CLINICAL DRUG TRIALS IN

PSYCHIATRY:

FORMATION OF THE INVESTIGATOR

A basic and applied training course

Michel BOURIN
MD, Pharm.D, Psychiatrist
University of Nantes, France

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Translated with the help of C.I.N.P

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Introduction and presentation of module I 1

Prerequisites for phase I and II clinical drug trials 3

Pharmacokinetic concepts 9

The first administration in man: phase I clinical trials 17

Phase II trials 19

Phase III 25

Phase IV 29

Introduction and presentation of module II 35

Criteria of patient selection 39

Choice of evaluation criteria in a clinical trial 43

Planning clinical trials 47

Recommendations for drafting study protocols in biomedical research

57

Introduction and presentation of module III 61

Selection and recruitment of investigators 63

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Specific requirements of the multicenter trial 65

Monitoring the clinical trials 69

The auditor in clinical trials 73

Data collection 77

Conclusion of module III 79

Protocol for a clinical trial 81

Good clinical practice for trials on medicinal products in the

European community 111

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 INTRODUCTION AND PRESENTATION OF
MODULE I

The essential purpose of this module is to consider in detail the different phases of
drug development, which requires a knowledge of the prerequisites for drug studies in
humans. In fact, the transition from the animal to man is always difficult, and very strict
regulations have been established so that phase I trials (the first level of studies in man)
can be performed in conditions ensuring the greatest safety for the individuals
concerned.

Phase I, the first application to humans, involves a study of the pharmacokinetics

of the drug, but also, and increasingly, the pharmacodynamics, i.e. the different
pharmacological properties. In particular, tolerability is studied very precisely in a
considerable number of subjects in order to determine the dose at which side effects
begin to occur. These side effects must of course remain bearable.

Phase II is critical since the purpose is to prove the therapeutic efficacy of the
drug in the sick patient and to determine the scale of active doses. This phase is
particularly sensitive since it will demonstrate or confirm the potential clinical
effectiveness of the drug. Later trials will depend largely on phase II. If the effective
dose is not clearly determined, convincing phase III trials cannot be conducted.

Phase III is in fact the clinical trial, the most classic therapeutic study, which
involves the largest number of investigators. The methodology in this module will be
developed in a relatively succinct manner, insofar as the later modules, particularly
module III, will specify the bases of evaluation in a clinical trial as well as the
procedures for coordination and monitoring.

Phase IV has been particularly developed in this module since studies of this type
are of interest if they avoid the risk of becoming only means of enlarging the scope of
prescription and thus reinforcing the marketing strategy.

Finally, the last part of this module will be devoted to pharmacovigilance, which
is absolutely essential for the practitioner, who is legally required to declare any adverse
effects. The methodology of pharmacovigilance is quite different from that of the phases
outlined above since it is based essentially on the notion of monitoring and imputability.

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PREREQUISITES FOR PHASE I AND II CLINICAL
DRUG TRIALS

Regardless of the pharmacological class of the drugs used in clinical trials before
their approval and registration, certain prerequisites are essential before the start of
phases I and II. These prerequisites have been considered in different directives of the
European Community Council which have appeared in the Official Journal of the
European Community and in a work on toxicology. The purpose of the present
document was to present a summary of these recommendations.

Five types of files concerning the new drug should be made available to
investigators before the start of phase I and II clinical trials: the analytic file, the galenic
file, the file on animal pharmacology, the pharmacodynamic file and the toxicologic file.

According to the Guide to Good Clinical Practices for drug trials, these files are
prepared under the supervision of the manufacturer promoting the trials who is
responsible for communicating them in their entirety to the investigators. However, the
investigators must solicit this information from the manufacturer and be fully informed
before the final phase of drafting the protocol—and necessarily before the start of the
clinical trials. This information (or a detailed summary) must also be communicated to
the Advisory Committee for the Protection of Biomedical Research Subjects (a state-
authorized ethics committee) which gives its opinion on proposed protocols.

