lessons learned from opioid addiction trials rachel skeete, md, mhs medical officer division of...
TRANSCRIPT
Lessons Learned from Opioid Addiction Trials
Rachel Skeete, MD, MHSMedical Officer
Division of Anesthesia, Analgesia, and Addiction Products (DAAAP)
Center for Drug Evaluation and Research
Food and Drug Administration
MOST MeetingMarch 25, 2015
1
Key Lessons Learned:Probuphine Case Study
2
3
Background: Probuphine (buprenorphine; ethylene vinyl acetate)
• Product/ClassProduct/Class: Implantable formulation of buprenorphine (BPN)• Sustained release of buprenorphine (BPN) for up to 6 months
• Dosage/AdministrationDosage/Administration:
Sublingual (SL) BPN induction implantation removal– INDUCTIONINDUCTION: SL BPN 12–16 mg/day ≥ 3 consecutive days prior to
implantation– IMPLANTATIONIMPLANTATION: 4 rods inserted into inner side of upper arm 12–24 h post
induction• 5th rod > 2wks later based on supplemental SL BPN needs
– ROD REMOVALROD REMOVAL: 6 months after implantation– CONTINUATIONCONTINUATION: Implant in opposite arm same day
• re-induction otherwise
Probuphine Efficacy and Safety Trials:PRO-8055 and PRO-8066
Study Design 24-week, P3, R, DB, PC trials in opioid-dependent adults
Treatments
(1) Initial Treatment: Target dose of SL BPN 12–16 mg/day(2) Probuphine/Placebo Rods: 4 rods for 24 wks
• Dose increase (+1) rod if supplemental SL BPN needs criteria met
Supplemental Buprenorphine
• Criteria: COWS > 12 Opioid Craving VAS > 20 mm Patient request for dose increase
• Obtained at clinic or pharmacy• Dose increase (+1 rod)
Supplemental needs ≥ 3 dys/wk in 2 wks or ≥ 8 dys in 4 wks
4
Probuphine Efficacy and Safety Trials:PRO-805 and PRO-806
Assessments• Urine toxicology – thrice weekly collection
Results blinded• Self-report every 2 weeks
Early WithdrawalCriteria
•Treatment Failure Supplemental buprenorphine needs
•Noncompliance 9 missed consecutive urine visits 6 consecutive counseling sessions missed
Endpoints
•Cumulative Distribution Function (CDF): CDF % opioid (-) urines, Weeks 1–24
Urine toxicology & self-report Missed samples considered (+)
5
Cumulative Distribution Function (CDF)
6Adapted from Sponsor Presentation at March 21, 2013, Advisory Committee Meeting
7
Primary Efficacy Results, Weeks 1 – 24
% (-) urines Weeks 1 – 24
Study % (-) urines % of subjects
Probuphine Placebo
PRO-805 ≥ 30 45 27
≥ 50 32 16
≥ 75 15 7
≥ 80 10 5
≥ 85 6 2
≥ 90 2 -
≥ 95 1 -
100 - -
PRO-806 ≥ 30 42 7
≥ 50 27 6
≥ 75 13 4
≥ 80 12 2
≥ 85 9 2
≥ 90 4 2
≥ 95 1 -
100 - -
CDF % (-) urines, PRO-805
CDF % (-) urines, PRO-806
Adapted from March 21, 2013, Advisory Committee Meeting Presentation
8
Lesson Learned: Treatment Response/Failure DefinitionsSubject-level results of urine samples – PRO-805
Placebo (n=55) Probuphine (n=108)
Week
Presented at Advisory Committee Meeting, March 21, 2013
9
Probuphine (n=114)Placebo (n=54)
Lesson Learned: Treatment Response/Failure DefinitionsSubject-level results of urine samples – PRO-806
Week
Presented at Advisory Committee Meeting, March 21, 2013
10
Lesson Learned: Placebo Failure/Placebo DropoutSubject-level use of SL BPN – PRO-805
Placebo (n=55) Probuphine (n=108)
Study Day
Presented at Advisory Committee Meeting, March 21, 2013
11
Lesson Learned: Placebo Failure/Placebo DropoutSubject-level use of SL BPN – PRO-806
Placebo (n=54) Probuphine (n=114)
Study Day
Presented at Advisory Committee Meeting, March 21, 2013
12
Lesson Learned: Treatment Retention ≠ Accrued Clinical BenefitSubject Disposition – PRO-805 & PRO-806
Disposition – n [%]
PRO-805Probuphine
N=108
PRO-805Placebo
N=55
PRO-805Probuphine
N=114
PRO-805Placebo
N=54
Early Withdrawal 37 [34] 38 [69] 41 [36] 40 [74]
Common Reasons
Non-Compliance 12 [11] 7 [13] 10 [9] 9 [17]
Treatment Failure 0 17 [31] 6 [5] 9 [17]
Subject Request 8 [7] 9 [16] 5 [4] 9 [17]
Lost to Follow-Up 10 [9] 4 [7] 9 [9] 3 [6]
Treatment Retention1.Early withdrawal based on supplemental buprenorphine use, but not urine toxicology
2.Clinic visits for daily treatment vs. implant
Adapted from March 21, 2013, Advisory Committee Meeting Presentation
Lesson Learned: Treatment Retention ≠ Accrued Clinical BenefitAllowing a Grace Period – PRO-805
13
Weeks 17-24
Weeks 1-24
Presented at Advisory Committee Meeting, March 21, 2013
Lesson Learned: Treatment Retention ≠ Accrued Clinical BenefitAllowing a Grace Period – PRO-806
14
Weeks 17-24
Weeks 1-24
Presented at Advisory Committee Meeting, March 21, 2013
Lesson Learned: Response Profile InterpretationCDF – PRO-805 & PRO-806
PRO-805 PRO-806
15Presented at Advisory Committee Meeting, March 21, 2013
16
Lesson Learned: Response Profile Interpretation – Graphical Display Matters CDF -PRO-805
Presented at Advisory Committee Meeting, March 21, 2013
Key Lessons LearnedSummary
17
Questions
18