DDMAC to weigh in on trial design?

The FDA Law Blog has an incredibly interesting entry regarding last week's Untitled Letter from the FDA's Division of Drug Marketing, Advertising, and Communications (DDMAC) to Novartis.

The letter, regarding a detail aid for Novartis's Focalin XR, accuses Novartis of making "unsubstantiated superiority claims" for Focalin XR in comparison to Concerta. What is interesting -- and completely new as far as I can tell -- is that the claims DDMAC are taking exception to are, in fact, primary endpoints of two controlled clinical trials:

Treatment for ADHD consists of symptom relief over an extended time period; thus, ADHD medications must control disease symptoms over the entire treatment course. However, the referenced clinical studies only focused on one specific time point (2 hours post-dose) as the primary efficacy measure in the treatment course of Focalin XR and Concerta. By focusing on the 2 hour post-dose time point, the studies did not account for the different pharmacokinetic profiles and subsequent efficacy profiles associated with Focalin XR and Concerta over the entire treatment course.

So, in essence, DDMAC appears to be taking exception to the trial design, not to Novartis's interpretation of the trial results. This would seem to be a dramatic change in scope.

I am not familiar with the trials in question -- I will post an update with more information shortly. Of special interest to me would be to understand: Were these pivotal trials that played a role in Focalin XR's approval? If so, did the FDA review them in a Special Protocol Assessment (and therefore are two distinct branches of FDA providing divergent opinions on these endpoints)?

Social Networking for Clinical Research

No matter what, negative clinical trial results are sad. We can appreciate, intellectually, that clinical equipoise is important and that negative results are a natural consequence of conducting ethical trials, but it is impossible not to feel disappointed when yet another promising therapy fails to hold up.

However, the negative results published today in Nature Biotechnology on a groundbreaking trial in ALS deserve to be celebrated. The trial was conducted exclusively through PatientsLikeMe, the online medical social network that serves as a forum for patients in all disease areas to “share real-world health experiences.”

According to a very nice write-up in the Wall Street Journal, the trial was conceived and initiated by ALS patients who were part of the PatientsLikeMe ALS site:

Jamie Heywood, chairman and co-founder of PatientsLikeMe, said the idea for the new study came from patients. After the 2008 paper reporting lithium slowed down the disease in 16 ALS patients, some members of the site suggested posting their experiences with the drug in an online spreadsheet to figure out if it was working. PatientsLikeMe offered instead to run a more rigorous observational study with members of the network to increase chances of getting a valid result.

The study included standardized symptom reporting from 596 patients (149 taking lithium and 447 matched controls). After 9 months, the patients taking lithium showed almost no difference in ALS symptoms compared to their controls, and preliminary (negative) results were released in late 2008. Although the trial was not randomized and not blinded – significant methodological issues, to be sure – it is still exciting for a number of reasons.

First, the study was conducted at an incredible rate of speed. Only 9 months elapsed between PatientsLikeMe deploying its tool to users and the release of topline results. In contrast, 2 more traditional, controlled clinical trials that were initiated to verify the first study’s results had not even managed to enroll their first patient during that time. In many cases like this – especially looking at new uses of established, generic drugs – private industry has little incentive to conduct an expensive trial. And academic researchers tend to move a pace that, while not quite glacial, is not as rapid as acutely-suffering patients would like.

(The only concern I have about speed is the time it took to get this paper published. Why was there a 2+ year gap between results and publication?)

Second, this trial represents one of the best uses of “off-label” patient experience that I know of. Many of the physicians I talk to struggle with off-label, patient-initiated treatment: they cannot support it, but it is difficult to argue with a patient when there is so little hard evidence. This trial represents an intelligent path towards tapping into and systematically organizing some of the thousands of individual off-label experiences and producing something clinically useful. As the authors state in the Nature paper:

Positive results from phase 1 and phase 2 trials can lead to changes in patient behavior, particularly when a drug is readily available. [...] The ongoing availability of a surveillance mechanism such as ours might help provide evidence to support or refute self-experimentation.

Ironically, the fact that the trial found no benefit for lithium may have the most far-reaching benefit. A positive trial would have been open to criticism for its inability to compensate for placebo effect. These results run counter to expected placebo effect, lending strong support to the conclusion that it was thoughtfully designed and conducted. I hope this will be immense encouragement to others looking to take this method forward.

A lot has been written over the past 3-4 years about the enormous power of social media to change healthcare as we know it. In general, I have been skeptical of most of these claims, as most of them fail to plausibly explain the connection between "Lots of people on Facebook" and "Improved clinical outcomes". I applaud the patients and staff at PatientsLikeMe for finding a way to work together to break new ground in this area.

Accelerated Approvals are Too Fast, Except When They're Too Slow

A great article in Medscape reports on two unrelated articles on the FDA’s process for granting (and following up on) Accelerated Approvals of oncology drugs.

First, a very solid review of all oncology drugs approved through the accelerated process since 1992 is in the latest journal of the National Cancer Institute. The review, written by FDA personnel, is in general concerned with the slow pace of confirmatory Phase 3 trials – over a third (18 of 47) have not yet been completed, and even the ones that have completed have taken considerable time. The authors consider process changes and fines as viable means for the FDA to encourage timely completion.

Second, over at the New England Journal of Medicine, Dr Bruce Chabner has a perspective piece that looks at the flip side: he argues that some compounds should be considered even earlier for accelerated approval, using the example of Plexxikon’s much-heralded PLX4032, which showed an amazing 80% response rate in Metastatic Melanoma (albeit in a very small sample of 38 patients).

I would argue that we are just now starting to get enough experience to have a very good conversation about accelerated approval and how to improve it -- still, less than 50 data points (47 approved indications) means that we need to remind ourselves that we're still mostly in the land of anecdote. However, it may be time to ask: how much does delay truly cost us in terms of our overall health? What is the cost of delayed approval (how many patients may potentially suffer from lack of access), and correspondingly what is the cost of premature approval and/or delayed confirmation (how many patients are exposed to ineffective and toxic treatments)?

The good news, to me, is that we're finally starting to collect enough information to make a rational estimate of these questions.