Oleksandr Sverdlov

Handling Covariates in the Design of Clinical Trials

There has been a split in the statistics community about the need for taking covariates into account in the design phase of a clinical trial. There are many advocates of using stratification and covariate-adaptive random ization to promote balance on certain known covariates. However, balance does not always promote efficiency or ensure more patients are assigned to the better treatment. We describe these procedures, including model-based procedures, for incorporating covariates into the design of clinical trials, and give examples where balance, efficiency and ethical considerations may be in conflict. We advocate a new class of procedures, covariate-adjusted response adaptive (CARA) randomization procedures that attempt to optimize both efficiency and ethical considerations, while maintaining randomization. We review all these procedures, present a few new simulation studies, and con clude with our philosophy.

Multicenter, Randomized, Double-Blind, Placebo-Controlled, Single-Ascending Dose Study of the Oral γ-Secretase Inhibitor BMS-708163 (Avagacestat): Tolerability Profile, Pharmacokinetic Parameters, and Pharmacodynamic Markers

BACKGROUND γ-Secretase inhibitors (GSIs) are being investigated for their potential to modify the progression of Alzheimer disease based on their ability to regulate amyloid-β (Aβ) accumulation. BMS-708163 (avagacestat) is an oral GSI designed for selective inhibition of Aβ synthesis currently in development for the treatment of mild to moderate and predementia AD. In addition to the desired effect on Aβ synthesis, GSIs affect Notch processing, which is thought to mediate some toxic adverse effects reported with this drug class. Avagacestat produced up to 190-fold greater selectivity for Aβ synthesis than Notch processing in preclinical studies and may therefore produce less toxic adverse events than other less selective compounds. Presented here are the results of the first in-human study for this new GSI compound. OBJECTIVE The goal of this study was to assess the tolerability profile, pharmacokinetic properties, and effects on pharmacodynamic markers (Aβ, trefoil factor family 3 protein, dual specificity phosphatase 6, and hairy and enhancer of split-1) of single, oral doses of avagacestat in healthy, young, male volunteers. METHODS This was a multicenter, randomized, double-blind, placebo-controlled, single-ascending dose study in 8 healthy young men (age, 18-45 years) per dosing panel. Each study participant was randomized to receive a single dose of placebo (n = 2) or avagacestat (n = 6 for each dose) as an oral solution in 1 of 9 sequential dose panels (0.3, 1.5, 5, 15, 50, 100, 200, 400, and 800 mg). For determination of avagacestat, blood samples were obtained before dosing and for up to 144 hours after dosing. For participants in the 800-mg avagacestat dose panel, additional samples were obtained at 216, 312, and 648 hours. For 40-amino acid isoform of Aβ (Aβ(1-40)) assessment, plasma samples were collected before avagacestat administration and up to 72 hours after dosing. RESULTS Avagacestat concentrations peaked quickly after oral administration and then had a biphasic decrease in concentrations with a prolonged terminal phase. Exposures were proportional with doses up to 200 mg. Avagacestat was well tolerated at single oral doses up to 800 mg, with a biphasic effect on plasma Aβ(1-40). Adverse events were predominately mild to moderate in severity with no evidence of dose dependence up to 200 mg. CONCLUSIONS Results from this single-ascending dose study suggest that avagacestat was tolerated at a single-dose range of 0.3 to 800 mg and suitable for further clinical development.

Pharmacodynamics of Selective Inhibition of γ -Secretase by Avagacestat

A hallmark of Alzheimer’s disease (AD) pathology is the accumulation of brain amyloid β-peptide (Aβ), generated by γ-secretase-mediated cleavage of the amyloid precursor protein (APP). Therefore, γ-secretase inhibitors (GSIs) may lower brain Aβ and offer a potential new approach to treat AD. As γ-secretase also cleaves Notch proteins, GSIs can have undesirable effects due to interference with Notch signaling. Avagacestat (BMS-708163) is a GSI developed for selective inhibition of APP over Notch cleavage. Avagacestat inhibition of APP and Notch cleavage was evaluated in cell culture by measuring levels of Aβ and human Notch proteins. In rats, dogs, and humans, selectivity was evaluated by measuring plasma blood concentrations in relation to effects on cerebrospinal fluid (CSF) Aβ levels and Notch-related toxicities. Measurements of Notch-related toxicity included goblet cell metaplasia in the gut, marginal-zone depletion in the spleen, reductions in B cells, and changes in expression of the Notch-regulated hairy and enhancer of split homolog-1 from blood cells. In rats and dogs, acute administration of avagacestat robustly reduced CSF Aβ40 and Aβ42 levels similarly. Chronic administration in rats and dogs, and 28-day, single- and multiple-ascending–dose administration in healthy human subjects caused similar exposure-dependent reductions in CSF Aβ40. Consistent with the 137-fold selectivity measured in cell culture, we identified doses of avagacestat that reduce CSF Aβ levels without causing Notch-related toxicities. Our results demonstrate the selectivity of avagacestat for APP over Notch cleavage, supporting further evaluation of avagacestat for AD therapy.

Adaptive Randomization for Clinical Trials

In February 2010, the U.S. Food and Drug Administration (FDA, 2010) drafted guidance that discusses the statistical, clinical, and regulatory aspects of various adaptive designs for clinical trials. An important class of adaptive designs is adaptive randomization, which is considered very briefly in subsection VI.B of the guidance. The objective of this paper is to review several important new classes of adaptive randomization procedures and convey information on the recent developments in the literature on this topic. Much of this literature has been focused on the development of methodology to address past criticisms and concerns that have hindered the broader use of adaptive randomization. We conclude that adaptive randomization is a very broad area of experimental design that has important application in modern clinical trials.

