lines, and those that represented breast carcinomas were MDA-MB 231, MFM223 and T47D cell lines. All the cell lines supplied by ECACC undergo comprehensive quality control and authentication procedures, such as mycoplasma testing, species and identity verification and STR’s analysis. In order for cells to proliferate, they were incubated at 37oC, in a 5% CO2 environment, in 75cm2 flasks (5520200, Orange Scientific) that contained the growth medium essential for each cell line, as well as with the appropriate amount of heat-inactivated Foetal Bovine Serum (FBS) (10106-169, Invitrogen) and 2mM L-Glutamine (G5792, Sigma). In this study, the panel of the experiments included chemo-sensitivity – colorimetric assays, which were based on the quantification analysis of living cells by using indirect parameters. Cells were cultivated according to the cell culture protocols provided by ECACC in sterile conditions. During the logarithmic phase, the cells were detached by trypsinisation (Trypsin-0.25% EDTA, 25200-072, Invitrogen) and were plated in triplicates in 96-well plates (3599, Corning, Costar) (18,000 cells/well) in a final volume of 200μl of culture medium per well. After 70-80% confluence of the culture, the medium was removed and CDDP and CV247, as well as the two substances together, were added in the following concentrations. CDDP: 1 μg/ml, 5 μg/ml, 10 μg/ml, 50 μg/ ml and 100 μg/ml, diluted in N, N-dimethylformamide (DMF, 15440, Fluka). CV247: 100 μg/ml and 200 μg/ml diluted in water (the maximum equivalent of 800 μg of ascorbic acid, 700 μg of sodium salicylate, 5.6 μg of copper gluconate and 5 μg of manganese gluconate per well). CDDP + CV247: 1 μg/ ml + 100 μg/ml, 5 μg/ml + 100 μg/ml, 10 μg/ml + 100 μg/ml, 50 μg/ml + 100 μg/ml, 1 μg/ml + 200 μg/ml, 5 μg/ml + 200 μg/ ml, 10 μg/ml + 200 μg/ml, 50 μg/ml + 200 μg/ml, diluted in the appropriate buffers each. The optical absorbance resulting from the number of living cells was measured in a time period of ten days, with every measurement made every two days, starting on day zero (0 day) of the incubation period. This was the first panel of the colorimetric experiment. In the second panel, the sixth day, an extra amount of CV247 was added in the cells that had previously been incubated with both CDDP and CV247. In this way we are able to compare the interaction between the two substances with or without the extra amount of the CV247 compound. As it is proven all methods and protocols have advantages and disadvantages, three colorimetric assays were used in order to exceed problems such as the linearity and sensitivity of each of them. The colorimetric assays that were used were MTT (3-(4,5 diamethylthiazol-2-yl)-2,5 diphenyl tetrazolium Volume 4 Issue 1


Therapeutics bromide) which is metabolised in the mitochondria of were conducted in triplicate, and were tested for the range of metabolically active cells to a dark blue insoluble formazan the dilutions mentioned above in comparison with untreated product, SRB (Sulforhodamide B assay) which is a protein cells. The statistical significance of all effects was evaluated binding assay, and CV (crystal violet dye elution assay) which by a “difference of the means” test (p< 0.05). is a protein staining assay. At the end of the incubation periods the number of living cells were measured at an optical density Results of 570nm using a μQuant™ Biomolecular Spectrophotometer, The results that have been generated indicate that there were MQX200, and Gen5™ Microplate Data Collection & Analysis some differences between colon and breast carcinomas. software (BioTek® Instruments.Inc, April 2008, ®2006-2008, Concerning colon cancer, it was observed that the population Revision E). Since absorbance measurements are influenced of cancer cells was obviously decreased when an extra by many factors, such as sample turbidity, dust particles and amount of CV247 agent was added on the sixth day. The bubbles, dirty microplates, well geometry and absorption to concentrations that had a greater effect were CV247 100μg/ well surfaces, a second wavelength of absorbance for all the ml and CV247 200μg/ml combined with CDDP 50μg/ml. individual assays was studied in order to subtract the noise However, comparing the effect of the above two combinations, and deviations. In the MTT assay, the absorbance value at A570nm was corrected by a second measurement at A630nm. The Table 1: Statistic evaluation of absorbance values in HCT8 cell line same method was used for the SRB and CV assays, with an additional measurement at 690nm1, 2, 3, 4. Colorimetric – chemo-sensitivity assays • For the MTT protocol, 20 μl of 5mg/ml MTT [bromide 3-(4,5-dimethyltio-azo-2)2,5-diphanyl-tetrazole] (M2128, Sigma) was added to each well of plated cells which were then incubated for 3h at 37oC. At the end of the incubation period, the medium was removed and cells were rinsed with PBS (P3813, Sigma). The formazan crystals were dissolved with 100 μl of dimethyl-sulphoxide (DMSO) (D4540, Sigma)5, 6, 7, 8, 9, 10, and 11. • For the SRB assay, cells were fixed by layering 50 μl of 10% trichloroacetic acid (91228, Fluka,) and the plates were incubated at 4oC for 1h. After this period, cells were rinsed with water and stained with 100 μl of 0.4% SRB (341738, Sigma), dissolved in 1% acetic acid (401422, Carlo Erba), for 15 min. The unbound stain was removed, by washing twice with 1% acetic acid followed by the addition of 200 μl of 10mM Tris Buffer pH 10.5 (T6791, Sigma) in order to release the bound dye12,13,14. • For the CV assay, the medium was removed from the 96-well plates and each well was rinsed with PBS. Cells were fixed by adding 100 μl of 10% formalin (1.04003.2500, MERCK) for 20 min. The formalin was removed and then 100μl of 0.25% aqueous crystal violet (HT901, Sigma) was added for 10 min. Finally, by adding 100μl of 33% acetic acid, the stain or dye was dissolved13, 15, 16, and 17.

Table 2: Statistic evaluation of decrease fold values in HCT8 cell line

Table 3: Statistic evaluation of absorbance values in MDA-MB 231 cell line

Statistical Analysis In order to have statistically acceptable results, all treatments for every cell line 38 Journal for Clinical Studies

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Therapeutics the CV247 100μg/ml combined with CDDP 50μg/ml had more acceptable results in all three assays performed (MTT, SRB and CV assay). The decrease in HCT8, human colon adenocarcinoma, ranged from 82% to 94% (MTT assay), 37% to 49.7% (SRB assay) and 89.5% to 94.7% (CV assay) on the sixth day. To conclude, there was an obvious decrease rate of the percentage of colon cancerous cells when these were incubated with CV247 100μg/ml combined with CDDP 50μg/ml, on the sixth day of the incubation period (see Tables 1-2 and Figure 1). In the breast cancer cell lines that were tested, it was observed that the extra amount of CV247 component that was added in the sixth day of the incubation period had no positive impact in the decrease of the cancerous cells. There Figure 1: Decrease fold values in HCT8 cell line

was an obvious decrease rate of the cells when treated with the combination of CV247 and CDDP in all their different concentrations. However, the optimum concentration that had decreased the breast cancer cells was CV247 100μg/ml combined with CDDP 50μg/ml during the eighth day of the incubation period. See Tables 3-4 and Figure 2. In order to calculate the decrease fold, the absorbance measurements have been used. The absorbance is given by the Beer-Lambert law where the formula is A=Ecl, (where A is absorbance, E is the extinction coefficient, l is the distance the light travels through the material, and c is the concentration of the absorbing species within the material18. Discussion During the last year, it has been observed an increased number of patients who suffer from many types of cancer. The need to prevent, treat as well as to improve the standard of living of these patients is imperative. For this purpose many compounds have been established. CDDP is a platinum-based chemotherapy drug that is used to treat various types of cancer but basically sarcomas and ovarian carcinomas19,20,21,22. Its biochemical mechanism involves the binding of the drug to DNA and non- DNA targets and the subsequent induction of cell death through apoptosis and necrosis. This molecular model is regulated by the intracellular redox, potential generated by the pyridine nucleotide pool (NAD+/NADH and NADP+/ NADPH) as well as by the free cellular energy available from the ATP/ADP ratio. It is generally acceptable that when CDDP binds to genomic DNA (gDNA) into the cell nucleus, is mostly responsible for its antitumor properties.23. Although CDDP is a widely used chemotherapeutic agent, it causes considerably adverse side effects when it is used alone in a chemotherapeutic model. At first, it causes high toxicity (nephrotoxicity, neurotoxicity, ototoxicity, electrolyte disturbance, nausea and vomiting) so there is a dose-limiting factor which reduces its healing properties24,25,26. On the other hand, the most common hallmark characterizes the majority of anticancer agents, including CDDP, is the drug resistance pre and/or after treatment. In comparison with other cancer types (such as head, neck, testicular or ovarian carcinomas) colorectal and breast tumors are resistant to CDDP therapy exhibiting several resistant pathways acting simultaneously in order for cancer cells to escape cell death24, 27, 28, 29, 30 & 31. Another substance that has been used as a chemotherapeutic agent and has been proved to be cytotoxic-cytostatic against colon and breast tumors, is the CV247 compound. It consists of four already known substances: gluconate manganese, gluconate copper, ascorbic acid (vitamin C) and sodium salycylate (SS), and improves symptoms as well as prolonging life in patients with terminal cancer types by stimulating the immune system or by stimulating or down-regulating the production of cytokines such as IL-1832, 33. Journal for Clinical Studies 39

Therapeutics According to previous studies, CDDP has a synergist effect when combined with other anti-cancer drugs. The purpose of this study was to evaluate the efficacy of CDDP and CV247 separately as well as in combination, in three human colon cancer cell lines (LOVO, HCT8, HT55) and in three human breast cancer cell lines (MDA-MB 231, T47D, MFM-223) over a time period of a ten-day assay. According to the results, there is clear evidence that the combination of CDDP and CV247 decreases dramatically the percentage of both colon and breast cancer cells when compared with the effect of each substance separately. This suggests that the doses are timeand concentrate-dependant, and if the therapeutic regimen will be administered over a more extensive time period (ten days) and in relatively low concentrations, it will reduce the negative consequences of CDDP and CV247 separately 34, 35, 36, 37, 38, 39, 40, 41, 42 . Conclusion In conclusion, this study enhances the cytotoxic-cytostatic effect of CDDP and CV247 in colon and breast carcinomas in a time period of ten days. It was found that the CDDP and CV247 combination was able to decrease the number of viable cancer cells by up to 80% of the total cell population on the sixth day of the incubation period, particularly in human colon cancer cell lines when compared to untreated cell lines. Further study is warranted to determine the efficacy of this combination regimen in a greater spectrum of cell lines. References 1. Mosmann, T. Rapid colorimetric assay for cellular growth and survival: application to proliferation and cytotoxicity assays. J Immunol Methods 65, 55-63 (1983). 2. Haselsberger, K., Peterson, D.C., Thomas, D.G. & Darling, J.L. Assay of anticancer drugs in tissue culture: comparison of a tetrazolium-based assay and a protein binding dye assay in short-term cultures derived from human malignant glioma. Anticancer Drugs 7, 331-338 (1996). 3. Skehan, P. et al. New colorimetric cytotoxicity assay for anticancer-drug screening. J Natl Cancer Inst 82, 11071112 (1990). 4. Grady, J.E., Lummis, W.L. & Smith, C.G. An improved tissue culture assay. III. Alternate methods for measuring cell growth. Cancer Res 20, 1114-1117 (1960). 5. Liu, Y., Peterson, D.A., Kimura, H. & Schubert, D. Mechanism of cellular 3-(4,5-dimethylthiazol-2-yl)-2,5diphenyltetrazolium bromide (MTT) reduction. J Neurochem 69, 581-593 (1997). 6. Sargent, J.M. The use of the MTT assay to study drug resistance in fresh tumour samples. Recent Results Cancer Res 161, 13-25 (2003). 7. Hayon, T., Dvilansky, A., Shpilberg, O. & Nathan, I. Appraisal of the MTT-based assay as a useful tool for predicting drug chemosensitivity in leukemia. Leuk Lymphoma 44, 19571962, doi:10.1080/1042819031000116607 (2003). 8. Berridge, M.V. & Tan, A.S. Characterization of the cellular reduction of 3-(4,5-dimethylthiazol-2-yl)-2,5diphenyltetrazolium bromide (MTT): subcellular localization, substrate dependence, and involvement of mitochondrial electron transport in MTT reduction. Arch Biochem Biophys 303, 474-482 (1993). 40 Journal for Clinical Studies

