Abuse Liability Potential Working Group Dinner Session IDENTIFYING AND ANALYZING ADVERSE EVENTS RELATED TO ABUSE AND DEPENDENCE POTENTIAL IN CLINICAL TRIALS Chairs: Marta Sokolowska, PhD; Michael Klein, PhD; Beatrice Setnik, PhD February 16, 2016 Objectives 1. To overview the FDA Draft Guidance on Assessment of Abuse Potential of Drugs with the focus on Adverse Event collection in clinical trials of CNS‐active drugs 2. To propose a consensus list of adverse events (AEs) related to abuse and dependence evaluation of CNS‐active drugs 3. To review case examples and methods of summarizing AEs for regulatory filings Agenda Time Topic Presenter 6:30‐6:40 Welcome Co‐chairs 6:40‐6:55 Regulatory considerations for the evaluation of M. Klein clinical trial data relative to abuse and dependence potential assessments 6:55‐7:10 Abuse potential adverse events –a review of the M. Sokolowska recently approved labels for scheduled products. 7:10‐7:25 A consensus list proposal for adverse events B. Setnik related to abuse and dependence potential 7:25‐7:40 Organization and presentation of adverse events S. Ratcliffe and other relevant data 7:40‐8:30 Discussion All Regulatory considerations for the evaluation of clinical trial data relative to abuse and dependence potential assessments Michael Klein, PhD (FDA/CDER/CSS) Working Group Session: Identifying and Analyzing Adverse Events Related to Abuse and Dependence Potential in Clinical Trials 11th Annual Scientific Meeting Washington, DC February 16, 2016 The opinions and information in this presentation are those of the author and do not necessarily reflect the views and policies of the FDA Abuse and Dependence of Drugs Regulatory Areas 1. Drug Product Labeling (Section 9 requirement) 2. Drug Scheduling of Drug Substance (8 Factor Analysis: Factor 1 [Potential for abuse] and Factor 7 [Physical & Psychological dependence]. 3. 3 Findings required a. Relative abuse potential b. Accepted medical use in treatment c. Relative dependence liability 4. Evaluation requires nonclinical and clinical assessment a. Relies on study data results b. Safety studies 5. Recent FDA opioid action plan may impact review process a. Public health risk assessment is emphasized http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/ Guidances/UCM198650.pdf Final Guidance 1. 2010 Guidance sets standards for assessment; applies to a range of CNS active drugs: opioids, depressants, stimulants, hallucinogens, and cannabinoids 2. Issuing final guidance on abuse potential is a 2016 goal 3. Update Draft Guidance on Abuse Potential Assessment of Drugs a. Not to be confused with guidances (final & pending) of abuse deterrent products 4. Provides advice on content of abuse potential assessment in NDA a. Studies – nonclinical and clinical b. Scheduling proposal, draft labeling, basis c. 21 CFR 314.50(d)(5)(vii) 5. Information on abuse evaluation: a. Design and conduct of appropriate studies b. Recommendations Clinical Data 1. Human abuse potential studies (HAPS) as well as studies that evaluate human cognition and performance. 2. Most of the important clinical data is acquired from non‐patient populations 3. Collected data (from HAPS) are subjective responses (drug liking at the moment, overall drug liking, take drug again, high?, stoned? Hallucinations, mood changes, etc.) as opposed to physiological/pharmacological events (memory effects, sedation, somnolence, delirium, agitation, confused, abnormal thinking, etc.) from patient and non‐patient subjects a. Interesting b. But not always related to abuse potential 4. Rely on VAS measures and Adverse Events in non‐patient populations 5. We have seen that the VAS measures (drug liking)often correlate with Adverse Events (euphoria, elation). DRUG B –AE RATE COMPARISONS PHASES 1 ‐3 Phase 1 Phase 2/3 Phase 2/3 All Phase 2/3 PCT Placebo PCT Preferred Term AEs (n = 470) (n = 430) (n = 810) (n = 1370) Euphoric Mood 40 (8.5%) 0 4 (0.5%) 6 (0.4%) Somnolence 63 (13.4%) 51 (11.9%) 179 (22.0%) 389 (28.5%) Confusional State 29 (6.2%) 11 (2.6%) 75 (9.2%) 162 (11.9%) Feeling Drunk 26 (5.5%) 0 7 (0.9%) 20 (1.5%) Hallucination 23 (4.9%) 0 8 (1.0%) 15 (1.1%) Disorientation 8 (1.7%) 3 (0.7%) 14 (1.7%) 29 (2.1%) Feeling Abnormal 7 (1.5%) 0 1 (0.1%) 41 (0.3%) Drug C : HAPS Positive Subjective Mean Responses in Emax Metric Placebo A (2.0) A (4.0) C (300) C (500) C (1000) VAS –Drug Liking 53 67 66 62 69 76 VAS –High297483567494 ARCI – Euphoria 2998 1216 ARCI – Abuse 1.05456 7 Potential DRUG B –AE RATES in Healthy Subjects (Phase I) QT Study Preferred Term Drug daily dose (PT) Placebo / Placebo (mg) All (Drug) Moxifloxacin 15 40 N=60 N=60 N=60 N=64 N=124 Euphoric mood 1 (1.7) 0 (0.0) 5 (8.3) 6 (9.4) 11 (8.9) Feeling abnormal 0 (0.0) 0 (0.0) 1 (1.7) 0 (0.0) 1 (0.8) Mood altered 0 (0.0) 0 (0.0) 1 (1.7) 5 (7.8) 6 (4.8) Abnormal dreams 1 (1.7) 0 (0.0) 2 (3.3) 2 (3.1) 4 (3.2) Patient Narratives 1. Detailed case narratives for abuse and abuse related adverse events should be included with the study report 2. Narratives of adverse events should include time to onset and duration of the event, dose of drug taken, severity and outcome a. Sponsors should include a description of the suspected adverse reaction, along with all relevant information, such as symptoms, demographics, comorbid conditions, pertinent laboratory test results 3. If available, PK values for each individual reporting these adverse events should be provided to gain an understanding if there is a temporal correlation between drug plasma levels and adverse events 4. Include an explanation of how analysis was conducted and how conclusions were reached 5. See FDA Guidance for Industry and Investigators: Safety Reporting Requirements for INDs and BA/BE Studies, December 2012 Presentation of AE Data Subject demographics and history Dosage Time to onset mg/kg dose Dose regiment Exposure Duration of treatment Total daily or cumulative dose, if appropriate Drug‐disease and drug‐product interactions Concomitant/concurrent medication use Study Data: pooled vs. not pooled Dependence 1. Studies a. Spontaneous withdrawal b. Human dependence study 2. Use of scales and analysis of adverse events a. Symptoms of withdrawal 3. Safety and abuse a. Drug can be dependence producing even if not abusable Definition of Physical Dependence 1. Distinguish between dependence and addiction 2. The discontinuation/withdrawal syndrome Consists of 2 clinical aspects: a) Recurrence of symptoms of the treated disorder in patients, sometimes more severe b) Discontinuation/withdrawal effect: which can include other signs and symptoms, which typically do not represent a relapse of the underlying condition, but are related to the disruption of neuro‐regulatory changes established during drug administration. c) The specific symptom profile of discontinuation syndromes depends on the pharmacology and pharmacokinetics of the drug being administered and neurotransmitter system affected. DSM-V Diagnostic Criteria Substance-Induced Disorders Substance Intoxication and Withdrawal Example: Sedative, Hypnotic Withdrawal Human Dependence Study‐ Design Dose: Highest tolerated therapeutic dose administered (Treatment) period. Include Placebo arm. During the withdrawal period, placebo should be given for both drug and placebo arms Treatment time: ~ 4 weeks, depending on T1/2 and time to steady state, the time on steady state should be at least 3 weeks Time of withdrawal: Multiples of the drug’s half‐life plus 1‐2 weeks (to ~0 drug plasma levels), total ~14‐30 days (as in patient) Use Validated PD and Withdrawal Scales‐administration time points: Baseline, Last day on drug, First day of discontinuation, Then depends on T1/2 but generally first 2‐3‐ 5 day, then alternate days, depending on drug. Validated Withdrawal Scales: For benzodiazepines, opioids, SSRI’s, cannabinoids, drug classes, etc. Other PD scales‐ Depression, Anxiety, Columbia‐Suicide Severity Rating Scale (C‐SSRS) Divided Attention Test (DAT), Digit‐Symbol Substitution Task (DSST) AEs collection: Report separately during treatment and withdrawal phases Blood sampling: for PD‐PK correlation: Time points: to follow the PD time‐points and Rationale for PK evaluation: to distinguish between AEs due to drug toxicity or underlying disorder vs withdrawal, as symptoms are sometimes identical, so, PK is critical to provide clarification Known withdrawal syndromes in different drug classes Opiates Benzodiazepines Stimulants (amphetamine, cocaine, methamphetamine,) Ketamine Club drugs (MDMA, heroine) Testosterone and androgenic anabolic steroids (AAS) Antidepressants (“Prozac withdrawal syndrome”) Anti-psychotics (Quetiapine, Clozapine) Beta-blockers and clonidine Corticosteroids Factors that influence development of drug dependence Pharmacology of drug Time of exposure Dose Drug potency Neurotransmitter system affected (ex: opiate vs serotonin) Gender Age Next Topics: Identifying & Analyzing Adverse Events Related to Abuse and Dependence Potential in Clinical Trials 1. Adverse events related to abuse and dependence 2. Organization and presentation of adverse events and other relevant data 3. Case examples 4. Discussion Summary – Regulatory Issues 1. Abuse and dependence are safety issues 2. Section 9 of drug labeling for marketed drugs includes description of abuse and dependence liability 3. Abuse and dependence assessment are needed for drug scheduling 4. Refer to 2010 FDA draft guidance for reporting and analyzing adverse events in clinical trials related to abuse potential and how to apply the guidance Summary 5.