Optimal response-adaptive randomized designs for multi-armed survival trials.

We considered design issues for multiple treatment arms in survival intervention trials and used optimal design theory to allocate patients adaptively in such trials. We proposed three types of optimal designs: one ensures that we have the most precise estimates of the treatment effects, another guarantees that we have the minimal sample size subject to user-specified allocation ratio assignments among treatment arms, and the third ensures that the design has minimal total hazard for the cohort. The latter two types of optimal designs are also subject to user-specified power constraints for testing contrasts among treatment effects. The operating characteristics of these optimal designs along with balanced designs are compared theoretically and by simulation, including their robustness properties with respect to model misspecifications. Our results show that the proposed optimal designs are frequently unbalanced and that they are generally more efficient and more ethical than the popular balanced designs. We also apply our response-adaptive allocation strategy to redesign a three-arm head and neck cancer trial and make comparisons.

Utility of Covariate-Adjusted Response-Adaptive Randomization in Survival Trials

Covariate-adjusted response-adaptive (CARA) randomization is used in clinical trials to balance the competing goals of assigning a greater number of study subjects to the better treatment and achieving high statistical efficiency in estimating treatment effects in the presence of covariates, while maintaining randomness in treatment assignments. In this article, we propose CARA randomization procedures for survival intervention trials with two treatment arms when the primary outcomes follow an exponential regression model. We demonstrate, through extensive simulation, that our CARA procedures can achieve some reduction in the number of events in the study without compromising power and Type I error, compared with balanced randomization designs, including in situations when the exponential model is misspecified. We conclude that the proposed CARA procedures can be suitable alternatives to the traditional balanced randomization designs in survival trials, provided response data are available during the recruitment phase to enable adaptations in the design. We illustrate the proposed methodology by redesigning two survival trials from the literature.

On Recent Advances in Optimal Allocation Designs in Clinical Trials

One of the fundamental questions in the design of clinical trials is how to optimally allocate treatments to study subjects to achieve selected experimental objectives. In this article we review major recent methodological advances in optimal allocation for clinical trials. A literature review shows that starting from the 2000s many new allocation methods have been proposed to enhance the design of multiobjective and multiarm clinical trials. These allocation designs can provide improvements over traditional balanced allocation designs both in terms of statistical efficiency and ethical criteria. We also discuss state-of-the art response-adaptive randomization procedures for implementing optimal allocation designs in practice.

A contrast in safety, pharmacokinetics and pharmacodynamics across age groups after a single 50 mg oral dose of the γ-secretase inhibitor avagacestat

AIM To evaluate the single dose pharmacokinetics, pharmacodynamics, and preliminary tolerability of the γ-secretase inhibitor BMS-708163 (avagacestat) in young and elderly men and women. METHODS All subjects received double-blinded administration of a single 50 mg dose of avagacestat in capsule form or matching placebo. Main evaluations included pharmacokinetics, safety, plasma amyloid-β (Aβ)(1-40) concentratios and exploration of Notch biomarkers. RESULTS Avagacestat 50 mg capsule was well tolerated and rapidly absorbed among young and elderly subjects, with a median t(max) between 1 and 2 h post dose and an average half-life between 41 and 71 h. In general, subjects aged 75 years or more had higher AUC(0,∞) values than those aged less than 75 years. An exploratory analysis of Aβ(1-40) serum concentrations showed a pattern of decreasing concentrations over the first 4-6 h followed by a rise above baseline that was maintained until the end of the assessment period. Adverse events were generally mild, occurring more frequently in elderly subjects, with no observed difference between subjects receiving avagacestat and placebo. No dose limiting gastrointestinal effects of avagacestat were observed and exploratory biomarkers of Notch inhibition did not change significantly. CONCLUSIONS The favourable safety profile and pharmacokinetic effects of avagacestat in this study support its continued development, especially in the target population of elderly subjects with mild cognitive impairment or Alzheimers disease.

Adaptive clinical trial designs for phase I cancer studies

Adaptive clinical trials are becoming increasingly popular research designs for clinical investigation. Adaptive designs are particularly useful in phase I cancer studies where clinical data are scant and the goals are to assess the drug dose-toxicity profile and to determine the maximum tolerated dose while minimizing the number of study patients treated at suboptimal dose levels. In the current work we give an overview of adaptive design methods for phase I cancer trials. We find that modern statistical literature is replete with novel adaptive designs that have clearly defined objectives and established statistical properties, and are shown to outperform conventional dose finding methods such as the 3+3 design, both in terms of statistical efficiency and in terms of minimizing the number of patients treated at highly toxic or nonefficacious doses. We discuss statistical, logistical, and regulatory aspects of these designs and present some links to non-commercial statistical software for implementing these methods in practice. MSC 2010 subject classifications: Primary 62L05, 62L10, 62L12; secondary 62L20.

Efficient and ethical response-adaptive randomization designs for multi-arm clinical trials with Weibull time-to-event outcomes.

We consider a design problem for a clinical trial with multiple treatment arms and time-to-event primary outcomes that are modeled using the Weibull family of distributions. The D-optimal design for the most precise estimation of model parameters is derived, along with compound optimal allocation designs that provide targeted efficiencies for various estimation problems and ethical considerations. The proposed optimal allocation designs are studied theoretically and are implemented using response-adaptive randomization for a clinical trial with censored Weibull outcomes. We compare the merits of our multiple-objective response-adaptive designs with traditional randomization designs and show that our designs are more flexible, realistic, generally more ethical, and frequently provide higher efficiencies for estimating different sets of parameters.