9. Edmondson, J.M, Armstrong, L.S, Martinez, A.O. A rapid and simple MTT-based spectrophotometric assay for determining drug sensitivity in monolayer cultures. Methods in Cell Science 11, 15-17 (1988). 10. Freimoser, F.M., Jakob, C.A., Aebi, M. & Tuor, U. The MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay is a fast and reliable method for colorimetric determination of fungal cell densities. Appl Environ Microbiol 65, 3727-3729 (1999). 11. Lin, Z.X., Hoult, J.R. & Raman, A. Sulphorhodamine B assay for measuring proliferation of a pigmented melanocyte cell line and its application to the evaluation of crude drugs used in the treatment of vitiligo. J Ethnopharmacol 66, 141-150 (1999). 12. Vichai, V. & Kirtikara, K. Sulforhodamine B colorimetric assay for cytotoxicity screening. Nat Protoc 1, 1112-1116 (2006). 13. Voigt, W. Sulforhodamine B assay and chemosensitivity. Methods Mol Med 110 (2005). 14. Davey, J., Lord, J.M. (2003). Essential Cell Biology. p:25-31, Oxford University Press. 15. Chiba, K., Kawakami, K. & Tohyama, K. Simultaneous evaluation of cell viability by neutral red, MTT and crystal violet staining assays of the same cells. Toxicol In Vitro 12, 251-258 (1998). 16. Haselsberger, K., Peterson, D.C., Thomas, D.G. & Darling, J.L. Assay of anticancer drugs in tissue culture: comparison of a tetrazolium-based assay and a protein binding dye assay in short-term cultures derived from human malignant glioma. Anticancer Drugs 7, 331-338 (1996). 17. Keepers, Y.P. et al. Comparison of the sulforhodamine B protein and tetrazolium (MTT) assays for in vitro chemosensitivity testing. Eur J Cancer 27, 897-900 (1991). 18. Wu, D. & Cederbaum, A.I. Sodium salicylate increases CYP2E1 levels and enhances arachidonic acid toxicity in HepG2 cells and cultured rat hepatocytes. Mol Pharmacol 59, 795-805 (2001). 19. Chakraborty, B.K., Biswas, N., Choudhury, K., Neogy, R.K. & Das Sarma, B. Antitumour activity of some platinum compounds. Chemotherapy 31, 55-59 (1985). 20. Labianca, R. et al. Cisplatin + 5-fluorouracil versus 5-fluorouracil alone in advanced colorectal cancer: a randomized study. Eur J Cancer Clin Oncol 24, 1579-1581 (1988). 21. Wilson, A.P., Ford, C.H., Newman, C.E. & Howell, A. cisplatinum and ovarian carcinoma. In vitro chemosensitivity of cultured tumour cells from patients receiving high dose cis-platinum as first line treatment. Br J Cancer 56, 763-773 (1987). 22. Armstrong, D.K. et al. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med 354, 34-43 (2006). 23. Fuertes, M.A., Alonso, C. & Perez, J.M. Biochemical modulation of Cisplatin mechanisms of action: enhancement of antitumor activity and circumvention of drug resistance. Chem Rev 103, 645-662, doi:10.1021/cr020010d (2003). 24. Ohkawa, K., Tsukada, Y., Dohzono, H., Koike, K. & Terashima, Y. The effects of co-administration of selenium and cisplatin (CDDP) on CDDP-induced toxicity and antitumour activity. Br J Cancer 58, 38-41 (1988). 25. Rybak, L.P., Mukherjea, D., Jajoo, S. & Ramkumar, V. Cisplatin Volume 4 Issue 1

Therapeutics ototoxicity and protection: clinical and experimental studies. Tohoku J Exp Med 219, 177-186 (2009). 26. Zhang, P., Gao, W.Y., Turner, S. & Ducatman, B.S. Gleevec (STI-571) inhibits lung cancer cell growth (A549) and potentiates the cisplatin effect in vitro. Mol Cancer 2, 1 (2003). 27. Yuan, S.Q. et al. [Correlation of chemosensitivity tested using histoculture drug response assay to expression of multidrug resistance genes and proteins in colorectal cancer tissues]. Ai Zheng 28, 932-938 (2009). 28. Gosland, M., Lum, B., Schimmelpfennig, J., Baker, J. & Doukas, M. Insights into mechanisms of cisplatin resistance and potential for its clinical reversal. Pharmacotherapy 16, 16-39 (1996). 29. Andrews, P.A. Mechanisms of acquired resistance to cisplatin. Cancer Treat Res 73, 217-248 (1994). 30. Eastman, A. Mechanisms of resistance to cisplatin. Cancer Treat Res 57, 233-249 (1991). 31. Hospers, G.A., Mulder, N.H. & De Vries, E.G. Mechanisms of cellular resistance to cisplatin. Med Oncol Tumor Pharmacother 5, 145-151 (1988). 32. Toloudi, M. et al. The impact of CV247 component in human cancer cell lines. JCS 3 62-69 (2011) 33. 34. Yde, C.W., Gyrd-Hansen, M., Lykkesfeldt, A.E., Issinger, O.G. & Stenvang, J. Breast cancer cells with acquired antiestrogen resistance are sensitized to cisplatin-induced cell death. Mol Cancer Ther 6, 1869-1876 (2007). 35. Smith, I.E. & Talbot, D.C. Cisplatin and its analogues in the treatment of advanced breast cancer: a review. Br J Cancer 65, 787-793 (1992). 36. Dejager, D., Redlich, P.N., Dayer, A.M., Davis, H.L. & Komorowski, R.A. Primary squamous cell carcinoma of the breast: sensitivity to cisplatinum-based chemotherapy. J Surg Oncol 59, 199-203 (1995). 37. Huerta, S. et al. Gene expression profile of metastatic colon cancer cells resistant to cisplatin-induced apoptosis. Int J Oncol 22, 663-670 (2003). 38. Dropcho, E.J., Rosenfeld, S.S., Vitek, J., Guthrie, B.L. & Morawetz, R.B. Phase II study of intracarotid or selective intracerebral infusion of cisplatin for treatment of recurrent anaplastic gliomas. J Neurooncol 36, 191-198 (1998). 39. Yoshioka, T. et al. A new combination chemotherapy with cis-diammine-glycolatoplatinum (Nedaplatin) and 5-fluorouracil for advanced esophageal cancers. Intern Med 38, 844-848 (1999). 40. Boyle, P.J., Ma, R., Tuteja, N., Banerjee, S. & Basu, S. Apoptosis of human breast carcinoma cells in the presence of cis-platin and L-/D-PPMP: IV. Modulation of replication complexes and glycolipid: Glycosyltransferases. Glycoconj J 23, 175-187, doi:10.1007/s10719-006-7923-5 (2006). 41. Basu, S. et al. Apoptosis of human carcinoma cells in the presence of potential anti-cancer drugs: III. Treatment of Colo-205 and SKBR3 cells with: cis -platin, Tamoxifen, Melphalan, Betulinic acid, L-PDMP, L-PPMP, and GD3 ganglioside. Glycoconj J 20, 563-577 (2004). 42. Bunn, P.A., Jr. & Kelly, K. New combinations in the treatment of lung cancer: a time for optimism. Chest 117, 138S-143S (2000).

42 Journal for Clinical Studies

Maria Toloudi studied molecular biology and genetics in the University of Thrace and now I have been working for about three years in the R.G.C.C as a member of the research and development department. I am active especially in the field of cellular and molecular biology dealing with human cancer stem cells. Email: Panagiotis Apostolou graduated from the Department of Molecular Biology and Genetics, Democritus University of Thrace, in 2007. Since October 2008 I have been working in the research and development department of the R.G.C.C. (Research Genetic Cancer Center Ltd,, and I am active in the field of molecular biology. Email: Marina Chatziioannou was born and grew up in Greece. I studied biochemistry and biotechnology at the University of Thessaly (2001-2006). I have worked at the R.G.C.C. laboratory since 2006, at the clinical department, flow cytometry section. I mainly work on Human Circulating Tumour Cells (CTCs). Email: Dr Roger Oakes is a biochemist with over 35 years experience in drug development. Email:

Ioannis Papasotiriou was born in Germany in 1973 and returned in childhood to Greece, where I studied in the Medical School of Thessaloniki, specialising in human genetics in Switzerland. Two master degree awards have been obtained in molecular biology in medicine from Westminster University (UK), and in oncology from the University of Nottingham (UK). I was promoted to MD in MLU in Germany under the field of evaluation of TKIs in human cancer cell lines. Since 2004 I have been the director and founder of RGCC Ltd, which is active in both areas of service (research and clinical). Email:

Volume 4 Issue 1

IT & Logistics

Bringing Proven Clinical Trial Electronic Payment Solutions to Emerging Markets North America is the largest market for CROs, with over 36,281 sites having completed clinical trials and actively recruiting in the United States, and 3032 in Canada.1 Western Europe has the second largest share of clinical trial sites across its numerous countries. As such, these two regions have long been considered the traditional markets for clinical research organisations (CROs). However, emerging markets are presenting significant potential for the expansion of clinical trial services. The various emerging markets that are being identified as huge potential growth areas each have unique benefits with regards to regulatory landscapes, potential patient population, patient access, recruitment and retention, and treatment naivety. However, the emerging markets also present substantial challenges that can impede clinical trial progress and sometimes even threaten the overall success of a trial. Clinical trial payments represent one of the challenges CROs, investigators and sites face in both traditional and emerging markets. Approximately 20% of clinical trial sites worldwide are located in countries which have relatively poor banking infrastructures compared to North America and Europe.2 This can make obtaining payments via traditional methods difficult for subjects in emerging markets due to lack of bank accounts or large administration fees. Payments to clinical trial subjects are often a topic of hot debate, and are generally considered either a primary motivator for patient participation or at least a measure of fair subject compensation for time, risk, and travel expenses. CROs can differ substantially in the marketing tactics they use to recruit subjects for clinical trials, based on these perceived patient priorities. With regards to subject payment, CRO Parexel states that “it is therefore considered ethical and appropriate that you should be paid for your time and inconvenience”3 and therefore does not push payment as a principal benefit of clinical trial participation, but rather as a necessary and ethical obligation. Conversely, Covance attempts to generate interest by mentioning financial reimbursement ahead of medical advancements: “By volunteering for medical trials with Covance, everyone from students to office workers to retired couples are being paid up to £2,500 and helping to make a real difference to pioneering medical breakthroughs.”4 While patient payments have been an integral element in clinical trials for decades, both in established and emerging clinical trials markets, the technology to efficiently manage and deliver payments has remained a technological backwater, dominated by outdated manual processes. It is estimated that almost 1.3 million people worldwide participate in clinical trials at over 95,000 sites each year, meaning that 44 Journal for Clinical Studies

eight million payments are made by CROs, clinical research sites and investigators to patients.5 Traditionally the majority of these payments have been made using cheques, which have been reported to incur significant administration costs at both the site and sponsor levels, and can involve more than four manual steps to administer a single patient payment. These steps can also require review and approval by multiple departments at both the site and the sponsor.6 Payments in cash, although flexible, can also present significant problems to clinical trial subjects, with obvious security issues associated with carrying substantial amounts of cash. In addition to issues of patient safety, cash payments also present problems to CROs, sites and investigators as cash payments require extensive manual tracking and monitoring. The multiple drawbacks associated with traditional payment methods highlight the need for more time-efficient, costeffective and patient-friendly solutions to reimburse patients taking part in clinical trials. Patient retention and recruitment are often judged as two of the most important factors in a successful clinical trial.7 Statistics show that delays associated with missed recruitment targets can dramatically increase the cost of conducting the trial.8 Around 20-30% of patients drop out of Phase II/III trails which can be, in part, due to the lack of a robust and cost-effective patient payment solution.9 Electronic payment solutions, such as the ClinCard system from Greenphire, present subjects with a replacement for traditional chequebased and cash payment methods while providing additional benefits to help improve the patient experience. Reduced Site and Sponsor Administration Clinical trials using electronic payment solutions provide trial subjects with a prepaid debit card. Payment management is handled through a web-based platform which enables the centralisation of payments. Payments are made to the subject via the debit card which can be PIN-protected, FDIC insured and subject to consumer protection regulations. In comparison to traditional methods such as cheque or cash payment, prepaid cards dramatically reduce site and sponsor administration. The company does not have to cut, produce and mail hundreds of cheques to hundreds of individuals, saving on administrative costs associated with these manual procedures. Efficient Approval and Reporting Processes Through a centralised system, electronic payment solutions offer an efficient electronic approval system to ensure the payment process runs as accurately and efficiently as possible. Sponsors have the option of controlling and monitoring release of payments to patients, or delegating this responsibility to site administrators. Volume 4 Issue 1

IT & Logistics

Mitigated Regulatory Risk Electronic payment solutions help CROs avoid regulatory risks in the industry by enabling compliance with IRB and ethics committee guidelines for each study. International payments are also possible through the prepaid card, further ensuring compliance across various national regulatory codes. Automatic compliance functionality reduces the time spent ensuring that payments are managed in accordance with regulations, thus reducing the risk to the company. Improved Patient Experience and Increased Patient Retention Several in-house studies carried out across the United States and Canada provided evidence that electronic payment systems have a significant effect on patient retention. The study compared payment management and delivery processes across two groups. One, consisting of 1043 patients, was paid using a cheque-based method, and the second, consisting of 1509 patients, received payment via an electronic payment solution. The group which received payment in the form of a cheque experienced an attrition rate of 24.9%, whereas the group using the prepaid card had a lower attrition rate of 16.5%. Opportunities for Electronic Payment Solutions in the Emerging Markets As emerging markets represent rapidly growing market potential for CROs in the coming years, companies are starting to streamline and adapt their services to harness the advantages offered by the largely unexplored markets. Electronic patient payment solutions have the potential to facilitate subject compensation in these markets where financial systems may be less robust and established than the traditional clinical trial markets of Western Europe and North America. Conclusion Electronic payment solutions and communication technologies present a cost-effective and efficient alternative to traditional payment methods which can often cause problems and unnecessary administration, and affect patient retention rates and overall clinical trial success. With over 50% growth

predicted in the clinical trials market before 2015, CROs have the opportunity to move into the less traditional markets such as Latin America, Eastern Europe and Asia present. Innovative solutions and technologies can help companies overcome challenges and replicate the successful CRO model in emerging clinical trial markets. References 1. Thiers, F.A., Sinskey, A.J., Berndt, E.R. Trends in the Globalization of Clinical Trials, Nature Reviews Drug Discovery 7, 13-14 (January 2008) 2. 3. 6.Whitaker, S. 2011. Put it on the Card. International Clinical Trials. August pp.29-31 7.w 8.IBID 9.Whitaker, S. 2011. Put it on the Card. International Clinical Trials. August pp.29-31 10. w media/8/Combined%20ClinCard%20System.pdf EMMIssue22009.pdf Samuel Whitaker â&#x20AC;&#x201C; Co-Founder & CEO Prior to founding Greenphire, Sam was a Vice President in the Product Development group of Citigroupâ&#x20AC;&#x2122;s prepaid card division. In this capacity, Sam was responsible for managing several existing products and developing new payment solutions for new and existing clients. Prior to working for Citigroup, Sam spent his career working in transactional finance both as an investment banker and as a member of the investment team of a Philadelphia based holding company. Sam earned a BA from the University of Pennsylvania. Email:

Journal for Clinical Studies 45

IT & Logistics

The Importance of Remote Data Access and Analysis in Clinical Trials The migration from paper-based data collection to electronic data capture (EDC) systems makes it possible to analyse trial data from any location as soon as it is collected. If leveraged properly, advanced data access and analysis methods can speed up the trial, make it safer, and even unlock substantial cost and time savings. The FDA has encouraged companies to implement these advanced methods in order to rely less on monitoring at clinical sites and more on centralised data analysis . This article will discuss the potential considerations that must be addressed when choosing remote data access and analysis platforms—including accessibility, security, ease of use, speed, data freshness, comprehensiveness, and correctness—and the specific advantages that can be gained when modern remote data analysis techniques are applied to a study. This article will also briefly discuss how modern data access and analysis can facilitate advanced adaptive trials. Accessibility and Security Accessibility considerations relate to who can access study data and by what means they access the data. The goal of accessibility is to make sure that data is available to the people who need it, when they need it, and in a manner that helps them do their job faster and better. The flip side of accessibility is security, or making sure that unauthorised users are not able to access study data. A well-designed remote data platform must find the optimal balance between removing friction points between clinicians and their data and preserving security. There are two main sources of friction from an accessibility standpoint: the data access point and the login structure. The first friction point is typically the relative flexibility of the data access point, the tool the user actually uses to see the data. For example, can the data be accessed from any computer, or only specific machines? Through other devices, such as an iPad or smartphone? Over any internet connection or only proprietary networks? Using common computer programs, like a web browser, or only through specific software that must be installed on all computers of all users? Although increasing the flexibility of the data access raises some security concerns, today’s modern data security methods allow for extremely flexible data access points, with the ideal data access option being any webenabled device. This would allow, for example, a study sponsor to access preliminary results from her hotel room while traveling, or for a study administrator to receive realtime information about serious adverse events (SAEs) on his smartphone when he’s out of the office. The other primary point of friction is the number of times a user must log in to gain access to all of the data and tools they need. Clearly strong user authentication is necessary to secure sensitive trial data, but ideally such authentication should follow a “single sign-on” model, where, for example, 46 Journal for Clinical Studies

a user can log in to an electronic portal once, and then the permissions embedded in the portal automatically provide the user with access to all of his authorised data and tools. Many EDC vendors have begun to recognise the importance of single sign-on, particularly where multiple systems are involved, and are developing integrated systems that allow users to work seamlessly across the multiple systems after a single authentication. This has the advantage of both creating less interruption in a user’s workflow, and also reducing the risk of security breaches from human error, such as users writing down their passwords in order to keep track of multiple logins. A key element of security that does not create accessibility friction is audit trails. It is essential that any remote data access platform keep an accurate audit trail of every action performed on the platform, and also respect and propagate the audit trail requirements of any underlying system. A comprehensive audit trail allows administrators to verify that logins, permissions and other security structures are functioning as designed, and is also imperative to have in the extreme case of an actual security breach. In this respect, an integrated EDC and remote data platform may be considered more secure than a manual data collection and on-site review system, because every step of the EDC system can be electronically recorded and reviewed, which is not true for all steps of manual data capture. When a remote data access platform is optimised for accessibility, it can reduce study bottlenecks, help clinicians and other users perform their jobs more efficiently, and ultimately decrease study duration. For example, suppose the study sponsor, reviewing preliminary results in her hotel room mentioned above, is looking at the results of patient recruitment screeners administered that day. If the sponsor notices that a certain aspect of the protocol is causing unnecessary screen failures, she could immediately start working on a protocol amendment to avoid the problem. If the data was less accessible, she may not have been aware of the problem until later, raising the number and cost of unnecessary screen failures. As noted above, any increase in accessibility must be counterbalanced by an assessment of the related security risks. Even small increases in accessibility can have a large impact on the efficiency of study administration. Ease of Use and Speed Once a user has access to the remote data platform, the next criterion to assess is how quickly and easily the user can obtain the information he needs to know about the data. The key components of this assessment are whether computer programming knowledge is required to interact with the data, how well the platform highlights and elevates key points of interest and, relatedly, how quickly a user can drill down on a point of interest, how closely different Volume 4 Issue 1

IT & Logistics systems are integrated, and whether the audit trail supports efficient data interaction. Each of these components is discussed below. Not every clinician is a programmer, nor should they need to be a programmer in order to make the most of their tools. Clinicians are domain experts, and their tools should complement their skills instead of getting in their way. This has not always been the case. One of the most basic workflows for reviewing clinical data, and one that is still often used today, requires a reviewer to determine what question they want to answer about the data and to then relay that question to an SAS programmer or statistician who then converts the question into a database query and returns the results to the reviewer. This process is both errorprone and time-consuming, not to mention frustrating for a reviewer, particularly if, for example, the reviewer realises very quickly upon seeing the results that she needs to ask a different question or that the database query didnâ&#x20AC;&#x2122;t match the question she had in mind. Smarter data platform tools can translate a clinicianâ&#x20AC;&#x2122;s input into the appropriate database query, allowing for ad hoc reporting and instant results. The best of these tools have intuitive interfaces that a clinician can quickly understand and leverage the metadata associated with standardised EDC data, so that the platform can handle even complex clinician questions without the need for programmer involvement. Another way that better remote data platforms help users review data more easily is by automatically highlighting important information. One feature that does this is highlevel dashboard overviews that are configurable by the user, enabling the user to see the metrics that he most cares about. For example, a clinical monitor may want to see a dashboard of how many patients are currently enrolled at each study site when she logs in to the platform, while a data manager may want to see how many data discrepancies have been reported in the data cleaning process and how they were resolved. All of these dashboards are possible if the appropriate databases are connected to the platform, and ideally the platform should allow the user to easily reconfigure the dashboard as their informational needs change. For information that needs to reach the user even faster than a dashboard can provide, a remote data platform should allow users to configure alerts that are triggered in real-time, as soon as certain events occur. These alerts can be configured to automatically send an email or text message, so the notified users do not need to wait until they log in to a computer to know about the event. The most common application of alerts is for serious adverse events (SAEs), but stakeholders may want to be alerted to other events, for example, if a patient misses a scheduled visit or drops out of the study. By receiving alerts, stakeholders can address potential issues quickly, before they become bigger problems that may delay or derail the study. On the other end of the spectrum from features that highlight information are features that allow users to quickly and easily drill down into the data and interact with it on a granular level. A well-designed data platform should bridge the two main barriers to a user being able to drill down on data quickly: the need to form database queries and the 48 Journal for Clinical Studies

need to integrate multiple data systems. As discussed above, a data platform should do the work of creating database queries so that a user without computer programming training can obtain query results through a simple interface. A data platform should also do the work of integrating multiple data sources. For example, if data collected at sites are stored in an Oracle database, but patient demographic information is collected in an Excel file, the data platform should have the ability to run a query involving both sets of information without moving the data from its source. The alternative method, to manually combine the data sources into one database, which is what many study administrators continue to do, tends to be extremely costly and introduces an unnecessary opportunity for error. Finally, a data platform can allow for quicker and easier data review by leveraging the audit trail, which, as noted above, is a necessary feature for security reasons. For example, if a reviewer can easily review their audit trail and annotate it with notes describing the review process, the reviewer can easily go back to the beginning of a review path that turns out to be unhelpful and start a new branch, or another reviewer can use the audit trail as a template for looking at a different set of data, speeding up the process of data exploration. The advantages of a fast, easy to use data platform that empowers non-programmers to review study data are tremendous. By eliminating the number of steps between a reviewer determining a question and the reviewer receiving the data that answer that question, advanced data platforms can substantially decrease costs, remove common sources of error, help identify potential issues quickly, before they become costly problems, and greatly increase the speed at which clinical data can be reviewed. Volume 4 Issue 1

IT & Logistics the budget and expense system can help the sponsor track the costs of its study and manage the financial aspects of the study. A relevant data source may also be the results of another study. The ability to compare results across studies can be extremely important in identifying adverse effects or confirming drug effectiveness. The cutting-edge features of advanced data platforms are limited in value if the underlying data are of low quality. A data platform should facilitate the rapid input of fresh data and the integration of multiple data sources by, for example, connecting directly to EDC sources and incorporating software components that can run queries across different data sources without moving the data from the sources.

