The birth of the new technologies marks the peak of drug discovery. In our modern society, with rapidly growing technology, we are now able to push research to a level never seen in the past centuries. Hence, biotechnology has given us more tools to understand the insights of the human body and its mechanisms. Everyday, new discoveries bring us closer to a longer and healthier life by giving us the aid to fight diseases, but also to prevent them.

.

Human Fetal Lung Fibroblast Cells (MRC-5 Line). These cells were taken using a confocal microscopy . Confocal microscopy allow us to look at specific part of the cells at a high resolution.

In the old days, discovery of drugs often happened by fluke. A good example is the extraordinary discovery of the penicillin by Alexandre Fleming in 1928. A spore from a rare plant (Penicillium) from a mycology lab one floor below drifted in his lab, on a bacterial culture dish, leading to one of the greatest drug discoveries. Nonetheless, if we always had to wait for that type of fortune to happen, discoveries would be extremely rare. Nowadays, new successful drug discoveries depend less on luck and more on the combination of modern benchwork and great science. This is made possible by our more in-depth understanding of the human body and biology combined with more sophisticated tools. In spite of the skyrocketing number of drug discoveries, steps between drug discoveries and their marketing on our drugstore shelves are numerous and often laborious.

Clinical Trial Definition

In search of a new medicine

Clinical trials  (also known as clinical research trials or clinical research studies) study the impact of a drug that is intended to be use in humans on human subjects. Clinical research trials, are part of an important process allowing the collection of data about safety and efficacy before new drugs (including new devices) can be marketed. They are also intended to detect or verify the clinical, pharmacological or pharmacodynamic effect of the drug, identify any adverse event relative to the drug and allow to research other important elements in the comprehension of the drug, such as its distribution and excretion. Clinical research trials can only take place after adequate information have been collected on the product: thorough and promising non-clinical research findings have had to be made first. Consequently, Health Authorities has to approve of them, in the granted country, before any studies on human subjects can start to take place.

Clinical research trials are strictly regulated in every country and follow what are called Good Clinical Practices (GCP), provided by the International Conference on Harmonisation (ICH). GCPs are intended to define a standard in clinical trials across the world and are especially important in the fact that their guidelines include the protection of human rights as a subject in clinical trial, therefore allowing any volunteer that passes the inclusion criteria to join a trial and more importantly, to remove their consent at any given time. They also ensure proper habits and safe practices among the professionals of the industry. Hence, clinical research trials are subjected to international regulations, to regulations specific to each country in which the investigation is conducted, but can also be subjected to regulations specific to a state/province and even to the institution where the study is taking place (ex: hospital).

The International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) is a unique project that brings together the regulatory authorities of Europe, Japan and the United States and experts from the pharmaceutical industry in the three regions to discuss scientific and technical aspects of product registration.

[...continue reading below...]

Clinical research trials follow very strict protocols, designed by experts in the domain, and all study investigators must adhere and comply to the given protocol. Any deviations needs to be recorded and authorized by the sponsors.

There are 4 possible phases in clinical trials, which indicate the stage of the product development and each phase can include very distinct elements. Depending on the type of products as well as the stage of the product development, healthy volunteers(controls) or patients can be enrolled. The number of enrolled patients can be increased if and as more positive safety data are collected. The overall number of enrolled volunteers and patients varies for each clinical trial which size also also varies. A trial can be as small as one center in one country or as large as a multicentres trial in multiple countries.

The number of steps between drug discovery and its approval by Health authority for its marketing are fastidious and lengthy. However each step is essential and ensure both efficacy and safety of any new drug. And it is through these trials that investigational drugs, devices and diagnostics may show their benefits.

References:
(1) U.S. Food and Drug Administration (FDA)
(2) Health Canada
(3) Mickey C. Smith (1996), Pharmaceutical Marketing in the 21st century, The Harworth Press

Clinical research studies are classified into four phases (Phase I-IV). Each phase is viewed as a distinct clinical trial. While Phase I, Phase II and Phase III of a clinical trial have to be approved by the regulatory authorities  before they can take place, Phase IV are ‘post-approval’ studies.

Each phases consists of an accumulation of many studies (see Article «Clinical trial design – Studies»).

