Pre-clinical – unwrapped for a Clinical audience Gareth Thomas Philip Jarvis Mike Aylott PSI Conference 2014 www.huntingdon.com Agenda Aim of Session Toxicology SIG History Pre-clinical vs Clinical: Are we significantly different? Influence of Toxicology studies on Clinical How can Toxicology learn from Clinical? www.huntingdon.com Aim of Session To raise awareness of Pre-clinical Statisticians and our role in Pharmaceutical Development www.huntingdon.com ToxSIG History Founded in September 2006 Ran our first workshop in September 2007 Held a total of five 2-day workshops Run every 18 months, last one being March 2013 Around 40 affiliates on our mailing list www.huntingdon.com Statisticians Pre-clinical vs Clinical: Are we significantly different? Gareth Thomas Global Head of Statistics and Data Management Huntingdon Life Sciences www.huntingdon.com Differences Demonstrate our impact to business - to retain headcount Greater liaison with scientists Lower profile contribution to projects - less sense of belonging More variety Rapid turnover of studies - rapid turnover of stats analyses! New topics/challenges often www.huntingdon.com Day-to-Day Immediacy of work Less regulation Less idea of future workload – not sure what is around the corner Smaller studies, quicker turnaround More ad hoc (less defined duties and processes than clinical) and more freedom www.huntingdon.com Challenges Supporting many different studies Diverse range of scientific knowledge required Various levels of statistics buy in Multiple Statisticians working on one study Quick turnarounds Wide variety of data-types, study designs, areas of work Demonstrating our impact/contribution to business Finding and retaining resource www.huntingdon.com Advantages Huge variety of new challenges to be tackled Easy to make a difference See results quickly Interactions with scientists and new scientific areas New things frequently come up Freedom to operate www.huntingdon.com Disadvantages Distant from good news (drugs to market) No clear career path More vulnerable if budgets cut (than clinical)! Lack of knowledge about what we do and the value we add Too few of us Lack of recognition from regulatory authorities as an area where trained statisticians mandated www.huntingdon.com A life in the day of ... Morning 0615 – Get up, shower, get dressed 0645 – Feed cats, make lunch, enjoy Crunchy nut cornflakes and cuppa tea 0715 – Leave for work 0730 – Arrive at work 0735 – Cuppa tea and check emails 0745 – Sign and issue urgent US study stats report 0800 – S and K arrive – catch up with any questions they have 0815 – Continue checking Safety Pharm Telemetry Study 0852 – Meet all team for huddle 0930 – Meeting with HR about recruitment 1000 – Check Repro Tox Litter Stats for Study A 1100 – Finished checking, time for tea. Make tea for team! Hopefully chocolate treat to enjoy! 1115 – Senior Management meeting to discuss workload, prioritises and scheduling www.huntingdon.com A life in the day of ... Afternoon! 1215 – Eat sandwich quickly at desk 1230 – Analysis of bracketing assay data for CMC area 1330 – Answer email query from SD about ANCOVA 1400 – Analyse Genetic Tox Micronucleus study data 1500 – Wonder how it is 1500 already – time for another cuppa?!! 1505 – Analyse ADA cutpoint data 1600 – Update meeting on SEND 1700 – Go to the gym (or for a run) 1800 – Home, shower etc 1830 – Time for dinner 1900 – Finish checking any other emails 2000 – Cuppa tea and Star Trek! www.huntingdon.com Contract Research Snapshot Jobs – 110 booked in January Time spent on them 0.25 hrs Protocol Amendment Review >40 hrs Telemetry Study Turnaround – Same day to 18 days Analyses per study – 70 x 1, 17 x 2, 2 x 3 Data analysed – Activity, AUC, Bracketing Assay, Cytokines… …Respiration, Telemetry, Xenopus & Zooplankton www.huntingdon.com Survey results In which area of pharmaceutical drug development do you work? 11% 19% 63% 7% www.huntingdon.com Survey results - continued Have you ever collaborated with statistician colleagues in the “other” area? 37% 63% www.huntingdon.com Survey results - continued Does the work of your colleagues from the “other” area influence activities in your area? 45% 55% www.huntingdon.com Impact ICH S6 Addendum – includes recommendations on both study design and sample size requirements for use in the Developmental Toxicology Assessment of Biologics OECD Comet Assay Guidelines reference (Bright et al, Recommendations on the statistical analysis of the Comet assay) www.huntingdon.com Impact Many papers published by ToxSIG members Jarvis P, Srivastav S, Vogelwedde E, Stewart J, Mitchard T and Weinbauer G. The Cynomolgus Monkey as a Model for Developmental