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  1. Designs for Clinical Trials

  2. Chapter 5 Reading Instructions • 5.1: Introduction • 5.2: Parallel Group Designs (read) • 5.3: Cluster Randomized Designs (less important) • 5.4: Crossover Designs (read+copies) • 5.5: Titration Designs (read) • 5.6: Enrichment Designs (less important) • 5.7: Group Sequential Designs (read include 10.6) • 5.8: Placebo-Challenging Designs (less important) • 5.9: Blinded Reader Designs (less important) • 5.10: Discussion

  3. Design issues ?

  4. Research question Statistical optimality not enough! Use simulation models! Objective Confounding Control Design, Variables Statistics Ethics Variability Cost Feasibility Design issues

  5. Test R Control 1 Control 2 Parallel Group Designs • Easy to implement • Accepted • Easy to analyse • Good for acute conditions

  6. Placebo Drug X 8 week blood pressure Where does the varation go? Anything we can explain Unexplained

  7. Between and within subject variation Placebo DBP Drug X mmHg Female Male Baseline 8 weeks

  8. What can be done? Randomize by baseline covariate and put the covariate in the model. Stratify: More observations per subject: Baseline More than 1 obsservation per treatment Run in period: Ensure complience, diagnosis

  9. Test Control 1 R Control 2 Baseline 8 weeks Parallell group design with baseline Compare bloodpressure for three treatments, one test and two control. Observation Model: Treatment Treatment effect Subject Subject effect Random error

  10. Change from baseline The variance of an 8 week value is Change from baseline The variance of change from baseline is Usually

  11. Test Control 1 R Control 2 Baseline 8 weeks Baseline as covariate Subject Model: Treatment Treatment effect Baseline value Random error

  12. (C) Stephen Senn 2004

  13. A B Sequence 1 A B R Wash out B A Sequence 2 B A Period 1 Period 2 Crossover studies • All subject gets more that one treatment • Comparisons within subject • Within subject comparison • Reduced sample size • Good for cronic conditions • Good for pharmaceutical studies

  14. Model for a cross over study Obs=Period+sequence+subject+treament+carryover+error

  15. 2 by 2 Crossover design Effect of treatment and carry over can not be separated!

  16. Matrix formulation Model: Sum to zero: Matrix formulation

  17. Matrix formulation Parameter estimate: Estimates independent and

  18. A B B A B B A A B A Alternatives to 2*2 Compare to Same model but with 3 periods and a carry over effect

  19. Parameters of the AAB, BBA design

  20. Matrix again Effect of treatment and carry over can be estimated independently!

  21. A A A A B A B A B A B A B B B B A B B A A A B B Other 2 sequence 3 period designs 1 1 2 3 4 0.19 0.75 0.25 N/A 2 0.25 1.00 1.00 N/A 3 0.0 0.87 0.50 N/A 4

  22. A B B A B B A A B A Comparing the AB, BA and the ABB, BBA designs Can’t include carry over Carry over estimable 2 treatments per subject 3 treatments per subject Shorter duration Longer duration Excercise: Find the best 2 treatment 4 period design

  23. B A C C B A A B C B C C A B C B C A A B C D C A B B D A C A C B C A D B B A C D C B A C B A More than 2 treatments Tool of the trade: Define the model Investigate Watch out for drop outs!

  24. Titration Designs Increasing dose panels (Phase I): • SAD (Single Ascending Dose) • MAD (Multiple Ascending Dose) Primary Objective: • Establish Safety and Tolerability • Estimate Pharmaco Kinetic (PK) profile Increasing dose panelse (Phase II): Dose - response

  25. Dose: Z1 mg Dose: Z2 mg Dose: Zk mg • X on drug • Y on Placebo • X on drug • Y on Placebo • X on drug • Y on Placebo Titration Designs (SAD, MAD) Stop if any signs of safety issues VERY careful with first group!

  26. Titration Designs Which dose levels? • Start dose based on exposure in animal models. • Stop dose based on toxdata from animal models. • Doses often equidistant on log scale. Which subject? • Healty volunteers • Young • Male How many subjects? • Rarely any formal power calculation. • Often 2 on placebo and 6-8 on drug.

  27. Titration Designs Not mandatory to have new subject for each group. X1 mg X2 mg X3 mg X4 mg X5 mg XY mg Gr. 1 Gr. 2 Gr. 1 Gr. 2 Gr. 3 Gr. 4 12+2 12+2 12+2 12+2 12+2 12+2 • Slighty larger groups to have sufficiently many exposed. • Dose in fourth group depends on results so far. • Possible to estimate within subject variation.

  28. P A A placebo B placebo A active B placebo B AB A placebo B active A active B active Factorial design Evaluation of a fixed combination of drug A and drug B The U.S. FDA’s policy (21 CFR 300.50) regarding the use of a fixed-dose combination The agency requires: Each component must make a contribution to the claimed effect of the combination. Implication: At specific component doses, the combination must be superior to its components at the same respective doses

  29. Factorial design Usually the fixed-dose of either drug under study has been approved for an indication for treating a disease. Nonetheless, it is desirable to include placebo (P) to examine the sensitivity of either drug give alone at that fixed-dose (comparison of AB with P may be necessary in some situations). Assume that the same efficacy variable is used for studying both drugs (using different endpoints can be considered and needs more thoughts).

  30. Factorial design Sample mean Yi ∼ N( μi , σ2/n ), i = A, B, AB n = sample size per treatment group (balanced design is assumed for simplicity). H0: μAB ≤ μA or μAB ≤ μB H1: μAB > μA and μAB > μB j=A, B Min test and critical region:

  31. Group sequential designs A large study is a a huge investment, $, ethics • What if the drug doesn’t work or is much better than expected? • Could we take an early look at data and stop the study is it look good (or too bad)?

  32. Stop, reject For If otherwise Continue to group If Stop, reject otherwise stop accept Repeated significance test Let: Test: Test statistic:

  33. True type I error rate Repeat testing until H0 rejected

  34. Pocock’s test Suppose we want to test the null hypothesis 5 times using the same critical value each time and keep the overall significance level at 5% Stop, reject For If otherwise Continue to group After group K If Stop, reject otherwise stop accept Choose Such that

  35. Pocock’s test All tests has the same nominal significance level A group sequential test with 5 interrim tests has level

  36. Pocock’s test 2.413 -2.413

  37. Choose Such that O’Brian & Flemmings test Increasing nominal significance levels : Stop, reject For If otherwise Continue to group : After group K If Stop, reject otherwise stop accept

  38. O’Brian & Flemmings test Critical values and nominal significance levels for a O’Brian Flemming test with 5 interrim tests. Rather close to 5%

  39. O’Brian & Flemmings test 0.0413 0.0225 0.0084 0.0013 0.000005

  40. Comparing Pocock and O’Brian Flemming

  41. Comparing Pocock and O’Brian Flemming

  42. Group Sequential Designs Pros: • Efficiency Gain (Decreasing marginal benefit) • Establish efficacy earlier • Detect safety problems earlier Cons: • Smaller safety data base • Complex to run • Need to live up to stopping rules!

  43. Selection of a design The design of a clinical study is influenced by: • Number of treatments to be compared • Characteristics of the treatment • Characteristics of the disease/condition • Study objectives • Inter and intra subject variability • Duration of the study • Drop out rates

  44. Backup Back up: