Worried
about data being hidden in clinical trials, with negative data regarding a
drug's safety and/or efficacy being buried? Worry no longer. At least that's
what the super-optimistic authors in the New
England Journal of Medicine would have us believe. Here's what they
wrote:
Of
special interest to us, an additional provision of the act requires sponsors of
all clinically directive therapeutic trials to register their studies, at
inception, in a public database sponsored by the National Library of Medicine.
Although some aspects of this provision are not ideal, such as the delayed
public availability of registration information on device trials and the
noninclusion of phase 1 trials, mandatory registration represents a critical
advance in making clinical trials of new treatments public knowledge.
AND
A
decade ago a clinical trial could be conducted in secret. The trial’s sponsor,
claiming proprietary rights, could keep all information about it, including its
very existence, private. Thus, if a drug had important adverse effects, this
information might never be made public. Legislators believed that such a
possibility was not in the best interests of the American people. Once a
clinical trial is mounted, the sponsor has an ethical obligation to publicly
acknowledge the contribution of the participants and the risk they have taken
by ensuring that information about the conduct of the trial and its principal
results are in the public domain. With the FDA Revitalization Act, the United
States joins other countries in recognizing that the human volunteers needed to
complete a trial are more precious than the money required to mount it.
Wow,
everything is looking up now! All data will be reported and all will be well. I
read what I think is a relatively updated version of said
legislation,
and I did not really see anything that requires that all results are reported
for every trial. Nothing even close to that is described, unless I missed something.
Data reporting requirements should be pretty simple: Data on every single
efficacy and safety measure must be reported in full. Nothing less is
acceptable. Otherwise, sponsors can continue to fund research from which
the positive data are reported and the negative data are minimized.
The Present System is Broken. Here's an example of why the present
Clinical Trials database is close to useless for learning about study results.
First come snippets from a registered
clinical trial,
then comes the publication based upon the results. Snippets from trial protocol
(what was going to happen in the study):
This
is a study of the effectiveness of adding Abilify (aripiprazole), an atypical
antipsychotic medication, to ongoing SSRI antidepressant treatment for
depressed outpatients who are not responding fully to SSRI treatment alone. It
is hypothesized that patients’ functioning will improve after 12 weeks of
treatment with Aripiprazole and SSRI medication...
Total Enrollment:
15...
Primary Outcome Measures:
- Hamilton Depression Rating Scale
(HDRS)
Secondary Outcome Measures:
- Clinical Global Impressions Scale
(CGI)
- Global Assessment of Functioning
Scale (GAFS)
- Beck Depression Inventory (BDI)
Study chairs or principal
investigators
David J. Hellerstein, MD, Principal Investigator, NY State Psychiatric
Institute, and St. Luke's - Roosevelt Hospital Center
Publications
Hellerstein DJ. Aripiprazole as an
adjunctive treatment for refractory major depression. Prog Neuropsychopharmacol
Biol Psychiatry. 2004 Dec;28(8):1347-8. No abstract available.
Clinical
Trial Entry vs. The Publication. You can
see the details above. 15 patients to be enrolled in the
study using four measures of outcome. Let's see what that cited publication had
to say about the results...
Ms.
V. is a 46-year-old single female with a 5-year history of severe depression...
What about the 14 other patients?
At that point [venlafaxine + mirtazapine not working], aripiprazole was
added, initially at 15 mg/day then increased to 30 mg/day. Within a month, Ms.
V. noted that her mood and concentration were improved, and she was no longer
anhedonic. She began socializing with family members again, began gardening and
was able to concentrate on reading and movies. After 3 months on the
venlafaxine extended-release, mirtazapine, and aripiprazole, Ms. V. noted that
her appetite remained good, she was sleeping 7 h per night, her mood was much
better, and she had begun to seek a new job, sending resumes and phoning
prospective employers... What happened to those measures of outcome
mentioned above?
The
linked publication discusses one case though the trial was to study 15
people. Did the
other 14 all jump off a bridge? What happened? If
we are going to have a clinical trial
registry that requires reporting of results, is this what you want? I
hope not. Next, the obligatory pro-Abilify propaganda, such as...
Furthermore,
aripiprazole’s benign side effect profile [including minimal weight gain,
sedation and parkinsonism, resulting from its low affinity for
alpha-1-adrenergic, histamine (H1) and muscarinic (M1) receptors] suggests that
it may be tolerable for refractory-depressed patients, who may need adjunctive
treatment for a long period of time. The case of Ms. V. suggests the possible
benefit of aripiprazole in treatment-resistant depression as an adjunct to
other antidepressant medications.
When
there is no clinical trial data to support your discussion, one can always fall
back on discussing various receptors and how, theoretically, tweaking
them in one way or another is going to lead to positive results.
The case study ends with:
Further
studies of aripiprazole as an adjunctive medication for treatment-resistant
depression are indicated.
Yeah,
but what happened to the 14 other patients in this study?? I did a search on Medline
to find if there were additional studies by Hellerstein using Abilify in
depression and I could find nothing that seemed to fit the bill. Please alert
me if I missed something in the search. One could argue that perhaps the study
is in the midst of being written up for publication -- if so, it's sure taking
a while...
There's
More. If I
had more time, I'd go through the clinicaltrials.gov registry and I'm sure I'd
find more interesting discrepancies between clinical trial protocols (where
researchers say what is going to happen) and what was actually published (the
official record of what actually happened). In fact, I've done this before, in
which I noted that a published study of Risperdal for depression was clearly
changed in its data
reporting
somewhere between the clinical trial registry and the eventual publication. A
rather thorough
investigation
into the topic found that:
"Overall,
50% of efficacy and 65% of harm outcomes per trial were incompletely
reported. Statistically significant outcomes had a higher odds of
being fully reported compared with nonsignificant outcomes for both
efficacy (pooled odds ratio, 2.4; 95% confidence interval [CI],
1.4-4.0) and harm (pooled odds ratio, 4.7; 95% CI, 1.8-12.0) data.
In comparing published articles with protocols, 62% of trials had at
least 1 primary outcome that was changed, introduced, or omitted.
Eighty-six percent of survey responders (42/49) denied the existence
of unreported outcomes despite clear evidence to the contrary."
Who Cares? Well, if you don't mind receiving only part of the efficacy
and safety data, then don't do anything. Send no emails, tell none of your friends,
don't bother your local journal editor, and don't ask your doctor if he/she is
aware that the so-called bedrock of evidence based medicine (i.e., results
published in scientific journals) is based on selectively reported information.
The Kool-Aid. I'm really stunned that the folks at the New England
Journal of Medicine would just rush off and publish an essay about how great
things are now going to be. People have been calling out for data to be shared
openly for quite some time, and now, magically, with the passing of some vague
legislation, all data will be made publicly available. The drug industry is
suddenly just going to publish all information on all of their clinical trials,
overnight? And some bigwigs at NEJM are
willing to drink this Kool-Aid? That is pathetic.
1 comment:
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Aubrey Blumsohn said...
All
excellent comments. To add one more:
A Clinical Trial register already exists and has existed for at least two
decades.
It is called the FDA (and the MHRA over here). That very register kept information
about drug safety secret and inaccessible, and colluded in the hiding of
results from negative trials (take GSK SSRI studies as a great example).
Pity they didn't do their jobs last time around.
Aubrey