I. ANALYTIC AND GALENIC FILES

These two files describe the characteristics of the new drug proposed for clinical
trials.
The analytic file provides a schema of the chemical formula of the drug, a
description of the physicochemical properties of the substance as well as its purity and
stability conditions, and various details concerning solubility, particle size, hydration
state, the oil/water partition coefficient, pK/pH values, etc.
The galenic file contains the complete description of the galenic (or pharmaceutic)
form(s) of the drug prepared for the clinical trials: galenic form (capsule, tablet, solution,
etc.), composition in active principle and excipient, stability period, possible sterilization

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conditions, special precautions for conservation, compatibility with injectable solvents,
nature and content of the recipient, etc. The labeling conditions for samples are also
indicated.
These files, which are prepared by the pharmacists in charge of pharmaceutical
laboratories, describe in detail the characteristics of the drug to be used during phase I
and II clinical trials. As it often happens that various galenic forms of the same drug are
produced and tested in man before the choice of the definitive galenic form(s), it is
important to specify clearly for each clinical trial performed the galenic form and the
batch number of the drug which has been tested. As the bioavailability of a drug can
vary from one galenic form to another, bioequivalence studies among the various galenic
forms should be planned if the form is modified during the trials (e.g. the administration
of an aqueous form of the drug for phase I trials and the use of capsules or tablets in
phase II trials).
It would of course be desirable to have the definitive galenic form of the drug
available as soon as possible for the clinical trials. However, this is rarely the case since
the choice of the definitive form often depends on the results of the first clinical trials.

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II. ANIMAL PHARMACOKINETIC FILE

Pharmacokinetic studies in animals are performed on several species of rodents

(most often the rat) or larger mammals (the dog) and can include studies in primates
(monkeys).

The purpose of these studies is to describe the following parameters: absorption

and bioavailability of the drug, distribution of the drug in the organism and its binding to
plasma proteins, and elimination of the drug.

The study of the metabolism of the drug in animals reveals the main metabolic
pathways, the possible existence of circulating metabolites, and their main elimination
route. The isolation of these metabolites, the characterization of their chemical structure,
and the study of their possible pharmacologic activity should be performed as soon as
possible in order to determine whether circulating metabolites should be taken into
account in pharmacologic and toxicologic studies. Moreover, these initial kinetic studies
in the animal will allow the detection of a possible accumulation of the parent product
(and/or its metabolites), which would require special precautions during preclinical
studies and the first human trials. The possibility of using substances labeled with
radioactive isotopes (H3, C14) without limitations in the animal greatly facilitates these
studies, allowing rapid performance of evaluative studies (absorption and elimination of
the drug) as well as studies of drug distribution in the animal organism.

Pharmacokinetic studies in the animal are of considerable interest because of their

value in predicting human kinetics. However, the importance of possible differences
between species should not be overlooked. The dog, for example, is a slow acetylator
and will synthesize few acetylated metabolites (if this metabolic pathway is involved).
The interpretation of the results of these studies must thus remain subject to criticism and
should always be compared with results for the human kinetics of the drug. In particular,
preliminary kinetic studies in man will allow the choice of "the species closest to (or
least remote from) man" in order to provide more thorough pharmacokinetic
investigations.

"Recommendation 83/571/EEC introduced for the first time the concept of

studying pharmacokinetics and metabolism in animals in terms of safety." The purpose
of such studies is to determine the concentrations of the drug and its metabolites, as well
as their kinetics in blood, biological fluids and organs; obtain information on the
relations between toxicity and drug concentrations; study the possibility of enzymatic
induction and of drug accumulation in case of repeated administration; and select
(insofar as possible) the animal species to be used for toxicologic studies on the basis of
a similarity with the human situation regarding the fate of the drug in the organism.

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 Thus, these investigations may require a preliminary study of the kinetics and
metabolism of the drug in a limited number of human subjects before a definitive choice
can be made of the animal species to be used for toxicity studies involving repeated
administrations.

III. PHARMACODYNAMIC FILE

This file is obviously of major importance to investigating physicians insofar as it

contains the description of all the known pharmacodynamic properties of the drug.

III.1 PHARMACODYNAMICS RELATIVE TO THE MAIN PROPERTY

The main pharmacologic property, which relates to the intended therapeutic use of
the drug, has generally been studied and determined in several types of preparations and
experimental models: in molecular, subcellular, cellular and tissue pharmacology when
the drug acts on individualized receptors in vitro; in isolated and perfused organs; and in
animal models in vivo (anesthetized and conscious animals), which reproduce as closely
as possible the human pathological situation corresponding to the intended threapeutic
use of the drug (relations between dose and effect and plasma concentration and effect
are determined in animals, sometimes allowing a modeling of the situation for
comparison with results obtained in human subjects in phase I and II trials).
These studies in animals also permit an approach to the mechanism of drug action,
although the physiopathology of the animal models must not differ too greatly from that
of the pathologic clinical situation.
Finally, pharmacologic studies in animals, by comparing the properties of the new
drug with those of reference products of the same therapeutic class, allow the relative
potency of the drug to be studied and to situate the new substance with respect to
existing compounds used in therapy.

