Professional Documents
Culture Documents
in Clinical Trials
• What is pharmacovigilance?
All things are poison, and nothing is without poison; only the dose permits
something not to be poisonous.
Paracelsus (1493-1541)
Thalidomide case
• In the late 50’s thalidomide was sold as OTC medication to treat several
conditions, including morning sickness in pregnant women
• Science and activities relating to the detection, assessment, understanding and prevention of
adverse effects or any other medicine-related problem.
• In line with this general definition, underlying objectives of pharmacovigilance in accordance with the
applicable EU legislation are:
• preventing harm from adverse reactions in humans arising from the use of authorised medicinal products within or outside
the terms of marketing authorisation or from occupational exposure; and
• promoting the safe and effective use of medicinal products, in particular through providing timely information about the
safety of medicinal products to patients, healthcare professionals and the public.
• Pharmacovigilance is therefore an activity contributing to the protection of patients’ and public
health.
• Detection
• Assessment
• Understanding
• Prevention
Definitions
* A.k.a. Adverse reaction, Adverse effect, Suspected adverse (drug) reaction, Undesirable
effect
AE vs ADR
Adverse
Event
“Temporal correlation does not imply causation”
Are the rabbit and the dog out running at the same time? (Temporal correlation)
Or is the rabbit running because the dog is chasing it? (Causality)
SERIOUS Adverse Event
NOTE FOR GUIDANCE ON CLINICAL SAFETY DATA MANAGEMENT: DEFINITIONS AND STANDARDS
FOR EXPEDITED REPORTING (CPMP/ICH/377/95)
AE vs SAE
Adverse
Event
Serious Adverse Drug Reaction (SADR)
• An AE that is considered
• serious (as per defined criteria)
AND
• possibly related to the medicinal product
Reference Safety Information (RSI)
• Summary of Product Characteristics (SmPC) is most commonly used as RSI in investigator initiated
trials testing authorised medicinal products in accordance with the marketing authorisation
SUSAR: Suspected Unexpected Serious Adverse Reaction
Understanding the SUSAR concept – start from the last word and move
backwards
• The event is suspected to be related Suspected Adverse Reaction
• And the event is serious Serious Adverse Reaction
• And the event is unexpected
Suspected Unexpected Serious Adverse Reaction (SUSAR)
Assessments
SUSAR
Expectedness
Expectedness
SAE Serious
ADR
Seriousness
Reaction
Relatedness
Adverse
Event
Adverse
Event
Legal framework in the EU/Norway
• Clinical trials:
• Directive 2001/20/EC (valid until 536/2014 is implemented)
• Regulation 536/2014 (to be implemented in Dec 2021?)
• FOR-2009-10-30-1321: Forskrift om klinisk utprøving av legemidler til mennesker (to
be updated when 536/2014 is implemented)
Investigator’s Responsibilities
Responsibilities
• Competent Authority
• Detection
• Assessment
• Sponsor
• Understanding
• Investigator • Prevention
• Patient
Responsibilities
• Detection
• Sponsor • Assessment
• Understanding
• Investigator
• Prevention
Investigator
• Detection
• SAE reporting, AE collection
• Assessment
• Relatedness
• Expectedness
• Understanding
• Investigator’s brochure
• Prevention
• Information to patients and clinical trial subjects
• Compliance with protocol
What must be reported?
• Causality assessment:
• Is the event considered to be caused by the investigational medicinal product?
• This assessment is made by both investigator and sponsor
• Grading of event
• e.g. mild – moderate – severe – life threatening
• Investigator Sponsor
• AEs
• Report as soon as possible (to allow for continuous safety assessment)
• Recorded in the CRF
• SAEs
• Report within 24 hours of becoming aware of the event
• Often separate report SAE report form to collect required information
Documentation
Reaction
Relatedness
Recording in CRF
Adverse
Event
Assessments – reporting
SAE
Seriousness
Reaction
Relatedness
Adverse
Event
Recording in CRF
Adverse
24h notification required
Event
Further AE reporting details
• Detection
• Clinical trial notifications (AE/SAE reports)
• Assessment
• SAE assessment (SUSAR), AE assessment/signal detection, DSUR, Investigator’s
Brochure, Data Monitoring Committee
• Understanding
• Ongoing risk assessment, Data Monitoring Committee, (DSUR)
• Prevention
• Information to patients and clinical trial subjects
• Detailed information in protocol
Planning phase
• Summary of the known and potential risks and benefits, if any, to human
subjects.
Clinical Trial Protocol – GCP requirements
• Risks to be assessed:
• Risks to participant safety associated with the intervention(s) being tested
• Risks associated with design and methods
• Requirements:
• Justification in protocol
• Supported by risk assessment
Examples (study specific risk assessments required)
• Risk assessment justifies that AEs should be collected only after the
investigational medicinal product has been administered and not from the
time of informed consent for study participation.
Data Monitoring Committee (DMC)
• The charter will be signed by all members BEFORE starting the reviews
• The charter contains:
• Stopping rules
• Safety issues
• Lack of efficacy (futility)
• Overwhelming evidence of efficacy
• Voting procedures: Open & closed sessions
• Meeting frequency
• Data provided and format
DMC
• YES
Responsibilities of a Medical Monitor
• Expectedness assessment
• Is the event included in the Reference Safety Information (IB or SmPC)?
Causality Assessment
Likely related
Definitely related • Related
If the investigator can choose between several options when assessing causality,
sponsor should up-front define which assessments are to be considered as “not
related” and “related” important from a regulatory reporting perspective
Causality assessment
SUSAR
Expectedness
Expectedness
SAE Serious
ADR
Seriousness
Reaction
Relatedness
Adverse
Event
Adverse
Event
SUSAR: Suspected Unexpected Serious Adverse Reaction
• Sponsor Investigators
• Line listings of blinded SUSARs
• In periods as warranted by the nature of the clinical development project and the volume of
SUSARs generated.
• Should be accompanied by comments on how/if the SUSARs changes the safety profile of
the test product
• IB update
• Annual review
Blinded Data - Investigators
Report unblinded to
Test product
CA + EC
SUSAR
Break blind Report unblinded to
CA+ EC
Control or Re-assess
Placebo criteria
Report
blinded to Treat as SAE
investigators
• If feasible, one single DSUR with data pertinent to all dosage forms and
strengths, all indications, and all patient populations under study with the
investigational drug, should be written. However, the sponsor is
responsible for including at least safety data from the clinical trial(s) for
which the organsiation is responsible.
Under 2001/20/EC:
• Submitted to competent authorities and ethics committees via their regular
reporting system (e-mail, database systems)
• Some ethics committees don’t want DSURs (example: Norwegian REK)
Under 536/2014:
• Submitted via the EU Portal
Alternative Annual Safety Report (Norway, only)