Toxicity Studies: Variability of Pregnancy Losses, Statistical power Estimates, and Group Size Considerations. Birth Defects Research (Part B), 2010: 89; 175187. Aylott M, Bate S, Collins S, Jarvis P and Saul J. Review of the statistical analysis of the dog telemetry study. Pharmaceutical Statistics, 2011; 10, 239-249. Weinbauer G , Jarvis P, Srivastav S, Mitchard T ,Vogelwedde E, Stewart J. Objective group size determination for developmental toxicity studies in a nonhuman primate model (Macaca fascicularis). Future Trends in Primate Toxicology and Biotechnology. Waxmann Publishing Company, Munster, 2011; 81-93. Jenkins M, Flynn A, Smart T, Harbron C, Sabin T, Ratnayake J, Delmar P, Herath A, Jarvis P and Matcham J. A Statistician’s perspective on biomarkers in drug development. Pharmaceutical Statistics, 2011; 10: 494-507. Bright J, Aylott M, Bate S, Geys H, Jarvis P, Saul J, Vonk R. Recommendations on the statistical analysis of the Comet assay. Pharmaceutical Statistics, 2011; 10: 485-493. Jarvis P, Saul J, Aylott M, Bate S, Geys H. An assessment of the statistical methods used to analyse toxicology studies. Pharmaceutical Statistics, 2011; 10: 477-484. Mitchard T, Jarvis P and Stewart J. Assessment of the Male Rodent Fertility in General Toxicology Six Month Studies. Birth Defects Research Part B: Developmental and Reproductive Toxicology, 2012 95: 410-420. www.huntingdon.com Significantly different? Do you like chocolate? No 10% Yes 90% Clinical Pre-clinical Yes, 79 No, 0 No, 10 Yes, 11 www.huntingdon.com Influence of Toxicology studies on Clinical Philip Jarvis 12th May 2014 FJ Spence February 18th, 2014 “ All substances are poisons; there are none which is not a poison. The dose differentiates a poison from a remedy” Paracelsus, 1531 How do we know that a drug is safe? All pharmacologically active substances have the potential to cause harm. Medicines are taken by patients with an expectation of benefit and usually some awareness that side-effects may occur. Some patients will experience harmful side-effects, sometimes leading to death or permanent disability. 24| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | The concept of safety (risk versus benefit) Safety is relative absence of harm or a low level of risk that, in context, can be considered acceptable. Toxicology assessment forms a key part of the risk/benefit evaluation • Need to identify the hazard, to be able to assess the risk • What is the potential benefit to humans versus the potential risk? i.e. efficacy versus toxicity Need to consider:• Therapy area and patient population – e.g. a toxicity risk which is unacceptable for an asthma therapy may be acceptable for cancer patients • The competition - what is already on the market what are its liabilities? The risk/benefit assessment is unique for each compound and evolves with the accumulation of further preclinical and clinical data 25| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Outline 1. Toxicology studies run prior to and in parallel with clinical development 2. Study design options are restricted by “Current” toxicology package • clinical trial duration, study inclusion criteria e.g. extending the clinical trial population into women of child bearing potential, children, etc. 3. Small molecules and biologics are different • duration of clinical effects, tox data required 4. The human relevance of a tox package finding may not be understood 5. Pre-clinical/Non-clinical data will appear on the drug label 26| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Outline 1. Toxicology studies run prior to and in parallel with clinical development 2. Study design options are restricted by “Current” toxicology package • clinical trial duration, study inclusion criteria e.g. extending the clinical trial population into women of child bearing potential, children, etc. 3. Small molecules and biologics are different • duration of clinical effects, tox data required 4. The human relevance of a tox package finding may not be understood 5. Pre-clinical/Non-clinical data will appear on the drug label 27| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Healthy Animals [Homogenous with respect to age, size, weight] Randomise Toxicology Basic Design Control (vehicle dosed) Low dose Intermediate dose High dose Dosing period All doses have to be tolerated Animals necropsied i.e. majority of animals display no overt signs of toxicity. [All major organs Analysed macro and microscopically] 28| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | 1. Toxicology studies run prior to and in parallel with clinical development sPoC Pre-clinical Safe to take cmpd / biological entity into humans? PoC Early Clinical Submission Late Clinical Safe to dose women of child-bearing potential? Safe to dose children? Safe to dose women who are pregnant? Safe to dose for extended duration? 29| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Post marketing Safe for use in the general patient population? Safe when used “offlabel”? 1. Toxicology studies run prior to and in parallel with clinical development PoC sPoC Pre-clinical Early Clinical Geneotox • Cells / rodents Safety Pharmacology • CVS, CNS, resp, GI [cells, rodents, nonrodent] General Tox • 1 month study [rodent & nonrodent] Submission Late Clinical Development and Repro Tox? General Tox [3, 6, 9 &12 month studies – 2 species]? Carcinogenicity Studies and/or transgenic mice Mode of action (tox) investigative studies 30| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Post marketing • Surveillance Word of caution • Think carefully before proposing a clinical Post marketing study as a means to evaluate the relevance of a toxicity study finding to humans. • These studies are long, difficult to manage and you will be held to your commitment. Ref: Jarvis et al (2011) Outline 1. Toxicology studies run prior to and in parallel with clinical development 2. Study design options are restricted by “Current” toxicology package • clinical trial duration, study inclusion criteria e.g. extending the clinical trial population into women of child bearing potential, children, etc. 3. Small molecules and biologics are different • duration of clinical effects, tox data required 4. The human relevance of a tox package finding may not be understood 5. Pre-clinical/Non-clinical data will appear on the drug label 31| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | 2. Study design options are restricted by “Current” toxicology package – Study duration Duration of clinical studies limited by “Tox coverage” • Duration measured by chronological time and animal lifespan covered ICH Topic M 3 (R2) Knowledge check. Will a typical pre-clinical package of toxicity studies support a one-year first in human clinical study? 32| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Correlation of body weight with different phases of postnatal days Int J Prev Med. Jun 2013; 4(6): 624–630. Rats live for 2 to 3.5 years and are sexually mature after approximately 6 weeks 33| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | 2. Study design options are restricted by “Current” toxicology package – Women of child bearing potential Women of child-bearing potential (WOCBP) up to a maximum of 150 women can be included in early clinical trials, provided • Confirmed to be not pregnant at the start of the study • Pregnancy risk is controlled throughout study • Duration of treatment no more than 3 months For studies of longer duration or in larger studies, the definitive reproductive toxicity studies package is required 34| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | 2. Study design options are restricted by “Current” toxicology package – Pediatric indications Generally, data from adult human volunteers and the supporting nonclinical data (in two species) will be available prior to pediatric clinical trials even when the product is not intended for development in adults. Section 12 of ICH M3(R2), Clinical Trials in Pediatric Populations, generally provides recommendations for the situation in which adult clinical trials precede pediatric trials and indicates that • juvenile animal toxicity studies are not considered important to support short term PK trials in pediatric populations. • However, if data from adult humans are not available and the drug will be developed only for pediatric subjects, then this is a case where juvenile animal studies in two species would be appropriate to support pediatric PK trials. 35| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Outline 1. Toxicology studies run prior to and in parallel with clinical development 2. Study design options are restricted by “Current” toxicology package • clinical trial duration, study inclusion criteria e.g. extending the clinical trial population into women of child bearing potential, children, etc. 3. Small molecules and biologics are different • duration of clinical effects, tox data required 4. The human relevance of a tox package finding may not be understood 5. Pre-clinical/Non-clinical data will appear on the drug label 36| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | 3. Small molecules and biologics are different 37| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Small molecule Linear PK often (but not always) reasonable Linear PK PD tracks PK J Am Coll Cardiol. 