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Clinical Trials

Joe Giffels, MAS, has written extensively on the regulation and practice of clinical research and is here to offer information. Here he shares information and advice on what you should know before, and how to decide if you should volunteer to participate in a clinical trial.

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WebMD Health News

Wednesday, May 30, 2007

FDA's New Adverse Event Guidelines
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Last month, the Food and Drug Administration (FDA) published a set of what it calls non-binding recommendations concerning when and how adverse events are reported.

In the world of clinical research the term "adverse events" refers to things that go wrong during a clinical trial. An adverse event may be caused by the drug or device being studied. It may be caused by the clinical trial itself, but not directly by the study drug. An adverse event may also be the result of a mistake made by the study team. In any case, researchers and those who regulate clinical trials are always on the lookout for adverse events - for lots of reasons. They may indicate that the drug or device being studied has side effects that may prove to be so significant that marketing, or even approval for marketing, becomes impossible. They may pose severe liability issues for the clinical trial sponsor. Most importantly, they are a sign that participants in the clinical trial are experiencing unwanted effects.

Existing federal regulations governing clinical research require all adverse events to be reported to IRBs - Institutional Review Boards that are responsible for reviewing, approving, and monitoring clinical trials at an institution such as a medical school or private clinic. As researchers and clinical trial sponsors have become more and more compliant with the reporting requirements due in some measure to enhanced FDA scrutiny, IRBs have become deluged with individual reports of adverse events. Such reports are often difficult, if not impossible to assess without analyzing the individual adverse event in the context of the entire clinical trial.

Even the existing definition of an adverse event as an "unanticipated problem" does not always help. While a severe headache may be considered an adverse event requiring reporting in a clinical trial of a drug for treating migraine, a single such report does not enable an IRB to determine whether or not there are global implications for the safety of research participants. Only if it became clear that severe headaches were being experienced by the research participants who received the study drug more often that those who received placebo and more often than the general population of migraine sufferers would it make sense for an IRB to consider taking some action regarding the study.

Next Time: What the FDA Guidelines are Recommending

~Joe

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Posted by: Joe Giffels_ WebMD at 2:50 PM

Tuesday, May 22, 2007

Cost of IRBs
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Today, virtually all clinical trials are subject to oversight by Institutional Review Boards (IRBs). Members of the IRBs are experts in science, medicine and ethics and are responsible for reviewing the design of the clinical trials and for monitoring the way they are conducted as well as the results. While health care professionals and scientists employed by the institution served by the IRB usually make up the majority of the membership of that institution's IRB, there is also a requirement for participation by non-institutional members. Although most of the members are employees of the institution, they are frequently not paid extra for their service on an IRB. Rather, their service is considered a part of their duties as employees. Nevertheless, there are costs associated with maintaining IRBs.

A recent peer-reviewed study published in the journals IRB: Ethics & Human Research and Academic Medicine presents some idea of the costs of IRB oversight of clinical trials at US medical schools.

Half of the nation's 125 medical schools participated in the cost study, reporting their own costs. Of those, the authors of the study subsequently visited 10 of the responding schools to validate the accuracy of the self-reported costs.

The number of clinical trials conducted at the medical schools varied from a few to several thousand. The lowest reported total cast was $171,000 (per year). The highest was $4,700,000. Quite a difference. Much of that difference is due to the difference in size of the IRB operation at the institutions. When the costs were reported per clinical trial, the numbers varied from $300 to $500.

Probably the most significant question emerging from this study involves the difference in costs among institutions. Do some institutions spend more on reviewing clinical trials than others simply because they are less efficient in their review processes? Or does the quality of the reviews explain some of the differences? That is, do the institutions that spend more review the clinical trials more carefully? And, if so, does that greater attention to the research protocols translate into better safety records?

Those are questions for future research.

~Joe

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Posted by: Joe Giffels_ WebMD at 7:45 AM

Thursday, May 03, 2007

Professional Research Subjects: Issues to Consider
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Luca Volpi
The way our system of drug and medical device testing is set up requires the participation of human subjects. And early phase testing often calls for healthy participants, for at least two reasons. First, side effects are usually more easily observed and measured in healthy individuals because they are not masked or affected by other health problems. Second, healthy individuals are more likely to be able to tolerate obnoxious side effects.

While it may seem to be more efficient and effective to enroll in more than one clinical trial at the same time, it is almost never a good idea. Clinical trial protocols usually prohibit it because it confounds the science. It is nearly impossible to be certain which of two or more drugs are causing a particular reaction. Maybe they both are, but it is unclear how much each drug is contributing to the reaction.

More important than the science, however, is the safety issue for research participants. Many side effects or reactions would not occur at all, or are magnified, by a combination of drugs. We pay attention to this when we ask the pharmacist or doctor about taking more than one medication at the same time. But it's even more a concern for drugs that have not been extensively tested!

When the need or desire for income outweighs the volunteer's ability to fully appreciate the risk and dangers of participating, then clearly that individual is unable to give truly informed consent. Often, this causes the potential subject to lie about something, such as whether they drink alcohol, smoke, have headaches, or have a history of a particular medical condition in their family, in order to meet the criteria for enrollment in the protocol. For obvious reasons, this is dangerous for the individual. And it's another factor that negatively affects the science. Potential participants should be truthful when being interviewed for enrollment. And clinical researchers should develop protocols so that inaccurate responses by potential participants are detected.

Finally, participants should consult their personal physicians about volunteering for clinical trials - both before they enter the trial and for the entire duration of their participation. Being up front with your doctor will help her advise you in your decision to volunteer.

In summary, with adequate medical oversight, participating as a clinical research subject may be a viable way of earning money on an occasional basis. As a career, I'd say it's not only risky, but it promotes bad science.

~Joe

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Posted by: Joe Giffels_ WebMD at 2:25 PM

Tuesday, May 01, 2007

Professional Research Subjects: Paid Guinea Pigs?
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The concept of earning something of a living by volunteering for clinical trials is not new. Clinical trials often pay volunteers to participate. Payment usually reflects to some degree the time required by the participant, as well as the discomfort and risk s/he will experience. A clinical trial requiring a 24-hour presence in a hospital setting to undergo safety monitoring for a drug which may have unpleasant side effects, for example, may pay several hundred dollars or more a day and may last a week or more.

This may be an appealing employment option for some, including the unemployed, those who are "between jobs," students, and others. Usually, the volunteers are healthy individuals, as required by the research protocols. Healthy, that is, until they subject themselves to potentially risky effects of the drug being tested. And that's the real challenge - balancing the desire of the subjects to enroll (for the money) and the desire of the researchers to enroll subjects against the risk (largely unknown both in nature and degree) to the subjects of enrolling in early phase testing.

That said, potential research participants and the clinical researchers who would enroll them should keep a few key issues in mind. Next time, I'll introduce those issues, which should also be of interest to health care providers of individuals considering volunteering for clinical trials.

~Joe

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Posted by: Joe Giffels_ WebMD at 7:55 AM

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