Data Quality (Freshness and Comprehensiveness) Many of the benefits of a well-designed remote data platform that are referenced above are amplified by the quality of the underlying data. For purposes of this discussion, the quality of the data is measured by how fresh it is and how comprehensive it is, as described in more detail in the following paragraphs. Freshness describes the length of time since data were collected; the more recently data are collected, the fresher they are. In a paper-based CRF system, it may take weeks between when the data are collected and when they are accessible in the data platform, whereas top-of-the-line EDC systems can provide real-time, instant access to data. The value of freshness depends on the purpose of the data. Where the goal is to identify potential issues in the study, such as SAEs, patient recruitment failures or cost overruns, fresh data are crucial. Freshness is also important for study sponsors planning to implement the FDAâ&#x20AC;&#x2122;s recommendation to use centralised analysis for ongoing studies. One purpose of centralising the analysis is to highlight sites that are not progressing appropriately compared to the other sites, and make appropriate adjustments while the study is ongoing. The fresher the data, the more valuable such adjustments are likely to be. Comprehensiveness describes the extent to which all relevant data sources are integrated into the remote data platform. For example, connecting IVR and recruitment data can help the sponsor keep track of how many screen fails, enrolments and randomisations are occurring. Connecting relevant clinical trial management systems (CTMS) and other clinical systems to an inventory system can help the sponsor track supplies and make sure each site has the right inventory for its scheduled patients, while connecting

Correctness It is important to note that, although advanced data platforms offer many exciting new features and the potential for valuable innovations in clinical trial design and process, they still must meet the most fundamental need of any software used in clinical data review: the software must be correct. In particular, any data used in part for electronic submissions to the FDA need to be Title 21 CFR Part 11 compliant. These regulations can create some obstacles for data platform design, and in evaluating any remote data platform, an essential question is whether its correctness has been validated through industry-accepted methods, and whether the platform provider is committed to responding quickly and thoroughly to any bugs that users may encounter. Remote Data Platforms and Adaptive Trial Design While advanced computer and data analytics technology have been transforming industries from finance to retail to national defence, the clinical trial industry has lagged in taking advantage of these new technologies. That is likely to change in light of recent recommendations by the FDA for study sponsors to adopt new processes, including the centralised data analysis described above, and adaptive trial design, which involves building decision points into a study protocol where clinicians can adapt the protocol based on the initial results of the trial. In order to implement adaptive trial design, clinicians need a data platform that supports quick, easy, and centralised review of the initial trial results. In selecting this platform, study sponsors should consider the criteria described in this article in order to maximise the benefit of both the trial methods recommended by the FDA and the substantial cost and time savings offered by the newest data platform and analytics technologies. References 1. RegulatoryInformation/Guidances/UCM269919.pdf Rick Morrison is co-founder and CEO of Comprehend Systems. Previously, Rick spent over a decade writing software for clinical trials, including tools that are now used by the FDA and top pharma. Email:

Journal for Clinical Studies 49

Special Feature

Translational Cardiovascular Safety A Primer of Non-clinical Investigations for Clinical Scientists Introduction Assessment of cardiovascular safety has become a central component of life-cycle drug development1 and integrated pharmaceutical medicine2. Such assessments are conducted in several stages of this cycle: drug discovery and ‘drug design’, a process involving computer simulation, medicinal chemistry, and structural molecular engineering3; in vitro, in vivo, and ex vivo non-clinical studies; pre-approval clinical trials; and post-marketing surveillance (both passive and active) once the drug is marketed and being used in clinical practice. Integration of information gained in different phases is critical to optimise the transition from information alone to knowledge, understanding, and rational decisionmaking4-7. However, while progress is being made, different components of this life-cycle cardiovascular safety continuum are still segmented in some settings. The goal of this paper is therefore to present scientists working in later-phase clinical drug development with a broad overview of the work conducted in non-clinical and translational cardiovascular safety. As Turner and Durham4 observed, “Many professionals bring diverse sets of skills to the domain of drug safety. The more integrated the efforts of everyone concerned, the better all patients will be served.” Safety Pharmacology Several ICH guidelines address non-clinical safety evaluations, including M3, S6, S7A, and S7B8-11. ICH S6, for example, commented as follows9: Safety pharmacology studies measure functional indices of potential toxicity. These functional indices may be investigated in separate studies or incorporated in the design of toxicity studies. The aim of the safety pharmacology studies should be to reveal any functional effects on the major physiological systems (e.g., cardiovascular, respiratory, renal, and central nervous system). Investigations may also include the use of isolated organs or other test systems not involving intact animals. All of these studies may allow for a mechanistically-based explanation of specific organ toxicities, which should be considered carefully with respect to human use and indication(s). In a non-clinical development programme, pharmacology studies fall into two categories. First, research pharmacology studies address primary and secondary pharmacology. Primary research pharmacology studies focus on the mechanism of action of the drug molecule, can be conducted in vitro and/ or in vivo, and have the goal of demonstrating that the drug compound has pharmacological (biological) activity relating to its proposed therapeutic use. Secondary research pharmacology studies focus on the overall pharmacological activity of the drug compound, including any activity not 50 Journal for Clinical Studies

directly related to the drug’s proposed therapeutic use. These studies can also be conducted in vitro and/or in vivo. Studies conducted in vitro include investigation of the drug molecule’s likely binding with off-target receptors. Safety pharmacology studies then examine physiological functional changes related to the drug molecule’s activity and include investigation of potentially undesirable effects. While they are typically conducted in rat and dog models, primate models can also be used. Typically, studies are singledose studies that focus on functional changes in major organ systems within the body. Discussion of function and structure can be meaningfully separated here: Functional changes can occur in the absence of structural change, precede structural change, and potentially contribute to structural change. Toxicology studies will then focus on structural change. Toxicological investigations involve single-dose and repeat-dose toxicity studies, and also address genotoxicity, carcinogenicity, and reproductive toxicity. Safety pharmacology studies investigate potentially undesirable effects of the drug molecule on the physiological function of several bodily systems. Some of the topics investigated are: • Central nervous system: Skeletal muscle tone, locomotion, reflexes, body temperature, autonomic function, learning and memory. • Respiratory system: Rate and depth of breathing. • Renal system: Renal function and renal dynamics. •G  astrointestinal system: Gastric acid secretion, gastric emptying, nausea, vomiting. •C  ardiovascular system: Blood pressure, heart rate, and electrophysiology, including electrocardiographic studies. Electrophysiological studies examine the potential for QT interval prolongation, discussed in more detail in due course. Bass and colleagues published an excellent historical review in 2004 entitled “Origins, practices, and future of safety pharmacology”12. The Safety Pharmacology Society and HESI The Safety Pharmacology Society was founded in 2000, following several years in which experts who formed the society had met more informally to discuss cardiotoxicity issues. As noted on its website, “The Society is committed to uniting the global safety pharmacology community in the development and safe use of biologically active molecular entities by bridging across disciplines to allow the identification, characterization, and monitoring of potentially undesirable pharmacodynamic activities in non-clinical studies and guiding their translation into clinical trials”13: see also 14-16 . Volume 4 Issue 1

Special Feature The Health and Environmental Sciences Institute (HESI) was established in 1989 as a global branch of the International Life Sciences Institute (ILSI) “to provide an international forum to advance the understanding of scientific issues related to human health, toxicology, risk assessment, and the environment”17. In 2002, HESI was recognised by the United States government as a publicly supported, tax-exempt organisation, independently chartered from ILSI. HESI’s programmes bring together scientists from global academic, regulatory and other governmental institutions, and industry, to address and reach consensus upon scientific questions that have the potential to be resolved through creative application of collaborative intellectual and financial resources17: see also 1820 . The Cardiac Safety Research Consortium21 should also be mentioned here. While its work spans a very wide spectrum of cardiovascular safety issues, including clinical development of both drugs and devices and also clinical practice, it is certainly interested in non-clinical and translational topics and has collaborated with HESI22. Drug-induced Cardiotoxicity: Function and Structure Following a series of marketing withdrawals in the late 1980s and 1990s due to proarrhythmic safety concerns, regulatory attention in Europe and then North America led to both nonclinical and clinical guidance on the assessment of a specific cardiac safety biomarker, i.e., acquired loss-of-function in the KCNH2/hERG cardiac potassium ion channel, leading to delayed repolarisation of ventricular cardiomyocytes, and prolongation of the QT interval of the surface electrocardiogram (ECG). This attention and regulation led to the field typically referred to as cardiac safety, which is discussed in the following section with a particular focus on translational cardiac safety investigations. However, while the terms certainly subsume cardiac safety, integrated cardiovascular safety and translational cardiovascular safety embrace a much wider scope of investigation, from subcellular changes in lipid accumulation to clinical endpoints such as myocardial infarction, urgent cardiovascular revascularisation, and sudden cardiac death. This broader field of investigation is discussed subsequently, again with a translational cardiovascular safety focus. KCNH2/hERG Channel Blockade and QT Interval Prolongation Ultimate interest in (proarrhythmic) cardiac safety lies with assessing a drug’s propensity to induce Torsades de Pointes (TdP) in humans. TdP is a polymorphic ventricular tachycardia that is very rare, often self-correcting, but potentially fatal. The occurrence of TdP often depends on the contemporaneous occurrence of multiple predisposing factors3, and its observation in pre-approval trials is probabilistically very unlikely. Therefore, while acknowledged to be a far from perfect predictor of torsadogenic liability, attention currently focuses on drug-induced QT interval prolongation as a proarrhythmic cardiac safety biomarker since the hard clinical endpoint, TdP, is so unlikely to be seen. Inherited long QT syndromes (LQTSs) are of great clinical concern since they represent cases where simple genetic mutations can have profound effects, where abnormal variants can cause life-threatening physiological states see 4

for extended discussion . A syndrome of particular relevance is LQT2. In this case, a specific mutation in the gene KCNH2 (also known as hERG), which encodes a 1,159 amino acid protein a comprising the pore-forming a-subunit of the KCNH2/hERG cardiac potassium ion channel, results in a loss-of-function in the channel, a reduction in IKr repolarising ionic current (KCNH2/hERG current) flowing through the channel, and hence delayed repolarisation. A similar loss-of-function can occur when a drug molecule becomes entrapped within the central pore of the KCNH2/hERG channel. While the mechanism of action of the loss-of-function is different in this scenario, commensurate clinical concern is present since delayed ventricular repolarisation can also result in this casesee 3, 4, 23-26 for more detailed discussions. The regulatory attention noted in the previous section began in 1997 in Europe, and resulted in various documents, culminating in the release in 2005 of ICH S7B11, addressing non-clinical assessments, and ICH E1427: see also 28, 29 addressing clinical assessments in the form of the Thorough QT/QTc (TQT) Study. Since an ICH Final Concept Paper30 was published in 2001, four years ahead of the release of ICH S7B, the nonclinical scientific community was already publishing related papers shortly before and around the time of ICH S7B’s release, bearing witness to considerable interest in this topic among multiple stakeholders31-34. In general terms, two central components of non-clinical proarrhythmic liability assessment are the in vitro KCNH2/ hERG current assay and the in vivo QT prolongation assay. The ICH S7B guideline listed the following objectives: • Identify the potential of a drug molecule (and its metabolites) to delay ventricular repolarisation; • Relate the extent of the delayed repolarisation to the concentration of the drug molecule and its metabolites; • Elucidate the mechanism of action of the relayed repolarisation; • In conjunction with other relevant information, estimate the extent of delayed repolarisation and QT prolongation in humans.

In vitro and in vivo methodologies can obtain information at several functional levels: • Ionic currents measured in isolated animal or human cardiac myocytes, cultured cardiac cell lines, or heterologous expression systems for cloned human ion channels; • Action potential parameters in isolated cardiac preparations or specific electrophysiological parameters indicative of action potential duration in anesthetised animals; • Proarrhythmic effects measured in isolated cardiac preparations or animals; • ECG parameters measured in anesthetised or conscious animals. Contemporary Approaches Non-clinical research always has to consider which model is the best one in a given circumstance (whatever the definition of ‘best’ might be). However, no animal model is a perfect predictor of the precise effects (on-target or off-target) of the drug when administered to humans. Nevertheless, non-clinical research currently provides the best available information with regard to the dose that should be given to Journal for Clinical Studies 51

Special Feature humans in initial clinical trials. From this paper’s perspective, the question of interest becomes: Can a non-clinical test, or more likely a battery of tests, correctly identify drugs that will, and will not, have a proarrhythmic liability in humans? Failing to identify a drug compound that is proarrhythmic in humans is far from desirable, but so is ‘identifying’ a compound that would not have been proarrhythmic in humans, and thereby terminating a compound that potentially could have been an efficacious and safe drug. In 2008, de Ponti noted that “as many as 60% of new molecular entities developed as potential therapeutic agents, when assayed for hERG blocking liability, test positive and are thus abandoned early in development, although their true torsadogenic potential is unknown”35. Cavero36 used the term exploratory safety pharmacology, noting that the objective of this discipline “would be to conduct early safety investigations on potential drug candidates by applying, outside the constraints of GLP [Good Laboratory Practice], in silico, in vitro, ex vivo and in vivo platforms translating clinical liabilities into simple, fast and cost-effective screening assays.” Bass et al.37 used the term exploratory drug safety to frame their discussions. New approaches continue to be reported in the literature. For example, drug-induced reduction of the cardiac electromechanical window (EMw) has been discussed38,39. In addition to electrical perturbations, left ventricular mechanical dysfunction may also contribute to ventricular arrhythmias. Hence, assessments of EMw may add predictive value beyond assays of QT interval prolongation. Gintant and colleagues 40,41 addressed the limitations of the KCNH2/ hERG assay and KCNH2/hERG safety margins, and discussed ventricular rate adaptation as a “novel approach for rapidly detecting drugs with torsadogenic risk using rapid rhythms that are typically not employed when evaluating proarrhythmic risk. This method is well suited for detecting and avoiding potential cardiac liabilities early in drug discovery (“frontloading”) prior to final selection of candidate drugs”41. Integrated approaches have been discussed by several authors. For example, Bass and colleagues42 described a non-clinical “TdP proarrhythmia model.” They proposed a multifaceted strategy employing test systems of increasing complexity: single cell, isolated cardiac tissue, isolated heart, intact animal, and diseased animal (a pathological model). The properties of this model include: • it should provide adequate testing throughput to meet the user’s needs; • intact animal models should employ conscious animals; • animal models should reliably develop TdP when challenged by a known torsadogenic agent (i.e., they should have high specificity); • the model should have high sensitivity at the clinical therapeutic dose and beyond. The need for “improved efforts to perform sensitive yet specific evaluations of functional cardiovascular parameters in nonclinical studies” was also discussed by Sarazan and colleagues19. Raschi et al.43 recommended an integrated risk assessment approach that brings together expertise from different areas and should encompass issues such as 52 Journal for Clinical Studies

interference with KCNH2/hERG protein trafficking and druginduced QT interval shorteningsee also 44-49. Finally here, the recommendations made by Leischman and collaborators on behalf of the Safety Pharmacology Society16 are noteworthy. They acknowledged that is it not possible to dictate a specific standard practice for assays that are conducted throughout the industry in very different facilities and using different equipment. However, realising that a framework could be described to improve comparison and interpretation, they summarised recommendations on the basis of three key criteria: 1) know your study population quantitatively and qualitatively; 2) know how well your current study matches historical data; and 3) support your conclusions on the basis of the specific study’s determined ability to detect change. For additional reading, see several papers in the Journal of Pharmacological and Toxicological Methods and a review in the British Journal of Pharmacology50-55. Also, the work of Fossa and colleagues is noteworthy since he has employed both the dog model and humans in his research on beat-to-beat analysis of cardiac electrical restitution and proarrhythmic liability56-59. Cardiotoxicity Induced by Oncology Treatments A paradox has arisen in the oncology arena. Pharmacotherapy (sometimes in conjunction with surgery and/or radiation therapy) has proved very successful: in many cases, disease states have gone into remission and patients are living for considerable periods of time following treatment. While this is a great success, unfortunately some individuals are experiencing cardiovascular disease that is likely druginduced. The time course of various cardiotoxicities can differ considerably. Acute concerns can arise, e.g., following a single dose of anthracycline therapy. Other conditions may take ten years or more to present, following multiple chemotherapies and/or bouts of radiation therapy. At therapeutic doses, some cytotoxic anti-cancer drugs, particularly the anthracyclines (e.g., daunorubicin, doxorubicin), can produce cardiotoxicity by direct damage to subcellular systems within cardiomyocytes. Cardiovascular manifestations of cancer chemotherapy include heart failure, cardiomyopathy, pericardial/pleural effusion, myocardial ischemia, arterial hypotension and hypertension, myocarditis, arrhythmias, and thromboembolism. Being aware of the risk of using these drugs is particularly important to early detection and institution of appropriate treatment to prevent irreversible myocardial injury, especially when some cancers can affect young people with expected long-term survival60. Clinicians are now aware of such possibilities, and some drugs are stopped once a cumulative total dosing in a patient is reached. There are also various non-invasive methodologies that can be used to monitor cardiotoxicity, including radionuclide ventriculography, ECG and stress myocardial perfusion imaging (ischemic complications), and 24-hour Holter monitoring (arrhythmias). However, in keeping with the theme of this paper, research facilitating mechanistic understanding and translational approaches is considered here, with a focus on targeted therapies.

Volume 4 Issue 1

Special Feature Cardiotoxicity Associated with Multi-targeted Tyrosine Kinase Inhibitors The development of targeted therapies, particularly drugs that inhibit the activity of tyrosine kinases, has led to remarkable progress in the treatment of neoplastic diseases60. These include the combination treatment of breast cancer patients with the HER2-targeting antibody with trastuzumab and doxorubicin (trastuzumab is discussed again in due coure), and the treatment of chronic myeloid leukemia (CML) and gastrointestinal stromal tumours (GISTs) with the C-Abl small-molecule inhibitor imatinib (small-molecule inhibitors are drug-like molecules designed to enter the cell and disrupt a specific cellular process). While some drugs have been designed to disrupt protein-protein interactions that are necessary for effective pathway signalling, the usual mechanism of action is the inhibition of a disease-promoting tyrosine kinase enzyme within the target pathway. The transition from single-targeted therapy to multitargeted therapies in cancer therapy (i.e., aspecificity) has proved to be a successful strategy61. However, for reasons of evolutionarily-driven molecular similarities, tyrosine kinase inhibitors (TKIs) can promiscuously inhibit many other enzymes (off-target responses leading to toxicities) in addition to the multiple on-target desired responses. Full kinome analysis has demonstrated that many small molecules are capable of inhibiting far more targets than originally anticipated: dasatinib, imatinib, sorafenib, and sunitinib, for example, are associated with cardiotoxicities. Therapeutic molecules may be designed to inhibit a target that also happens to be necessary for the health and function of normal tissues and organs. Of relevance here is that cancer cells and cardiomyocytes share signalling pathways, such that a drug molecule that would lead to a beneficial intervention in cancer cells can also lead to (a) deleterious effect(s) on cardiomyocytes. The health and function of the cardiomyocytes are dependent on a variety of enzyme-driven signal transduction pathways, many of which are shared with actively growing tumour cells e.g., HER2 and C-Abl. Therefore, functional inhibition assays that assess with which additional kinases a targeted drug molecule will interact can be very informative when deciding which of a group of drug molecules to progress toward clinical development. Inhibition and Activation of AMPK The â&#x20AC;&#x2DC;master metabolic regulating enzymeâ&#x20AC;&#x2122; AMP-activated protein kinase (AMPK) plays a key role in regulating cellular energy metabolism. When intracellular levels of adenosine triphosphate (ATP) fall it activates energy-producing pathways and inhibits energy-consuming processes. Inhibition of the AMP-activated protein kinase (AMPK) pathway by sunitinib has been shown to contribute to cardiomyocyte stress in vitro. In contrast, nilotinib demonstrates activation of the AMPK pathway (the mechanism of action is currently unknown, but under investigation), and this is assumed to be cardioprotective. Hence, by evaluating the activation state of AMPK by Western blot of in vitro treated human cardiomyocytes (HCMs), it can be determined whether the drug has either a detrimental or a beneficial influence on cardiac metabolism. Sunitinib induces intracellular lipid accumulation, an observation that correlates with its ability

to inhibit the AMPK pathway. In contrast, nilotinib reduces intracellular lipid accumulation, an observation which correlates with nilotinibâ&#x20AC;&#x2122;s ability to activate the AMPK pathway. Going a step further, intracellular lipid accumulation can take different forms. Sunitinib and daunorubicin are associated with an increase in lipid droplet abundance and hypertrophy, whereas cytarabine is associated with an increase in lipid droplet size and hypertrophy. The precise biology and effect of lipid droplet accumulation and size on cardiomyocyte health is under investigation. Other mechanisms that may be involved in cardiotoxicity include decreases in mitochondrial membrane potential, which is associated with apoptosis. Sunitinib has also been shown to induce reactive oxygen species (ROS) in human cardiomyocytes. Cardiomyocytes possess a high density of mitochondria to enable the generation of the energy needed for the beating heart, particularly in times of high energy demands such as exercise. Their primary function is to provide energy for the heart via oxidative phosphorylation that results in ATP production. As a result of the high rate of ATP generation, cardiomyocytes produce high levels of stress-inducing ROS that are quickly neutralised by natural antioxidants in the cell. However, ROS levels that exceed the detoxification capacity of the cell, either by a genetic or pathologic reduction in antioxidants or an excessive contribution of ROS from therapeutic regimes like anthracyclines, result in mitochondrial dysfunction and cell death. The mechanism of ROS-induced cell death involves a collapse in mitochondrial membrane potential, which is necessary to drive the production of cellular ATP. By measuring the mitochondrial membrane potential of HCMs in culture treated with a drug molecule, the risk of a mitochondrial collapse that could lead to cell death can be assessed. The reference list provides details of other relevant papers62-72. Utilisation of Human Induced Pluripotent Stem Cell-derived Cardiomyocytes Utilisation of human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) allows the assessment of druginduced changes to cardiac function in vitro. They are autonomously electrically active and recapitulate in vivo biology. Treatment of iPSC-CMs with various cancer drugs modulates intracellular lipid abundance as observed in primary HCMs. For example, sunitinib is associated with an accumulation of intracellular lipids, while nilotinib is associated with a reduction of such lipids. Guo et al.73 provided the first published report describing a high-throughput functional assay employing a monolayer of beating iPSC-CMs monitored by an impedance-based platform (Roche xCELLigence). This platform allows labelfree assessment of drug-induced alterations in iPSC-CM beating patterns, with real-time monitoring under cell culture conditions. The platform can differentiate between rhythmic and irregular beating patterns. Single-layered iPSC-CMs synchronously beat in a dish, producing a normal wave pattern. Drug-induced toxicity can be detected via observations of irregular beating frequency and/or amplitude. Toxicities identified in end-point assays for sunitinib and daunorubicin are also observed in functional assays. Sunitinib-treated iPSC-CMs demonstrated an irregular beat pattern similar to Journal for Clinical Studies 53

Special Feature that observed with drug-induced arrhythmia. Low doses of daunorubicin lengthen the beat period while higher doses completely abolish the rhythmic contractions of iPSC-CMs. While the focus in this section to date has not been on QT interval prolongation, it should be noted that these drugs can also have arrhythmogenic liabilities, information that can be found on their labels. For example, sunitinib has been shown to prolong the QT interval in a dose-dependent manner, which may lead to an increased risk for ventricular arrhythmias including TdP. As further examples, the labels for vemurafenib and lapatinib alert physicians and patients to QT prolongation liabilities, and nilotinib has a boxed warning for QT prolongation and sudden death. Crizotinib was approved by the FDA to treat certain patients with late-stage (locally advanced or metastatic), non-small cell lung cancers who express the abnormal variant anaplastic lymphoma kinase (ALK) gene. Of interest is that it was approved with a companion diagnostic test that will help determine if a patient for whom the drug is being considered has the abnormal variant ALK gene. Preliminary evidence suggests that crizotinib may elicit cardiotoxicity--evidence of irregular beating patterns and significant alteration of the beat rate. QT interval prolongation has been observed for crizotinib, as noted on its label. Thus, cardiacspecific functional assays, including in-dish analysis of beat rate, amplitude, and regularity, can add information to that yielded by end-point assays. So too can multi-electrode arrays. As a result of various discrepancies between KCNH2/ hERG testing, QT prolongation, and the risk of arrhythmia [see 69 for discussions], ion channel screening has been further developed to enable the assaying of currents from a wider variety of cardiac ion channels and the measurement of action potentials from stem cell-derived cardiomyocytelike cells. Wobus and Löser74 provided extensive discussions of present and future perspectives of using pluripotent stem cells in toxicology research. The International CardiOncology Society The International CardiOncology Society (ICOS) was founded in 2009 as a venue to bring together oncologists and cardiologists to work collaboratively on various topics including cardiological implications of oncological treatments such as chemotherapy medical treatments (e.g., monoclonal antibodies, TKIs, anti-angiogenesis factors, and other specific drugs devoted to cancer therapy), radiotherapy, immunoradiotherapy, locoregional chemotherapy treatments, high-dose chemotherapy, and multiple and combined oncological treatments75. ICOS has already become well integrated into other related activities. It held its 2011 Annual Meeting in association with the CSRC’s Annual Meeting in October of that year, and members were participants in the Drug Information Association’s 5th European Cardiovascular Safety Conference in December 2011. Computer Simulation Modelling and Structural Molecular Engineering Computer modelling and structural molecular engineering offer the possibility of creating the optimised molecule 54 Journal for Clinical Studies