III.2 GENERAL PHARMACODYNAMICS

The effects of the new drug on all important functions of the organism are studied
in animals. Thus, cardiovascular, renal, pulmonary, neurologic, sensory, gastrointestinal,
endocrine and metabolic properties are considered either in pharmacodynamic studies or
during toxicologic studies by comparing acute and repeated administrations of the drug.
Other properties, such as the effects on different experimental inflammation models or of
the drug on gastric mucosa, are studied more specifically.

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IV. TOXICOLOGIC FILE

The toxicologic file includes five types of studies.

IV.1 ACUTE TOXICITY OR TOXICITY BY A SINGLE

ADMINISTRATION
This study permits the calculation of the dose (and corresponding administration
route) inducing the death of the animal. The minimum lethal dose (MLD) by slow
intravenous infusion permits the choice of the doses to be used for determining the
median lethal dose (LD50).
LD50, i.e. the dose capable of killing half of the experimental animals by the
chosen administration route, is determined by suitable methods. It is calculated in two
animal species (most often the mouse and rat) using an equal number of animals of each
sex and at least two administration routes.

IV.2 TOXICITY BY REPEATED ADMINISTRATION FOR LIMITED

PERIODS
To avoid a delay until the end of the long-term toxicity studies (1 year) that
precede clinical trials, the European Union has proposed minimum periods for toxicity
studies before initial administrations of the drug to human subjects (Table 1).

Table 1: Relations between the period of drug administration in man during

clinical trials and the length of toxicity studies in experimental animals (83/571/EEC)

______________________________________________________________________
Planned treatment schedule Proposed period of toxicity studies
by repeated administration
____________________________________________________________________________________
One or several administrations in a single day 2 weeks

Repeated administration for up to 7 days 4 weeks

Repeated administration for up to 30 days 3 months

Repeated administration for more than 30 days 6 months

______________________________________________________________________

IV.3 "CHRONIC" TOXICITY

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 When the drug is intended for long-term administration in man, toxicity studies
should be performed over a one- or even two-year period, which corresponds to a large
part of the life of a laboratory animal. These studies are of particular interest if the
following conditions are satisfied:

- Choosing an animal species as close as possible to man with respect to drug

kinetics and metabolism.

- Choosing a dosage and administration route that allow undesirable effects to be

induced (in practice, three concentrations are required: a non-toxic one, a highly toxic
one leading to the death of a certain percentage of animals, and an intermediary one).
These toxicologic studies should include one using the same drug administration route as
that proposed for clinical trials.

- Requiring that the target organ and the active principle be the same as those
involved in the human therapeutic effect.

- Collecting as many data as possible on the experimental animals (mortality,

morbidity, behavior, weight, physiological and biological modifications,
histopathological analysis of 31 tissues or organs, etc.).

- Checking the effects of animal exposure to drugs (toxicokinetics) by

measurement of plasma concentrations and comparison with human data.

The pharmacologic data and the correlations between plasma concentrations and
effects observed during these studies can be of considerable predictive value for the
subsequent clinical trials.

IV.4 DETERMINATION OF MUTAGENIC POTENCY

This study concerns the potency of a substance in inducing a modification in
genetic material by acting on DNA. In practice, a mutagenic test is conducted on bacteria
as well as by means of a chromosomal mutation test. However, many other tests can also
be performed, particularly to determine metabolic activation.

IV.5 DETERMINATION OF EFFECTS ON REPRODUCTIVE

FUNCTIONS
Studies of the effects of new drugs on reproductive functions require three phases
or segments:

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 segment 1: a fertility study.

segment 2: studies of embryotoxicity, fetotoxicity and teratogenic potency.

segment 3: study of peri- and postnatality. Because of the length of these studies,
phase I and II clinical trials may be initiated without waiting for the results of
reproduction studies, provided that
1. women are excluded from the trials,
2. repeated toxicity studies have shown no gonadal anomalies,
3. the drug is not part of a "suspect" chemical series with a history of known
toxic effects on reproductive functions.

IV.6 DETERMINATION OF CARCINOGENIC POTENCY

These investigations also involve long-term studies (18 months in the mouse and
hamster and 24 months in the rat) which are only required if prolonged treatment is
planned in man or if frequent intermittent administration of the drug to human subjects
leads to prolonged exposure. Phase I and II clinical trials can be initiated without waiting
for the results of carcinogenic studies, provided that:

1. mutagenic tests have shown no anomalies,

2. the drug and/or its metabolities do not accumulate in the organism,
3. the drug is not part of a "suspect" chemical series with a history of animal
or clinical epidemiological observations indicative of an iatrogenic
carcinogenic risk.