Phase I
The Phase I of clinical research studies constitute the first set of testing of a new drug into humans. They typically include studies grouped under Human Pharmacology. Phase I  clinical research studies have non-therapeutic objectives and are therefore not usually used for treatment of a disease. They are conducted on a small group of healthy volunteer subjects or on certain types of patients (such as patients with mild hypertension) .  The participants often need to stay overnight at the trial center to be closely monitored and observed. However, drugs that are known to have a high potential of toxicity (such as cytotoxic drugs used in chemotherapy in cancer) are usually studied in patients.

The Phase I of a clinical trial design can be open, meaning that both researcher and subject may know the details of the treatment. Phase I studies can also be baseline controlled: there is an assessment of the volunteer before and after treatment. Randomisation and blinding may also be used. In this case, there is a random allocation of the treatment, without the researcher and/or the subject knowing what treatment is being administered, which lead to more accurate results. The clinical trial design Phase I can involve:

(a)Estimation of Initial Safety and Tolerability is ,used to determine the tolerability of the dose range expected to be needed for later clinical studies and to determine the nature of adverse reactions that can be expected.

(b)Pharmacokinetics information is used to characterize the profile of the new drug about its absorption, distribution, metabolism, and excretion by the human body. Although predominant in Phase I of clinical trials, PK are studied throughout the trial, and other PK studies are carried during Phase II, Phase III and even Phase IV.

(c)Assessment of Pharmacodynamics, to provide an early idea of the activity and the potential efficacy of the new drug. PD can also guide the dosage of the drugs in later studies.

(d) Early Measurement of Drug Activity. Although usually done in later phases, it is possible to carry preliminary studies about drug potential therapeutic benefit in Phase I of a clinical trial, as a secondary objective.

Phase II
Clinical research studies Phase II can be initiated after enough information have been collected from Phase I and safety been confirmed. Their primary objectives are to explore therapeutic efficacy in patients. Phase II studies are used to evaluate how well the drug works, and also to collect additional safety data in a larger group of volunteers and patients. While early studies of Phase II may include be baseline controlled, later studies of Phase II are usually randomized with a placebo control, to evaluate the efficacy of the new drug and its safety under specific conditions or indications.

In Phase II, the therapy or drug is usually administered on a relatively uniform patient population, and groups are larger than those of Phase I. Subjects are closely monitored and information collected is important to determine the doses and treatment indications that will be used during Phase III. More studies under Phase II may be used to assess potential study endpoints, therapeutic restrictions (such as simultaneous or concomitant medications) or target populations (such as mild versus severe disease) for further studies.

Phase III
Phase III studies in clinical trials complete the information needed for the actual drug marketing approval, and give the official product information. For a drug to be approved, it typically has to undergo at least two successful Phase III trials, showing that the drug is safe for human use and its efficacy in the targeted population.

Phase III studies aim to confirm the therapeutic benefits of the new drug on the targeted population, and also to confirm previously collected evidence about drug safety. Additional Phase III studies may be used to research the dose-response relationship or the drug’s use in wider populations, in different stages of disease, or in combination with another drug.

Phase III studies are done on large group patients and are randomized controlled multicenter trials. The size and the relatively lengthy duration of Phase III trials make them notably expensive and time-consuming. Phase III trials can be difficult to design and run, especially in therapies for chronic medical conditions (ICH E1 and ICH E7). Trials involving extended exposure to the drug may be started in Phase II of the clinical trial.

Phase IV
Phase IV studies are post-approval studies and include therapeutic use type of studies. Clinical research studies  Phase IV are not mandatory for drugs and therapies approval, but can be important to optimize their use. Clinical trial Phase IV can be used to refine the dosing recommendation of a drug or to identify rare side effects. Mortality and morbidity or epidemiological studies are other examples of a clinical trial Phase IV studies. Some Phase IV studies have lead to the findings of harmful side effects, and the discontinuation or use restriction of some drugs.
[...continue reading below...]

References:
(1) International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH), Topics 1,5,7
(2) Health Canada
(3) U.S. Food and Drug Administration (FDA)

For more information, visit http://www.clinical-trials-info.com/.

The International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) recommends to classify clinical trial studies accordingly to their objectives.

Studies classification
Studies can be classified into four different types, accordingly to their objectives.