for progression to non-clinical development by chemically engineering desirable characteristics into, and, of particular interest from this paper’s perspective, engineering undesirable characteristics out of, the lead compound molecule [see 3 for extended discussion]. To facilitate this, computer simulation modelling is first employed to predict the chemical structure of the optimised molecule. This approach contrasts with the traditional drug discovery strategy comprising a lengthy iterative process involving various candidates that successively more closely approximate the ideal molecule. A small-drug molecule can be conceptualised as a fairly rigid backbone (typically organic) that holds together functional or reactive groups of atoms. The relative rigidity of the backbone ensures that the three-dimensional geometry of the molecule does not alter too much. This defined geometrical array “allows the molecule to bind specifically to the targeted biological molecule” 76. Like receptors, drug molecules are three-dimensional, and interactions between drug molecules and receptors occur in three-dimensional space. The structural arrangement of atoms within the molecule influences the “geometry of approach” as the drug molecule enters the microenvironment of the receptor and prepares to dock with it76. The groups supported by the backbone include the pharmacophore, a group intended to interact with the target receptor(s) to achieve the drug’s desired effect(s), potentially one or more toxicophores, groups that may interact with nontarget receptors to produce undesirable off-target effects, and the metabophore, which is responsible for the molecule’s metabolic properties. From this paper’s perspective, the goal of drug design can be regarded as ‘engineering out cardiotoxicity’ to the greatest extent possible by removing or neutralising toxicophore(s) that lead to undesirable cardiac effects, while maintaining the molecule’s optimal therapeutic and metabolic qualities. The concept of engineering out toxicophores fits well with the intent of safety-related drug molecule design, i.e., removing (or functionally disabling) an arrangement of atoms and electronic forces within a molecule that leads to unwanted effects, while maintaining the molecule’s ability to reach the vicinity of its target receptor and then to present its pharmacophore to the receptor in the necessary three-dimensional geometry. It should be noted, however, that engineering out toxicophores can be considerably harder than engineering in pharmacophores, especially at the beginning of the process see 4 . While the single target receptor is known (or in the case of multi-targeted therapy, several target receptors are known), there is an enormous range of possible off-target receptors. Some functional groups on a drug molecule may be known to comprise a toxicophore that should be avoided when designing any new drug. However, there remains the constant possibility that a functional group on a new molecule will react with a known off-target molecule in an unexpected and undesirable manner, or will interact in an undesirable manner with a previously unknown receptor. It is likely that engineering out toxicophores can be more readily achieved when the mechanism of action of a specified adverse reaction is known, and also separable from the mechanism of action of the intended response. This may be achieved by either Volume 4 Issue 1

Special Feature limiting drug access to the location of the off-target receptor, or by increasing the drug specificity for the on-target versus off-target receptor4. The work of Fernández and colleagues has proved informative in this context. As they commented with regard to multi-targeted drugs, “it would be risky to welcome promiscuous compounds without a rational strategy to control therapeutic impact. This situation might change as novel selectivity filters are incorporated into drug design”77. Fernández et al78 reported the reengineering of imatinib. The aspecificity of imatinib facilitates its treatment of CML, where its target is the Bcr-Abl kinase, and also a proportion of GISTs, where its target is the C-Kit kinase. However, it also has cardiotoxic effects traceable to its impact on the C-Abl kinase. The researchers therefore engineered a “modification to imatinib that hampers Bcr-Abl inhibition; refocuses the impact on the C-Kit kinase; and promotes inhibition of an additional target, JNK, a change that is required to reinforce prevention of cardiotoxicity”78. Imatinib was thus reengineered as an agent to treat GISTs with reduced cardiotoxicity. Additional papers by this group are provided in the reference list79-81. Translational Biomarkers Goodsaid et al.82 observed that biomarkers may be qualified using different qualification processes. A passive approach “has been to accept the end of discussions in the scientific literature as an indication that a biomarker has been accepted.” In contrast, an active approach requires the development of a comprehensive process by which a consensus may be reached about the qualification of a biomarker. Goodsaid and Mendrick83 noted that “the gap between development of exploratory biomarkers and their acceptance in drug development and regulatory review is a hurdle in the development of better therapies,” and discussed how the FDA has developed a regulatory process for biomarker qualification to accelerate the process by which new biomarkers are integrated into drug development. Additional references on this topic are provided84-91. Laverty et al.92 provided a report of discussions at, and recommendations from, a workshop entitled “Cardiovascular Toxicity of Medicines,” hosted by the Medical Research Council Centre for Drug Safety Science. The authors noted that to understand, address, and ultimately reduce cardiovascular safety liabilities of new drugs there is an urgent need to address several items. One of these is the development of “more appropriate, highly relevant and predictive tools and assays to identify and wherever feasible to eliminate cardiovascular safety liabilities from molecules, and wherever appropriate to develop clinically relevant and reliable safety biomarkers.” This need for increased sensitivity and specificity has already been addressed19-42. Translational Challenges of Predicting Clinical Outcomes: A Case Study The case study of torcetrapib provides instructive commentary on biomarkers. Twenty years ago it was discovered that individuals in Japan had extremely high levels of high-density lipoprotein cholesterol (HDLc), the ‘good cholesterol,’ caused by a genetic variant involved with the cholesteryl ester transfer protein (CETP). Raising plasma

levels of HDLc became a therapeutic goal. CETP promotes the transfer of cholesteryl esters from HDL to other lipoproteins. Inhibition of this protein raises HDLc levels and decreases low-density lipoprotein cholesterol levels. Torcetrapib was a novel CETP inhibitor that was demonstrated to inhibit the development of atherosclerosis in non-clinical studies (a rabbit model), and, in early-phase clinical studies, to increase HDLc by 60 to 100% while at the same time lowering LDLc (the ‘bad cholesterol’) by up to 20%93. This evidence suggested a cardioprotective effect of torcetrapib. The Investigation of Lipid Level Management to Understand its Impact in Atherosclerotic Events (ILLUMINATE) trial therefore tested the proposition that torcetrapib would reduce the risk of clinical cardiovascular events. However, torcetrapib was associated with an increased risk of major cardiovascular events, and also increased mortality (from both cardiovascular and noncardiovascular causes). The drug’s sponsor terminated ILLUMINATE prematurely at the recommendation of the trial’s independent Steering Committee, based on advice from the Independent Data and Safety Monitoring Board94: see also 95-100 . Thus, two highly regarded cardiovascular safety biomarkers, increased HDLc and decreased LDLc, were associated with a drug that was then seen to be associated with an increased risk of clinical cardiovascular events (it remains a possibility that current assumptions about HDLc, LDLc, and cardiovascular disease are flawed88). It should be noted that an off-target response to torcetrapib was increased blood pressure. Twelve months into ILLUMINATE, systolic blood pressure had increased from baseline by a mean of 5.4 mmHg in the torcetrapib group. However, various aspects of blood pressure increases and the baseline values from which the increases were seen made clear statements of blood pressure effects difficult94. Blood Pressure as a Cardiovascular Safety Biomarker: A Developing Regulatory Landscape? Having just mentioned blood pressure, it is appropriate to note that the possibility of formalising some form of guidance document addressing the assessment of blood pressure as a cardiovascular safety biomarker was raised at several conferences in 2011see 101,102 and will likely be discussed further in 2012. The mechanism by which a non-cardiovascular drug impacts blood pressure may or may not be of relevance. Arterial blood pressure is a manifestation of the interaction between the heart and the systemic vasculature. Mean arterial pressure (MAP) is the product, figuratively and mathematically, of cardiac output (CO, the amount of blood ejected per unit of time) and total peripheral resistance of the systemic vasculature (TPR, the pressure against which the blood is ejected). It follows that a change in blood pressure can be the result of a change in CO, in TPR, or in both. It can be reasonably argued that off-target changes in blood pressure via any route are all equally undesirable, and hence the actual mechanism of action of a specific change is not of central importance. There is also merit, however, to the argument that we should indeed pay attention to the mechanism of action. An important question that would need to be resolved Journal for Clinical Studies 55

Special Feature is: Which blood pressure parameter(s) -- systolic blood pressure (SBP), diastolic blood pressure (DBP), MAP -- should be considered as the endpoint of primary interest? Or, is a general pattern of greater relevance? The statistical approaches would differ according to which approach were to be adopted. Relatedly, what degree of change(s) will elicit regulatory concern should a regulatory guidance document(s) be developed? That is, if the same approach to the prospective exclusion of unacceptable cardiovascular risk is taken here that was adopted for QT/QTc prolongation in general drug development27 and for the MACE composite endpoint in the development of antidiabetic drugs for type 2 diabetes mellitussee 103-105, where would the threshold(s) of regulatory concern be set? Clinical and regulatory science would be used to make this choice, and then statistical science used to identify instances when the threshold(s) has/ have been breached106. Another question of interest then becomes: Does the wealth of blood pressure data collected across the last few decades make the choice of thresholds easier than were the choices of 10 msec for QT prolongation and the relative risk ratios of 1.8 and 1.3 employed in the FDA guidance on the development of antidiabetic drugs? It will be of considerable interest to many stakeholders to follow this issue. Pharmacogenetics, Pharmacogenomics, and Companion Diagnostics The ultimate translational aspect of interest in pharmacotherapy, of course, is to translate all knowledge acquired beforehand, from computer simulation in the drug design phase through to therapeutic confirmatory trials, into successful patient pharmacotherapy once a drug receives marketing approval (experience gained over time can be used to further inform pharmacotherapy decisions). The concept and implementation of so-called personalised medicine has attracted enormous attention, particularly since the completion of the Human Genome Project 107: see also 108,109. Various other terms have been used to capture this concept, including individualised medicine, stratified medicine, information-based medicine, and precision medicine: this author prefers the latter term in almost all instances for reasons explained in due course. Two other terms of interest are pharmacogenetics and pharmacogenomics. Pharmacogenetics studies the contribution of genetic variation to variation in response to pharmacotherapy. Interest lies with both desired therapeutic effects and with the range and severity of adverse events. When a given drug is administered to different patients for whom, based on the best available diagnostic evidence, it is appropriate, many of them will safely experience a therapeutic benefit. However, there are other possible outcomes that may be experienced by a relatively small number of patients: • Some individuals may not show a beneficial therapeutic response (non-responders); • Some may show an undesired excessive therapeutic response (e.g., becoming hypotensive instead of normotensive following the administration of an antihypertensive agent); • Some may show relatively serious undesired effects (adverse responders). 56 Journal for Clinical Studies

While other factors (e.g., existing disease, concomitant medication, nutrition, and use of tobacco and alcohol) can influence why different people respond differentially to a given drug, the predominant factor is genetic variation, specifically variation in the structure of the target receptor and in pharmacokinetics110. Genetic variation in metabolism, pharmacokinetics, and pharmacodynamics are three mechanisms by which genetic variation can produce variation in individual drug responses111: • Variation within the drug target (e.g., ion channels). This may lead to altered drug efficacy and differences in the expression of a physiological phenotype; • Variation associated with altered distribution, metabolism, or uptake of the drug. This may lead to enhanced drug clearance, impaired drug clearance, or inactivation of the drug; •V  ariation resulting in an unintended drug action. Protein manufacture is under direct genetic control, and two factors are of particular relevance here. First, the precise structure and function of protein macromolecules, which commonly act as drug receptors targeted by a given drug, can vary among individuals. Since these properties are directly related to how the drug molecule will interact with that protein (recall earlier discussions of three-dimensional geometry of drug-receptor docking and interaction), individuals’ drug responses can vary. Second, there are genetic variations in metabolic enzymes (also proteins) and hence metabolism. These considerations take us into the domain of pharmacoproteomics, and also transcriptomics and metabolomics. Contrary to many statements in the literature, the term pharmacogenomics (PGx) is not synonymous with the term pharmacogenetics. Rothstein captured the difference succinctly and meaningfully, observing that pharmacogenetics addresses “the role of genetic variation in differential response to pharmaceuticals,” while pharmacogenomics addresses “the use of genomic technologies in assessing differential response to pharmaceuticals” 112: see also 113. Lesko and Woodcock114 noted that the FDA “has become a proactive and thoughtful advocate of PGx,” and that it believes it has a responsibility as a public health agency to play “a leading role in bringing about the translation of PGx, as well as other emerging technologies, from bench to bedside to facilitate drug development and improve the benefit/risk [ratio] of drug treatments in the marketplace.” Pharmacogenomics is well exemplified by companion diagnostics 115-118. A companion diagnostic is an assay that provides information concerning whether a given patient is likely to benefit from a given drug when others with a different genetic makeup may not, and/or to provide information concerning whether a given patient is likely to suffer a serious adverse reaction when others may not. Consider the case of trastuzumab, a drug used to treat earlystage breast cancer that is human epidermal growth factor receptor 2-positive (HER2+) see 119. Potential recipients of this drug must have a HER2 test to determine that their cancer is HER2-positive before taking trastuzumab, as benefit has only been demonstrated in patients whose tumours are HER2Volume 4 Issue 1