V. CONCLUSIONS

This brief presentation of prerequisites is intended as a reminder to investigating

physicians of the need to ensure the safety of subjects and patients included in phase I
and II trials respectively. Moreover, a thorough consideration of these prerequisites is
often decisive in orienting the first clinical trials of the drug, indicating the specific
parameters to be considered and guiding the first evaluations of the drug in man.

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 PHARMACOKINETIC CONCEPTS

Before the last decade, drug dosage was determined empirically in terms of meals,
which generally led to prescriptions of two or three doses per day. The development of
plasma assays for drugs provided better knowledge of their fate in the organism,
allowing the establishment of more rational therapeutic schedules and individual
adjustments in certain cases.

The achievement of pharmacokinetics is thus twofold. It has led to new theoretical

concepts, such as half-life, distribution volume, or the therapeutic plateau of equilibrium,
and it has provided practical results permitting the establishment of a rational therapeutic
schedule.

I. DRUG-RELATED ELEMENTS

The purpose of the prescribing physician is to maintain an effective concentration

at the level of the action site throughout the treatment period.

The drug, from its point of administration, passes successively through different
stages: absorption, distribution, transformation and elimination.

II. ABSORPTION

For convenience, most drugs are administered orally (per os), which presents
certain problems. First, the substances are not often totally absorbed, so that a part is
simply eliminated in stools. In practice, drugs which are well-absorbed (80% of the
administered dose) can be ingested together with food at mealtime. This is the case for
drops of digoxin, theophylline tablets, prednisone tablets and amoxicillin capsules.
Secondly, these drugs cause little interference relative to their absorbed fraction during
concomitant administration with other drugs.

Some drugs are absorbed better when taken with food, e.g. beta-blockers,

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griseofulvin or nitrofurantoin, whereas others are well-absorbed during fasting (50 to
60%) but inadequately at mealtime.

Non-absorbed drugs are used only to induce local effects in the digestive tract
(intestinal antiseptics).

The intravenous route is ideal for ensuring good drug absorption, except for the
possible inconvenience involved. The intramuscular route allows more complete
absorption than the oral route, but the process is not always as rapid. The subcutaneous
route is generally used to obtain a delayed action.

III. DISTRIBUTION

The drug is distributed more or less rapidly in all tissues, depending on their
vascularization. In practice, it is difficult to determine the tissular concentration of a
drug, although the plasma level is generally a rather good indicator of its concentration
at action sites. One exception to this good correlation between tissue and plasma
concentrations is when the drug has too great an affinity for proteins, which introduces
the notions of affinity and binding percentage relative to bound and free forms since only
the latter can be diffused at the plasma level. The most important notion is distribution
volume, which is the theoretical volume in which the drug would be distributed if the
concentration were the same everywhere in the plasma. This apparent distribution
volume thus represents the capacity of the drug to diffuse: the higher the distribution
volume, the greater cellular tropism becomes:
SR < 20 liters : the drug is distributed only in the blood and intercellular
fluid
(easily unchangeable).
201 < SR < 40 liters : the drug is distributed in the blood and body fluids.
SR > 40 1iters : tissue uptake is high.

This capacity of the drug to diffuse in body fluids and tissues allows a stable
plasma concentration to be obtained when steady state is reached.

IV. BIOTRANSFORMATION

Most drugs during their transit through the organism undergo various metabolic
transformations. As metabolites may have appreciably different characteristics,
particularly from a pharmacologic point of view, depending on the drug involved, it is

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useful to know both the general principles governing these biotransformations and the
mechanisms relative to each type of drug which need to be taken into account in the
dosage.

Metabolic transformations generally inactivate the drug, although the opposite can
occur, which is the case with certain pro-drugs that are metabolized to
pharmacologically active derivatives (e.g. clorazepate dipotassium which is transformed
into demethyldiazepam). Finally, some drugs are not metabolized at all and simply pass
through the organism that receives them (e.g. urinary antiseptics).

There are essentially four types of biotransformation: oxidation, reduction,

hydrolysis and conjugation.

IV.1 OXIDATION REACTIONS

These reactions, which account for most drug biotransformations, involve the
microsomal oxidation system which is composed of two elements, a lipid fraction and
cytochrome P-450. The latter represents several families of hem-containing enzymes.