2003;41(4):557-564. doi:10.1016/S0735-1097(02)02868-1 38| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Large molecule 1 mg/kg 0.1 mg/kg Time (days) Higher dose Extended period of Receptor Occupancy Extended duration of clinical effect Receptor Occupancy (%) 10 mg/kg 10 mg/kg 1 mg/kg 0.1 mg/kg Time (days) Clinical effect Change from BL Concentration Non-Linear PK, duration of receptor occupancy and clinical effect linked 39| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Time (days) The TeGenero Incident March 13, 2006 UK TGN1412-a Superagonist Anti-CD28 Antibody 40| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | TeGenero Incident - 1/2 Facts TGN1412 - Humanized IgG4 mAb derived from precursor mouse mAb 5.11A1 Superagonist - Binds to CD28 and activates Tc without need for TCR preactivation, resulting in polyclonal Tc expansion/activation and IL2 production. Treatment for B cell CLL (chronic lymphocytic leukemia) in which T cells are deficient, and for AIDs in which Treg cell expansion might be beneficial March 13, 2006, the first dose administered was 0.1 mg/kg Rapid onset of severe life-threatening AEs in all 6 HVs • Rapid T cell activation, systemic inflammatory response, proinflammatory cytokine release, depletion of circulating Tc ... nausea, diarrhea, vasodilatation, hypotension • Intensive CU, intensive cardiopulmonary support (incl. dialysis), high-dose methylprednisolone, and an aIL2R antagonist Ab It was concluded that TGN1412 had caused a ‘‘cytokine storm’’ followed by modest Tc proliferation 2 weeks later All six volunteers survived. One Pt has since had all of his toes and the tips of several fingers amputated 41| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | TeGenero Incident - 2/2 Investigation of the incident and review of the science behind Expert Group on Phase One Clinical Trials appointed by the Medicines and Healthcare Products Regulatory Agency. Leadership of Professor Gordon Duff. ‘Duff report’ 2006 • Royal Statistical Society in 2007 ; Early Stage Clinical Trial task Force in 2007 MHRA initially concluded that ‘an unpredicted biological action of the mAb in humans was the most likely cause of the adverse reactions’ ‘The preclinical development studies performed with TGN1412 did not predict a safe dose for use in humans, even though current regulatory requirements were met’ Well ... really un-avoidable ? Probably not ! Jan. 2007 - Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMEA) announced that a guideline would be created ‘Guideline on Strategies to Identify and Mitigate Risks for First-in-Human Clinical Trials with Investigational Medicinal Products’ was final July 19, 2007 Application to both biologics and NCEs 42| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Receptor Occupancy and Dose Escalation in First in Human studies RO 100 90 128 µg/kg; 93% RO 80 64 µg/kg; 86% RO RO [%] 70 32 µg/kg; 75% RO 60 FIH dose >60 times higher than 1.5 µg/kg, calculated to lead to 10% RO RO 16 µg/kg; 58% RO 50 40 8 µg/kg; 40% RO FIH dose administered (100 µg/kg*) 30 4 µg/kg; 24% RO 20 2 µg/kg; 13% RO 1 µg/kg; 7% RO 10 *Leading to > 90% RO. 0 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 TGN1412 single dose (i.v.) [µg/kg] Split dose approach may be an option for mAbs with very steep dose/response curves expected in humans: » Initially, 10% of the intended dose is administered, followed by » A few hours later further 40% » A few hours later remaining 50% 43| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Beyond the ‘Safety Factor Approach’ for Defining the 1st Dose in Human Toxicological effect Target-related PD effect 100% 100% Toxicology Most-sensitive animal species Anticipated Human Toxicology Anticipated Human PD No observable adverse effects Animal PD Minimal PD Effect MABEL 1st dose in human Human NOAEL (HED) MABEL: Minimum Anticipated Biological Effect Level Animal NOAEL Dose or Exposure NOAEL: No Observable Adverse Effect Level 44| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | The Journal of Immunology, 2007, 179: 3325–3331. 45| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Outline 1. Toxicology studies run prior to and in parallel with clinical development 2. Study design options are restricted by “Current” toxicology package • clinical trial duration, study inclusion criteria e.g. extending the clinical trial population into women of child bearing potential, children, etc. 3. Small molecules and biologics are different • duration of clinical effects, tox data required 4. The human relevance of a tox package finding may not be understood 5. Pre-clinical/Non-clinical data will appear on the drug label 46| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | 4. The human relevance of a tox package finding may not be understood The assessment of safety is not trivial • Safe for use in the general patient population? • Safe when used “off-label”? Needs to be tailored to mechanism/mode of action for a given therapeutic indication For end-points that are understood, “normal” can be defined and departures from “normal” can be identified. However, not everything can be predicted. • Hyper-sensitivity / Idiosyncratic drug reactions 47| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Safety record of phase 1 trials However, some healthy subjects have died. A man died of cardiac arrest after taking an IMP in a trial in Ireland in 1984. When he was screened for the trial, he did not declare that he had recently been given a depot injection of an anti-psychotic medicine (Darragh A et al. Sudden death of a volunteer. Lancet 1985; 1: 93-94). A woman died after receiving a high dose of lidocaine - a widely used local anaesthetic - to prevent discomfort from endoscopy in a trial in the USA in 1996 (Trigg et al. Death of a healthy volunteer. Int J Pharm Med 1998; 12: 151153). Another woman with mild asthma died of lung damage after inhaling hexamethonium in a trial in the USA in 2001 (Steinbrook R. Protecting research subjects. NEJM 2002; 346: 716-720). 48| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Outline 1. Toxicology studies run prior to and in parallel with clinical development 2. Study design options are restricted by “Current” toxicology package • clinical trial duration, study inclusion criteria e.g. extending the clinical trial population into women of child bearing potential, children, etc. 3. Small molecules and biologics are different • duration of clinical effects, tox data required 4. The human relevance of a tox package finding may not be understood 5. Pre-clinical/Non-clinical data will appear on the drug label 49| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | 5. Pre-clinical/Non-clinical data will appear on the drug label e.g. rHu-Growth Hormone In the late 1980s soon after the approval of rHu-growth hormone there were some concerns about de novo leukemia in paediatric patients without risk factors Watanabe et al (letter) 1988, Lancet 331:1159-1160 After more than 20 years, leukemia has not been confirmed, but other signals, including risk of second malignancies in patients previously treated with irradiation, have been detected or confirmed through the National Cooperative Growth Study (NCGS) which monitored the safety and efficacy of rHu-GH in 54,996 children Bell et al, 2010, J Clin Endocrinol Metab 95(1):167-177 Carcinogenicity studies conducted in rats and mice with recombinant rat and mouse growth hormones – no effect on incidence of tumours at high doses selected to provide systemic exposure of GH up to approx 10-fold over basal levels and administered daily SC for 2 years Farris et al, 2007, Toxicol. Sci. 97:548-561 50| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Rat carcinogenicity studies for rHu Parathyroid hormone (1-34) and rHu PTH (1-84) rHu PTH (1-34) (teriparatide) –FORTEO/FORSTEO approved in US & EU rHu PTH (1-84) – Preotact is approved in EU Both produce osteosarcoma in carcinogenicity studies in Fischer rats (not tested in other rat strains or in mice) • The clinical relevance of these findings to patients will not be known with certainty until extensive clinical experience has accrued • Risk believed to be low & benefit of treatment considered to outweigh risk But USPI carries black box warning 51| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Example: Lorcaserin Mammary tumours in female rats Lorcaserin dose (mg/kg/day) Vehicle 10 30 100 Plasma exposure margin Number of Animals Adenocarcinoma Fibroadenoma 65 26 24 7 65 21 54* 24 65 24 55* 82 75 51* 51* * p<0.01 http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/EndocrinologicandMetabolicDrugsAdvisoryCommittee/UCM303198.pdf (Table 9) 52| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Example: Lorcaserin Tumours in male rats * p<0.05; ** p<0.01 Plasma exposure margin Lorcaserin dose (mg/kg/day) Vehicle 10 30 100 Skin: Subcutis; benign fibroma 65 3 7 65 7 24 65 11** 82 75 17** Nerve Sheath: Scwannoma; all 0 0 2 9** 0 0 1 0 4 2 6** 2 0 1 0 0 4 4 5* 8** Number of Animals sites Mammary gl, benign fibroadenoma Mammary gl, adenocarcinoma Skin; squamous cell carcinoma Brain; Astrocytoma http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/EndocrinologicandMetabolicDrugsAdvisoryCommittee/UCM303198.pdf (Table 3c) 53| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Examples: US label lorcaserin, 2013 http://www.belviq.com/pdf/Belviq_Prescribing_information.pdf 54| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | 55| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Outline 1. Toxicology studies run prior to and in parallel with clinical development 2. Study design options are restricted by “Current” toxicology package • clinical trial duration, study inclusion criteria e.g. extending the clinical trial population into women of child bearing potential, children, etc. 3. Small molecules and biologics are different • duration of clinical effects, tox data required 4. The human relevance of a tox package finding may not be understood 5. Pre-clinical/Non-clinical data will appear on the drug label 56| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | “Knowledge is experience. The universities do not teach all things, so a doctor must seek out old wives, gypsies, sorcerers, wandering tribes, old robbers and such outlaws and take lessons from them”. Paracelsus 1493-1541 Old wives, gypsies, ......... • Richard Knight • Simon Chivers • Pascal Espie • Patrick Y. Mueller • Per Sjoeberg 57| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | Any Questions 58| PSI Conference 2014 - Influence of toxicology on Clinical | Philip Jarvis| 12th May 2014 | How can Toxicology Learn from Clinical? Mike Aylott 12th May 2014 Contents 1. A Dose Response approach 2. Moving away from p-values 3. Using Bayesian statistics 1) Dose Response • Traditionally in Toxicology studies three or more dose levels are identified, and all are compared directly to the control • But the current thinking in Clinical is to look at the Dose Response curve, to gain a better understanding of the therapeutic window • In January the EMA issued a recommendation on model-based design and analysis of Phase II dose-finding studies • If we could model toxicity against dose, would this put us at an advantage? Traditional Approach No information on the toxicity of the compound, other than at these three dose levels Dose Response Approach A far greater idea of the relationship between the dose and the response Benefits of the Dose Response Approach • • • • • • • A better understanding of the entire dose range Essential when running adaptive designs More knowledge of the variability of the response The NOAEL may not exist with only three dose levels No great increase in overall data No loss in power by having smaller group sizes You can predict certain doses, e.g. TD90. Barriers to the Dose Response Approach • Toxicologists would need a change of mindset! o • • • They like to know which dose levels are safe and which are not High toxicity levels could be unethical Having more dose levels might cause:o housing difficulties o difficulties in preparing the test article Less information at any given dose o rare findings could be missed (as fewer animals would be used at each dose level) o • Comparisons against background levels may be harder Could not be applied to all study designs o Would be easier to apply to Early Tox studies o Carcinogenicity study designs must be acceptable to the regulators! 2) Moving away from p-values • • Toxicologists love p-values, and tend to only look at significant stars We are trying to move away from p-values, towards confidence intervals, as this gives us:- • o an indication of the magnitude of change o the direction of change o the precision of the study o statistical significance (yes or no) The distinction between statistical significance and biological relevance • We are winning the battle! 3) Using Bayesian Statistics • In most Genetic Tox assays, the Treated groups are compared to the concurrent control first… Control Treated • Historical Control • … and then compared to the Historical control If the Treated group falls within the Historical control bounds, then it is assumed that there is no biological relevance As we have prior belief of how the control values are distributed, this is an area that should use Bayesian Methodology! This also has the potential to reduce sample sizes. MPE Vehicle 24hr Counts (2000&4000 combined, average /2000) Study A 3.29 1.69 Summary What I would like to see in Toxicology in 10 years’ time:- • A Dose Response approach applied in Toxicology, particularly early Toxicology studies • • Confidence intervals routinely used instead of p-values Bayesian statistics used in Genetic Toxicology, or any assays with large historical datasets. Questions / Discussion Conclusions Pre-clinical and clinical role responsibilities (should) overlap We are working on the same compounds/projects We can learn from each other www.huntingdon.com Any final questions? www.huntingdon.com
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