Special Feature positive120. Two types of test are available to determine HER2 status. One is a fluorescence in situ hybridisation (FISH) test, which assesses whether or not a patient’s cancer cells have a normal number of HER2 genes. The other is an immunohistochemistry (IHC) test to assess how much HER2 protein there is on the surface of the cancer cells. (It should be noted that patients who do receive trastuzumab need to be monitored closely, given the drug’s association with serious cardiac side-effects.) Another case study is provided by abacavir, an antiretroviral used against infection with the human immunodeficiency virus (HIV). Approximately 6% of individuals carry the HLAB*5701 allele, a genetic variant that is strongly associated with hypersensitivity to abacavir. This hypersensitivity is a multi-organ systemic illness that can have life-threatening complications if the drug is continued while symptoms progress, or if it is given again following termination of treatment once the symptoms have dissipated (re-challenge). Screening potential recipients of the drug for the presence of the HLA-B*5701 allele has proved to be a successful strategy in reducing hypersensitivity reactions, while also allowing the large majority of patients to take the drug without fear of a serious adverse drug reaction see 121, 122. Moving back the domain of cardiovascular safety, two drugs approved by the FDA during 2011 in combination with an FDA-approved companion diagnostic test are informative. Crizotinib is indicated for the treatment of patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) that is anaplastic lymphoma kinase (ALK)-positive as detected by an FDA-approved test. Vemurafenib, indicated for melanoma, can only be prescribed for patients with a certain abnormal variant of the BRAF gene, BRAFV600E, as identified by an FDA-approved test. (Note: QT interval prolongation is discussed in the prescribing information for both crizotinib and vemurafenib.) Precision Medicine and Clinical Practice In their 2004 paper discussing the completion of the euchromatic sequence of the human genome, the International Human Genome Sequencing Consortium (IHGSC) noted that “The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead” 107. Since that time there has been great expectation that this information would revolutionise pharmacotherapy and that ‘personalised medicine’ would soon be commonly practised. However, as Monte et al.123 observed, “Many clinicians hoped that the completion of the Human Genome Project would result in “individualized drug therapy,” i.e., determining the right medication at the right dose 100% of the time based upon the individual’s genetics. The pharmacogenomic prediction of drug efficacy and safety has not become a reality due to continuing realization of the complexity dictating the human-drug interaction.” Human biology (as is the biology of other species) is enormously complex. The ultimate goal of drug development is to produce a biologically active drug that is well tolerated, acceptably safe (where “acceptably” is operationalised via benefit-risk assessment: see 124), and useful in the treatment or prevention of patients’ biological states that are of clinical concern125. To do this requires optimising our understanding

of biological processes. Undoubtedly, exponentially increasing amounts of information are being collected, but our understanding of these processes is not increasing at anywhere near the same pace. While the examples considered previously (trastuzumab, abacavir, crizotinib, and vemurafenib) are encouraging, it is perhaps not surprising that progress is less dramatic than desirable. Relatedly, Monte et al.123 also noted that “new methods of metabolomics, proteomics, and transcriptomics that account for this complexity hold promise for translational researchers hoping to increase drug efficacy and decrease drug toxicity.” As noted earlier, the term precision medicine has been deliberately used in this paper in preference to other common general terms. Clinicians can legitimately argue, both reasonably and forcefully, that they have always practised individualised medicine to the limit of medical and scientific knowledge at any given point in time4. Clinical care of an individual patient has always involved, and will always involve, using all available evidence concerning that individual’s unique set of circumstances along with knowledge of all available treatment options to tailor a course of treatment specifically for that patient. The major difference in the context of present discussions is the availability and incorporation of information regarding the individual’s biological makeup into decisions regarding the treatment to be given (or not to be given) to the patient. That said, the term personalised medicine is certainly appropriate in some cases, e.g., a cancer vaccine whose manufacture incorporates the use of an individual patient’s biological material in preparing a treatment uniquely tailored to that individual126. Girardi et al. 127noted that treatment with the angiogenesis inhibitors sunitinib (discussed earlier), bevacizumab, and sorafenib, as single agents or in combination with conventional chemotherapy, “is becoming a cornerstone of modern anticancer therapy.” However, as these authors noted (and as discussed earlier), the potential cardiotoxicity of these drugs is still being investigated. Therefore, appropriate actions are required during clinical practice. Baseline assessment of a patient about to receive therapy is of critical importance. This includes the evaluation of risk factors and screening for past or present cardiovascular disease. Once treatment has been commenced, strict monitoring of treatment-related adverse effects must be conducted to allow the early detection of cardiovascular toxicities and their prompt treatment. The authors reviewed the most frequent cardiovascular toxicities and their mechanisms of action with the goal of providing indications for the most effective patient management 127: see also 128-130 . Concluding Comments Translational cardiovascular safety, like all translational medical disciplines, is by definition multifaceted. This paper has therefore integrated a broad range of topics to provide clinical scientists working in later-phase clinical drug development with a broad overview of the work conducted in non-clinical and translational cardiovascular safety. Discussions have also worked their way to clinical practice since the ultimate translation of all previous investigations is into optimum patient care.

Journal for Clinical Studies 57

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Special Feature by vardenafil. Clinical Pharmacology and Therapeutics, 90:449-54. 60. G  arcia-Alvarez A, Garcia-Albeniz X, Esteve J, Rovira M, Bosch X, 2010, Cardiotoxicity of tyrosine-kinase-targeting drugs. Cardiovascular and Hematological Agents in Medicinal Chemistry, 8:11-21. 61. Petrelli A, Giordano S, 2008, From single- to multi-target drugs in cancer therapy: When aspecificity becomes an advantage. Current Medicinal Chemistry, 15:422-432. 62. F ogarty S, Hardie DG, 2010, Development of protein kinase activators: AMPK as a target in metabolic disorders and cancer. Biochimica et Biophysica Acta, 1804:581-591. 63. S hell SA, Wappel R, Turner JR, Bacus SS, 2011, Early safety testing for oncology therapies. Drug Discovery & Development. (Accessed January 10th 2012). 64. S pector NL, Yarden Y, Smith B, 2007, Activation of AMPactivated protein kinase by human EGF receptor 2/EGF receptor tyrosine kinase inhibitor protects cardiac cells. PNAS, 104:10607-10612. 65. S hell SA, Lyass L, Trusk PB, et al., 2008, Activation of AMPK is necessary for killing cancer cells and sparing cardiac cells, Cell Cycle, 7:415-421. 66. Y  un H, Ha J, 2011, AMP-activated protein kinase modulators: a patent review (2006 - 2010). Expert Opinion on Therapeutic Patents, 21:983-1005. 67. Feldman AM, Koch WJ, Force TL, 2007, Developing strategies to link basic cardiovascular sciences with clinical drug development: Another opportunity for translational sciences. Clinical Pharmacology and Therapeutics, 81:887-892. 68. C  heng H, Force T, 2010, Molecular mechanisms of cardiovascular toxicity of targeted cancer therapeutics. Circulation Research, 106:21-34. 69. C  urigliano G, Mayer EL, Burstein HJ, Winer EP, Goldhirsch A, 2010, Cardiac toxicity from systemic cancer therapy: A comprehensive review. Progress in Cardiovascular Diseases, 53:94-104. 70. F orce T, Kolaja KL, 2011, Cardiotoxicity of kinase inhibitors: the prediction and translation of preclinical models to clinical outcomes. Nature Reviews. Drug Discovery, 10:111-126. 71. Khakoo AY, Liu PP, Force T, et al., 2011, Cardiotoxicity due to cancer therapy. Texas Heart Institute Journal, 38:253-256. 72. X  i B, Wang T, Li N, et al., 2011, Functional cardiotoxicity profiling and screening using the xCELLigence RTCA Cardio System. Journal of the Association for Laboratory Automation, 16:415-421. 73. G  uo L, Abrams RMC, Babiarz, JE, 2011, Estimating the risk of drug-induced proarrhythmia using human induced pluripotent stem cell-derived cardiomyocytes. Toxicological Sciences 123:28-289. 74. W  obus AM, Löser P, 2011, Present state and future perspectives of using pluripotent stem cells in toxicology research. Archives of Toxicology, 85:79-117. 75. I nternational CardiOncology Society, http://www. (Accessed January 5th, 2012). 76. Norgrady T, Weaver DF, 2005, Medicinal Chemistry: A Molecular and Biochemical Approach, 3rd Edition. Oxford University Press. 77. Zhang X, Crespo A, Fernández A, 2008, Turning promiscuous 60 Journal for Clinical Studies

kinase inhibitors into safer drugs. Trends in Biotechnology, 26:295-301. 78. Fernández A, Sanguino A, Peng Z, et al., 2007, An anticancer C-Kit kinase inhibitor is reengineered to make it more active and less cardiotoxic. Journal of Clinical Investigation, 12:4044-4054. 79. C  respo A, Zhang X, Fernández A, 2008, Redesigning kinase inhibitors to enhance specificity. Journal of Medicinal Chemistry, 51:4890-4898. 80. Fernández A, Sessel S, 2009, Selective antagonism of anticancer drugs for side-effect removal. Trends in Pharmacological Sciences, 30:403-410. 81. S essel S, Fernández A, 2011, Selectivity filters to edit out deleterious side effects in kinase inhibitors. Current Topics in Medical Chemistry, 11:788-799. 82. Goodsaid FM, Frueh FW, Mattes W, 2008, Strategic paths for biomarker qualification. Toxicology, 245:219-23. 83. Goodsaid FM, Mendrick DL, 2010, Translational medicine and the value of biomarker qualification. Science Translational Medicine, 2:47. 84. Hong H, Goodsaid F, Shi L, Tong W, 2010, Molecular biomarkers: A US FDA effort. Biomarkers in Medicine, 4:215225. 85. Sistare FD, Dieterle F, Troth S, 2010, Towards consensus practices to qualify safety biomarkers for use in early drug development. Nature Biotechnology, 28:446-454. 86. Sistare FD, DeGeorge JJ, 2011, Promise of new translational safety biomarkers in drug development and challenges to regulatory qualification. Biomarkers in Medicine, 5:497-514. 87. M  atheis K, Laurie D, Andriamandroso C, et al., 2011, A generic operational strategy to qualify translational safety biomarkers. Drug Discovery Today, 16:600-608. 88. C  ohen O, Smith B, Stocum M, Verst C, 2012, Commentary: Building value through biomarkers: The “Smarter Development” imperative. Drug information Journal, in press. 89. The SAFE-T Consortium. (Accessed January 3rd 2012). 90. T  he Predictive Safety Testing Consortium. http://www.c-path. org/pstc.cfm (Accessed January 3rd 2012). 91. Food and Drug Administration, HHS, 2011, International Conference on Harmonisation; Guidance on E16 Biomarkers Related to Drug or Biotechnology Product Development: Context, Structure, and Format of Qualification Submissions; availability. Notice. Federal Register, 76(155):49773-4. 92. L averty H, Benson C, Cartwright E, et al., 2011, How can we improve our understanding of cardiovascular safety liabilities to develop safer medicines? British Journal of Pharmacology, 163:675-693. 93. R  ader DJ, 2007, Editorial. Illuminating HDL — Is it still a viable therapeutic target? New England Journal of Medicine, 357:2180-2183. 94. B  arter PJ, Caulfield M, Eriksson M, et al., 2007, Effects of torcetrapib in patients at high risk for coronary events. New England Journal of Medicine, 357:2109-2122. 95. McKenney JM, Davidson MH, Shear CL, Revkin JH, 2006, Efficacy and safety of torcetrapib, a novel cholesteryl ester transfer protein inhibitor, in individuals with below-average high-density lipoprotein cholesterol levels on a background of atorvastatin. Journal of the American College of Cardiology, Volume 4 Issue 1