Oxidations occurring in liver microsomes lead to the formation of hydroxylated

derivatives which can be "definitive" metabolites, for example of barbiturates (para-
hydroxyphenobarbital), but are generally only an intermediary step in drug degradation
processes.

The other oxidation reactions will not be discussed here. They are essentially
oxidative deaminations, formation of sulfoxides or N-oxides, or formation of aldehydes
(oxidation of alcohols).

Some oxidation reactions can occur outside microsomes, e.g. monoamine oxidase
catabolizing catecholamines in the mitochondria of different tissues (liver, intestine,
kidney, brain).

Oxidation reactions increase the polarity and thus the water-solubility of

substances, thereby favoring their elimination through the kidney.

IV.2 REDUCTION REACTIONS

These reactions, which are less frequent than those for oxidation, concern
especially the reduction of azo and nitro groups, which are transformed into primary
amines, as in the case of chloramphenicol.

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 IV.3 HYDROLYSIS REACTIONS
Two types of hydrolysis reaction occur in the digestive tract: one by enzymes,
bacterial esterases and pancreatic lipase; and the other in the acid medium of the
stomach, e.g. penicillin G is inactivated when administered orally, which has led to the
use of semisynthetic derivatives (penicillin V, amoxycillin).
IV.4 CONJUGATION REACTIONS
These reactions, which occur mainly in the liver, are numerous and always
involve the combination of the drug with small polar molecules, producing water-soluble
inactive derivatives easily eliminated from the organism. Depending on the drug
considered, they involve glucuronic acid, certain amino acids, acetyl groups, or sulfates.

Glucuronic conjugation is the type most often encountered, occurring in the liver,
kidneys, skin and gastrointenstinal tract.

The drug can be eliminated:

1. in unchanged form (A)
2. in unchanged form (A) + an oxidized or reduced form (B)
3. in unchanged form (A) + a conjugated form (C)
4. in forms (A) + (B) + (C)

IV.5 GENERAL FACTORS INFLUENCING METABOLISM

Biotransformations do not occur in the same way in all individuals. These
peculiarities have been rarely studied, although several general influential factors have
been determined.

V. FACTORS AFFECTING BIOTRANSFORMATIONS

V.1 INDIVIDUAL FACTORS OF A GENETIC ORDER

Biotransformations do not occur in the same way in all individuals. Natural
variations in the DNA sequence of genes coding for an enzyme can cause differences in
biotransformation. Genetic polymorphism exists when the frequency of a particular gene
is greater than 1% for homozygous subjects in the general population as compared to the
most frequent gene. The frequency of polymorphism differs according to the reaction
involved.

V.1.1 Acetylation
Isoniazid, an antituberculous drug, is acetylated more or less rapidly in
individuals, who have for this reason been classified into two categories, slow and fast
acetylators. The proportion differs according to ethnic origin (50% of the Caucasian

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population consists of slow acetylators as compared to only 10% of the Japanese
population). Other drugs are also acetylated, namely iproniazid (IMAO drug)
sulfanilamides, procainamide and hydralazine.

To determine the dosage of isoniazid for each patient, a 300 mg dose is

administered and the plasma concentration of the drug is determined three hours later.
The inactivation index is then calculated in order to deduce the adequate dosage, which
can range from 3 to 10 mg/kg/day for different individuals.

V.1.2 CYP2D6-related metabolism

About 5% of the Caucasian population has a CYP2D6 deficit and thus consists of
slow metabolizers (as compared to fast metabolizers). The phenotype of an individual
can be determined by measuring his capacity, as revealed by urinary metabolites, to
metabolize a defined dose of dextromethorphan (dextromethorphan or sparteine test).
Familial studies have shown that there are ultrafast metabolizers. Several classical
antipsychotic drugs, i.e. haloperidol, chlorpromazine, zuclopenthixol and new drugs ; i.e.
risperidone are metabolized predominantly by CYP 2D6. Regarding side effects, some
studies have suggested that oversedation and possibly Parkisonian symptoms are more
likely to develop in poor metabolizers than ultrafast metabolizers during treatment with
classical drugs. In the case of risperidone, poor metabolizers have reduced formation of
9-hydroxyrisperidone which is equally active as the parent compound, resulting in
similar plasma concentration of active compounds in poor metabolizers and ultrafast
metabolizers.

V.1.3 CYP2C19-related metabolism

About 2 to 3% of the Caucasian population consists of slow hydroxylators as
compared to 15 to 25% of the Asian population. The phenotype of a subject can be
determined by measuring his capacity to metabolize a defined dose of mephenytoin
(mephenytoin test). CYP 2C19 is partly involved in the metabolism of the
antidepressants imipramine, clomipramine, amitriptyline, moclobemide, citalopram and
anxiolytics diazepam, desmethyldiazepam.