1.Human Pharmacology: Human pharmacology studies objectives are

- to assess how well tolerated by human subjects is the new compound;
- to define and describe the pharmakinetics (e.g. how much of the drug is absorbed, where the drug distributes in the human body, how fast is the drug excreted), the pharmacodynamics ( e.g. what are the mechanisms of action of the new compound);
- to explore the drug metabolism (biological processes) and interactions (e.g. with other proteins);
- and finally to estimate the drug activity.

General examples of human pharmacology studies are dose-tolerance studies, single and multiple dose PK and/or PD studies, drug interaction studies.

2.Therapeutic exploratory: Therapeutic exploratory studies objectives are

- to to explore use of the drug for the targeted indication;
- to estimate what is the needed dosage for subsequent studies,
- to provide a basis for subsequent study designs, endpoints (such as improvements in quality of life, relief of symptoms), methodologies

General examples of therapeutic exploratory studies are dose-response exploration studies or early trials of relatively short duration in small well-defined populations using endpoints/clinical measures

3.Therapeutic confirmatory: Therapeutic confirmatory studies are used -

- to demonstrate/confirm efficacy of the new compound;
- to establish a safety profile of the drug;
- to provide an adequate basis to assess the benefits and the risks associated to the new drugs to support the drug approval for release on the market
- to establish a dose-response relationship

General examples of therapeutic confirmatory studies are randomised parallel dose-response studies, studies of mortality and morbidity outcomes or comparative studies

4.Therapeutic use: Therapeutic use studies objectives are

- to ameliorate the understanding of the benefits and the risks of the new compound general relationships or those associated to specific populations or environments;
- to identify the less common sides effects
- to refine the dosing recommendation

Generals examples of therapeutic use studies are comparative effectiveness studies, mortality/morbidity outcomes studies or pharmacoeconomic studies

[...continue reading below...]

References:
(1) International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH), Topic 8
(2) Health Canada
(3) U.S. Food and Drug Administration (FDA)

For more information, visit Clinical Trials Info.

The development of a clinical trial follows a logical
and step-wise procedure. Clinical trials consist of four temporal
phases (phase I-IV). Each phase consists of a gathering of many
studies. Early studies are generally short and relatively small. The
information collected from those studies will be used to design the
next larger and more conclusive studies. Each study follow the
“Objectives → Design → Conduct → Analysis → Report” pattern.

Studies
A phase, in a clinical trial setting, consists of a gathering of “studies”.

Each study follows a similar pattern:

Objectives → Design → Conduct → Analysis → Report

The objectives represent the goals set for a particular study. For example, learning about the drug distribution in the human body, how long it takes before their excretion, pharmacodynamics, their side effects, are among the many possible objectives of a study.

The design represent how the study will look like and is planned by experts in the domain. The design always contains very specific instructions about every aspect of the test elements. Those instructions might, for example, involve time-points at which blood has to be drawn, how much blood needs to be drawn, time-points for urine collection, time-points for performing electrocardiograms or descriptive information of each test.

Conduct represents the act of running the study itself. For example, the act of drawing the blood, performing spirometry, doing an exercise test can all be part of the conduct of a study. Every study design has to be rigorously follow during conduct and every data collected as well as every procedure has to be documented.

Analysis represents the dissection and examination of the information collected. Analysis has to take in account every data and their results, but also any deviations to the protocols. Their results are a determinant to help decide the future outcome of the drug development and will be used to help decide what other steps are needed to complete the trial.

Report represents the summary and conclusions of the study. Using the results obtained by analysis, reports indicate what happens next. Accordingly to what the previous reports say, new studies with new objectives and designs might be investigated and conducted, and all new information collected and analyzed will be used to generate a new report.

Early studies
Clinical trials development follows a logical and step-wise procedure. The first studies done during a clinical trial are generally short and small (few centers, few subjects). The information collected from these early studies are critical to identify the profile of the new drug in order to sketch the next larger and more informative studies. Hence, these data allow to evaluate the new drug short-term safety and gives some preliminary insights of how well it is tolerated by the human body. Other information, such as PK and PD, is essential to determine what is the appropriate dosage and the proper scheduling to administer the new therapy.

Later studies and additional studies
Later studies are typically longer, larger and include a more varied population. Based on any new information collected, there is a possibility to add more studies. For example, finding of a severe side effect may suggest the need to do more non-clinical studies.
[...continue reading below...]

References:
(1) International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH)
(2) Health Canada
(3) U.S. Food and Drug Administration (FDA)

For more information, visit http://www.clinical-trials-info.com/.