Special Feature 48:1782-1790. 96.Joy T, Hegele RA, 2009, The end of the road for CETP inhibitors after torcetrapib? Current Opinion in Cardiology, 24:364-371. 97. R  obinson JG, 2010, Dalcetrapib: A review of Phase II data. Expert Opinion on Investigational Drugs, 19:795-805. 98. Hooper AJ, Burnett JR, 2011, Anacetrapib, a cholesteryl ester transfer protein inhibitor. Expert Opinion on Investigational Drugs, December 22nd [Epub ahead of print]. 99. Sirtori CR, 2011, Investigational CETP antagonists for hyperlipidemia and atherosclerosis prevention. Expert Opinion on Investigational Drugs, 20:1543-1554. 100. Boettcher MF, Heinig R, Schmeck C, et al., 2011, Single-Dose Pharmacokinetics, Pharmacodynamics, Tolerability, and Safety of BAY 60-5521, a Potent Inhibitor of Cholesteryl Ester Transfer Protein. British Journal of Clinical Pharmacology, August 12th [Epub ahead of print]. 101.Satin LZ, Gutstein D, 2011, Meeting Report. Drug Information Journal, 45. 102. Turner JR, Cardiovascular Safety Watch Column. Journal for Clinical Studies, 3(6):10. 103. Caveney E, Turner JR, 2010, Regulatory Landscapes for Future Antidiabetic Drug Development (Part I): FDA Guidance on Assessment of Cardiovascular Risks. Journal for Clinical Studies, January issue, 34-36. 104. Turner JR, Caveney S, 2010, Regulatory Landscapes for Future Antidiabetic Drug Development (Part II): EMA Guidance on Assessment of Cardiovascular Risks. Journal for Clinical Studies, March issue, 38-40. 105. Panicker GK, Karnad DR, Salvi V, Kothari S, 2012, Cardiovascular risk of oral antidiabetic drugs: Current evidence and regulatory requirements for new drugs. Journal of the Association of Physicians of India, 60:56-61. 106. Turner JR, 2010, Integrated Cardiovascular Safety: Employing a Three-component Risk Exclusion Model in the Assessment of Investigational Drugs. Applied Clinical Trials, 19(6):76-79. 107. International Human Genome Sequencing Consortium, 2004, Finishing the euchromatic sequence of the human genome. Nature, 431:931-945. 108. Venter JC, Adams MD, Myers EW, 2001, The sequence of the human genome. Science 291:1304-1351. 109. International Human Genome Sequencing Consortium, 2001, Initial sequencing and analysis of the human genome. Nature, 409:860-92. 110. Primrose SB, Twyman RM, 2006, Genomics: Applications in Human Biology. Blackwell Publishing. 111. Ferkol T, Israel E, Wechsler M, 2005, Gene therapy and pharmacogenomic studies. In Schuster DP, Powers WJ (Eds), Translational and Experimental Clinical Research. Lippincott Williams & Wilkins, 223-236. 112. Rothstein MA (Ed), 2003, Preface. Pharmacogenomics: Social, Ethical, and Clinical Dimensions. Wiley-LISS. 113. Brown SM, 2009, Essentials of Medical Genomics, 2nd Edition. Wiley-Blackwell. 114. Lesko KJ, Woodcock J, 2005, Regulatory perspectives on pharmacogenomics. In Kalow W, Meyer UA, Tyndale RF (Eds), Pharmacogenomics, 2nd Edition. Taylor & Francis, 265-286.

115. Goozner M, 2012, Drug Approvals 2011: Focus on Companion Diagnostics. Journal of the National Cancer Institute, January 3rd [Epub ahead of print]. 116. Philip R, Carrington L, Chan M, 2011, US FDA perspective on challenges in co-developing in vitro companion diagnostics and targeted cancer therapeutics. Bioanalysis, 3:383-389. 117. L a Thangue NB, Kerr DJ, 2011, Predictive biomarkers: a paradigm shift towards personalized cancer medicine. Nature Reviews. Clinical Oncology, 8:587-596. 118. Schmidt C, 2012, Challenges ahead for companion diagnostics. Journal of the National Cancer Institute, 104:14-15. 119. T  afe LJ, Tsongalis GJ, 2011, The human epidermal growth factor receptor 2 (HER2). Clinical Chemistry and Laboratory Medicine, September 15th [Epub ahead of print]. 120. w (Accessed January 7th 2012). 121. M  allal S, Phillips E, Carosi G, et al. for the PREDICT-1 Study Team, 2008, HLA-B*5701 screening for hypersensitivity to abacavir. New England Journal of Medicine, 358:568-579. 122. I ngelman-Sundberg M, 2008, Pharmacogenomic biomarkers for prediction of severe adverse drug reactions. New England Journal of Medicine, 358:637-639. 123. M  onte AA, Heard KJ, Vasiliou V, 2011, Prediction of Drug Response and Safety in Clinical Practice. Journal of Medical Toxicology, December 8 [Epub ahead of print]. 124. FDA, 2008, The Sentinel Initiative: National Strategy for Monitoring Medical Product Safety. 125. Turner JR, 2007, New Drug Development: Design, Methodology, and Analysis, 1st Edition. John Wiley & Sons. 126. K  aitin KI, 2008, Obstacles and opportunities in new drug development. Clinical Pharmacology and Therapeutics, 83:210-212. 127. Girardi F, Franceschi E, Brandes AA, 2010, Cardiovascular safety of VEGF-targeting therapies: Current evidence and handling strategies. Oncologist, 15:683-694. 128. Vaklavas C, Lenihan D, Kurzrock R, Tsimberidou AM, 2010, Anti-vascular endothelial growth factor therapies and cardiovascular toxicity: What are the important clinical markers to target? Oncologist, 15:130-141. 129. R  avaud A, 2011, Treatment-associated adverse event management in the advanced renal cell carcinoma patient treated with targeted therapies. Oncologist, 16(Suppl 2):3244. 130. Z  ambelli A, Della Porta MG, Eleuteri E, 2011, Predicting and preventing cardiotoxicity in the era of breast cancer targeted therapies. Novel molecular tools for clinical issues. Breast, 20:176-183. J. Rick Turner, PhD, is Senior Director, Integrated & Translational Cardiovascular Safety, Quintiles. He is an experimental research scientist and clinical triallist, Editor-in-Chief of the Drug Information Journal, a Senior Fellow at the Center for Medicine in the Public Interest, and a Fellow of the Society for Behavioral Medicine. He is an author of more than 100 peerreviewed papers and articles in professional journals, and an author of nine books. Email: Journal for Clinical Studies 61

Exhibition Previews & Reviews

CPHI/ICSE 2011 Review Record Year for UBM’s Pharma Events in Frankfurt (Events Host Over 2,200 Exhibitors, ABC audit Set to Reveal Highest Ever Attendance) November 29, 2011, Amsterdam – Leading event organiser UBM has announced a record breaking year for its flagship portfolio of annual pharmaceutical events including CPhI Worldwide for pharmaceutical ingredients, ICSE for contract and outsourcing services, P-MEC Europe for equipment, machinery and technology and the new InnoPack for innovative packaging solutions. Hosted at Messe Frankfurt, Germany from the 25th to 27th October 2011, the events attracted their highest ever exhibitor levels, with 2,200 global exhibitors on site. Overall attendance, though still subject to ABC audit, is also projected to smash all records set in more than twenty years of the events.* Throughout the three days in Frankfurt, attendees gathered to do business and network across various sectors of the pharmaceutical industry and each individual show experienced growth. P-MEC Europe grew more than 44% over 2010*, and despite exhibitors moving over to the new InnoPack event, ICSE still had a strong showing with over 220 exhibitors*. Notably, the new InnoPack event was met with positive feedback and attendance with over 100 global exhibitors hosting attendees from more than 140 countries. “The scale of the events has grown exceptionally over the years. As an events organiser, it is important to us that the size does not change the opportunity for each visitor to have a unique and personal experience and we invest a large amount of time and money to ensure this,” noted Greg Kerwin, UBM’s Portfolio Director Pharma. He continued, “Despite the financial challenges that still remain globally, to have a year like we just did in Frankfurt means that we are succeeding and that our client base sees the value of these events. As the Pharma industry regroups and rethinks their business plans for the years ahead, we are honoured to continue to be a part of them.” The 2011 pharmaceutical events were centred on a few popular returning features, as well as many new and expanded ones. The Pre-Show Conference on the Monday before the show offered a chance to learn and network before the events got underway. The zoning format also returned, with new additions and once again proved to be a positive feature of the shows by helping to facilitate better time management and ‘more talking, less walking’ while onsite. The expanded zoning format included new zones in CPhI for Generic APIs and Finished Dosage resources, three new zones for New Exhibitors, USA Exhibitors Zone, and Logistics and Supply Chain Zone within ICSE and a Labelling Zone in InnoPack. The CPhI Innovation Awards returned for their eighth year to recognise, celebrate and honour companies

62 Journal for Clinical Studies

and organisations that are breaking new ground in the pharmaceutical, packaging, contract services and biopharmaceutical sectors. The gold winner of the CPhI Innovation Award was Glycotope for their GlycoExpress platform that optimises the glycosylation of antibodies and other glycosylated biotherapeutics. The Silver medal went to Acuros for their disposable drug delivery device designed to deliver microlitres or millilitres per hour. Finally, bronze was awarded to Johnson Matthey Catalysts for their Colour-Tag-Protein technology that works as a marker for protein expression. The awards were handed out during an exhibitor party that also took a moment to recognize UBM’s shift towards celebrating and supporting sustainability in the events which included awarding Solvias with the Exhibitor Sustainability Award. In addition to the introduction of InnoPack as a standalone event, P-MEC Europe debuted the new LABWorld Pavilion to cater to high technology areas such as instrumental analysis, measuring and testing technologies, materials testing, quality control and laboratory equipment that are separate from the ‘traditional’ large-scale capital machinery, equipment and technology with which P-MEC has become associated. The LABWorld Pavilion was met with positive feedback. Other introductions to the show included Lunchtime Education Series, where high-level presentations from industry leading executives were given in a format that also offered attendees with time to enjoy a lunch while conducting targeted networking. Further new features included expanded social networking platforms and the introduction of virtual events to support attendance from guests that were not able to travel to the events in Frankfurt. CPhI Online has also been developed as a digital meeting spot where visitors can post and find news, information and resources while at the events and throughout the year. UBM’s market leading schedule of annual pharma events include India (30 November - 2 December, 2011, Bombay Exhibition Centre, Mumbai), Japan (21-23 March, 2012, Tokyo Big Sight Exhibition Centre, Japan), CPhI South East Asia (10-12 May, 2012, Jakarta International Expo, Indonesia), ICSE USA(22-23 May, 2012, Pennsylvania Convention Centre, Philadelphia), China (26-28 June, 2012, SNIEC, Shanghai, China), South America (21-23 August, 2012, Transamerica Expo Centre, Brazil) and Worldwide (9-11 October, 2012 at the Feria de Madrid, Spain). Pharma Publications with all their portfolio of publications (Journal for Clinical Studies, IPI – International Pharmaceutical Industry and Journal for Patient Compliance) will be there to support the industry through communications.

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Dora Wirth Languages

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Expert Briefings

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INTERLAB - central lab services - worldwide GmbH

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Medidata Solutions Worldwide

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PDP Couriers


Pierrel Research

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PRA International

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Ever wondered , why we choose flowers as the front cover of JCS? Each of the flowers we feature on the cover, represent the national flower of one of the emerging country we highlight in that particular issue. eg. In this issue we have featured a report on India. Lotus Flower is the National Flower of India, which features on the Front Cover.

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I hope this journal guides you progressively, through the maze of activities and changes taking place in these Emerging Countries. JCS has also launched a Weekly News Letter. Please visit and sign in to receive the very informative weekly news letter.

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