V.1.4 Pseudocholinesterase deficit

Suxamethonium is used by anesthetists to obtain good muscular resolution during
abdominal surgery. This compound induces a lengthening of curarization time,
prolonging paralyzation of the respiratory muscles, in subjects with a genetic deficit in
plasma pseudocholinesterases.

V.1.5 G6PD deficit

The deficit in glucose-6-phosphate dehydrogenase (G6PD) can cause hemolyses
when drugs such as antimalarial agents, aspirin and sulfanilamides are taken. This
enzymatic deficit is quite variable depending on the ethnic group.

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 V.2 PHYSIOLOGICAL FACTORS

V.2.1 Age
In some premature newborns, the immaturity of the hepatic enzymatic systems is
often apparent when drugs are administered (lack of glycuroconjugation, N-
demethylation, deamination, etc.). However, the rate of metabolic reactions increases
rapidly during the first weeks of life.

In some elderly persons, a predominant deficit can be observed at the level of

microsomal oxidation reactions, whereas phase II reactions are only slightly modified.

V.2.2 Pregnancy
Pregnancy reduces the activity of glycuronyltransferase, although overall hepatic
metabolic activity is increased, probably due to the influence of the progesterone
induced by certain enzymes.

V.3 PATHOLOGICAL FACTORS

V.3.1 Hormonal state

Thyroid hormones and corticosteroids, respectively, can increase and decrease
biotransformations.

V.3.2 Liver diseases

Pathologies such as heart failure, which reduce hepatic blood flow, can alter
biotransformations much more rapidly than hepatic insufficiency.

V.4 DIET AND THE ENVIRONMENT

The synthesis of certain enzymes may be reduced in a dieting subject. Some foods
can also modify the rates of biotransformations, e.g. Brussels sprouts and grilled meats
induce CYP1A2, grapefruit juice inhibits CYP3A4, and frequent alcohol consumption
induces CYP2E1. Moreover, tobacco exerts inductive effects on CYP1A2.Thus, the
plasma level of clozapine whose metabolism is partly catalysing by CYP 1A2 is lower in
smokers than in non-smokers. Some industrial pesticides (occupational exposure) are
also inducers.

The dibucaine test distinguishes three populations (homozygotes without the

defect, homozygotes with the defect and heterozygotes) and can allow the anomaly to be
detected. As the frequency of this defect is low (1/3,200 to 1/170,000, according to the

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population), it is not cost-efficient to systemize this test.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency can cause hemolytic

anemias induced by certain drugs such as antimalarial agents, aspirin and sulfanilamides.
This enzymatic deficiency is quite variable depending on the ethnic group: 0% in
Eskimos, 2 to 30% in blacks and 50% in Kurds.
V.4.1 Physiological changes
Age is the primary factor responsible for differences in drug biotransformation. In
some newborns, the immaturity of the hepatic enzymatic system is revealed when drugs
are taken (defect in glucuronic conjugation, N-demethylation, deamination, etc.). In
some elderly subjects, hepatic insufficiency can favor the accumulation of non-
metabolized products.

Other factors responsible for changes in biotransformation include a diet deficieny

which reduces the synthesis of certain enzymes and pregnancy which decreases the
activity of glucuronal transferase.
All these cases involve a reduction of enzymatic potential and hence the need for
lower dosage.

V.4.2 Consequences for drug development

As soon as the first results of the metabolism study in man are available, the
active and inactive metabolities should, if possible, be verified. An active metabolite can
sometimes be developed instead of and in the place of the parent product, provided that
its bioavailability is satisfactory. However, this is often unfeasible since the
bioavailability of the active metabolite(s) is not compatible with oral administration.
Moreover, it must be determined that the metabolites are not "toxic," particularly if they
prove different from those found in the animal species studied preclinically.

VI. ELIMINATION

This process is often facilitated by the transformations which make the drug more
water-soluble for renal elimination. A good number of drugs are subject to biliary
excretion with or without the enterohepatic cycle and elimination in feces. In case of
renal failure, the dosage can be adapted on the basis of nomograms which take creatinine
clearance into account.

VII. PHARMACOKINETIC PARAMETERS

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 A knowledge of all these steps enables the residence time of a drug in the
organism to be determined with respect to the notion of elimination half-life, i.e. the time
required for half of the drug to be eliminated after diffusion begins.
Clearance is another convenient notion, representing the removal of the drug from
plasma, i.e. the disappearance of the initial plasma compound with time, whether by
elimination or biotransformation.
Total body clearance is the sum of urinary, metabolic, hepatic and other
clearances, i.e.
Clt = Clu + Clm + Clh

In fact, clearance is usually referred to as renal or non-renal:

Clt = Clr + Clm

Renal clearance, which represents a plasma volume of a product totally removed
by the kidney in a given time period, is theoretically represented by the equation:

Clt = Kel Vd

where Clt is the total clearance of the substance, Ke the elimination constant, and Vd the
distribution volume.

The relation between half-life t1/2 and Kel,

t1/2 = 0.693
Kel

allows clearance to be related to half-life:

Clt = 0.693 x Vd
t1/2

VII.1 ESTABLISHMENT OF DOSAGE SCHEDULES

A knowledge of these different parameters allows the dosage and the interval for
administered doses to be determined. It is customary to administer the drug at each half-
life point if it is less than 24 h and if a state of therapeutic equilibrium is desirable. It is
commonly considered that this state is reached after 5 half-lives, provided that the half-
life is not dose-dependent, i.e. that it does not vary with the quantity of drugs
administered. The following examples illustrate these observations:

1. Theophylline, which has a mean half-life of 6 ± 2 h for adults, should be

prescribed three times per day (every 8 h), which implies considerable scheduling

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limitations. The state of therapeutic equilibrium will thus be reached after 8 x 5 = 40 h.
At that time, the amount of drug administered will compensate exactly for the amount
eliminated, i.e. the organism is saturated with theophylline.

2. Digoxin has a half-life of around 36 h, implying a waiting period of 36 x 5 =

180 h (about a week) before equilibrium is reached.

If the active metabolite has a longer half-life than the parent compound, the time
required to reach therapeutic equilibrium should be calculated as a function of the half-
life of the metabolite. This is the case for diazepam which has a half-life of 30 h,
whereas demethyldiazepam, its active metabolite, has a half-life of 70 h.

A knowledge of the pharmacokinetic parameters thus allows a mean therapeutic

schedule to be worked out for each patient. When the drugs used have a close therapeutic
index (difference between effective and toxic doses), it is advisable to perform plasma
assays. In fact, each drug has a particular pharmacokinetic profile which differs
depending on the patient. However, not all drugs can be assayed in current practice.

VIII. VARIATIONS DUE TO PATIENTS

Many factors can cause variations.

Those which can influence absorption are a slowing or speeding up of intestinal

transit, modification of gastric or intestinal pH, the nature of the foods and chemical
products ingested at the same time as the drugs, the speed of gastric emptying,
gastrectomy, resection of a part of the small intestine, or modification of mesenteric
blood flow.

Those which can affect distribution are height, weight, sex, obesity, or muscular
mass (which can modify distribution volume).

Those which can influence metabolism are genetic defects, enzymatic deficiency,
hypermetabolism, or hepatic insufficiency (regardless of the cause).

Finally, certain factors, such as acute or chronic renal failure leading to a

reduction in plasma clearance, can affect elimination. In this case, the dosage is adapted
in terms of creatinine clearance (if it is greatly decreased). However, when drugs are
eliminated mainly by the biliary system and thus in stools, the correlation with creatinine
clearance is not essential.

22
IX. DRUG INTERACTIONS
The association of two or more drugs raises problems since there may be
competition during absorption and at the action site as well as modifications of
metabolism. Inhibition or induction of metabolic enzymes may occur. While some drugs
are quite potent inhibitors of enzymes such as cytochrome P-450s, other drugs can
increase the activity or even the quantity of metabolizing enzymes, thereby inducing
drug transformations and thus reducing the activity of the parent drug. Two drugs,
rifampicin and phenobarbital, are unquestionably enzymatic inducers. These two
products are capable of increasing the metabolism of estroprogesterone oral
contraceptives and thus inactivating them, thereby leading to undesired pregnancies.

During long-term treatment, the plasma concentrations of phenobarbital or

phenytoin decrease at a constant dosage, which is a self-induction phenomenon and not a
problem of drug interaction.
Drug interactions may result in antagonism or potentiation. Potentiation can occur
in the case of aspirin, indomethacin and phenylbutazone which displace K antivitamins
and tolbutamide from their bonds with plasma albumin. Probenecid delays the
elimination of penicillin G or cephalosporins, but also of anabolic steroids.

X. IN PRACTICE

Drug administration is performed according to the mean pharmacokinetic

parameters, possibly corrected as a function of the pathologic state, e.g. renal failure.

Thus, the physician should know the elimination half-life of the products he
prescribes or their plasma clearance and, if possible, have an idea of their distribution
volume in order to adapt the dosage to the patient.

When certain long-term therapies are to be initiated, it would seem reasonable to

perform plasma assays in steady state. This practice is particularly warranted for drugs
with a low therapeutic index (phenobarbital, phenytoin, digoxin) and/or for valproate or
theophylline for which individual variations are very great.

In certain cases, plasma assays should be performed initially. This is notably the
case for isoniazid, for which plasma concentrations are determined after three hours as
well as the inactivation index to define the dosage (Cf. supra).

Non-continuous therapies, e.g. digoxin every other day, are suspect since it is

23
difficult to know when the drug should be assayed, especially as it may be ineffective for
many hours.

XI. CONCLUSION

The problem of the administration schedule, and especially of the interval

between doses, remains primordial. It is also necessary to emphasize the time required
to reach the plateau, which is only therapeutic insofar as the dosage initially chosen
allows the supposedly efficient plasma concentrations to be obtained after five half-lives.

Thus, an understanding of pharmacokinetics should permit more rational

prescribing of drugs, provided that the simple principles outlined here are respected.
Such an understanding is absolutely essential if a coherent development plan is to be
worked out for each drug.

24
 THE FIRST ADMINISTRATION IN MAN:
PHASE I CLINICAL TRIALS

Phase I clinical trials are performed in healthy volunteers for all studies except
those involving anticancer drugs which could induce cell lesions. It may be recalled that
the essential purpose of a phase I trial is to administer a drug for the first time to humans
to determine its tolerability and pharmacokinetics.

I. WHY ARE HEALTHY VOLUNTEERS USED INSTEAD OF

PATIENTS?

Healthy volunteers present fewer physiological variations than patients and are
thus generally more homogeneous. Moreover, they are more suitable for the active
participation required by these studies which often include numerous tests,
questionnaires or the taking of many samples. The ethical issue concerning the use of
volunteers has often been raised, but at the present time they are needed for the study of
certain parameters in healthy humans indicative of how a drug may perform in a patient.
In any event, a healthy volunteer undergoing a treatment of any sort cannot be enrolled.
Acceptable candidates should be fully informed about the study and its possible
consequences and give their express consent to participate.

II. WHAT STUDIES ARE PERFORMED IN THE HEALTHY

VOLUNTEER?

The initial studies performed concern the tolerance of the drug, which is
administered first in single and then repeated doses. The pharmacokinetics are
investigated to define, if possible, the mechanisms of action, even though such studies
may already have been amply performed in the animal. Clinical pharmacokinetic studies
are conducted to determine the fate of the drug in the organism. Actually, the parameters
obtained in the animal in this domain are often quite difficult to extrapolate to man.

The studies in healthy volunteers can only be performed in locations approved by

25
drug agencies or health ministries. Although the number of subjets participating in these
studies is relatively limited, the cost is considerable for the pharmaceutical firms
developing the new drug, and the investigations often extend over a long period.

The three aspects involved in these studies are interrelated. First, there is a
tolerability or tolerance study. Secondly, a pharmacodynamic study is performed, to the
extent that this is possible. For drugs such as antidepressants, it is quite apparent that
pharmacodynamic studies can only concern possible side effects. Finally,
pharmacokinetic studies are conducted. The chronology of these studies is the following:
determination of the tolerance of a single and then repeated doses, study of the
pharmacodynamics, study of the pharmacokinetics, and finally a biological evaluation.
The entire phase I trial, generally involving 6 studies, is conducted in about a year's time.

26
III. THE PHASE I TRIAL

III.1 DEFINITION
As noted above, the purpose of this trial is to evaluate the possible short-term
toxicity of the drug, define its administration route and determine the dose intervals, in
preparation for the phase II trial.
The subjects are healthy volunteers, whose inclusion criteria will be defined
below. These subjects are generally under 40 years of age.
The inclusion and exclusion criteria concern essentially age, sex, ethnic aspects
and sometimes pharmacogenetic characteristics. Some drugs, for example, may be well-
tolerated in Caucasians but give relatively severe side effects in other races.

III.2 JUDGMENT CRITERIA

These criteria are based on continuous clinical observation involving studies of
biological constants and simple, precise and reliable pharmacodynamic parameters. The
latter will of course vary greatly from one therapeutic group to another and be evaluated
in terms of what was previously determined in animal studies.

III.3. CHOICE OF THE INITIAL DOSE

The initial dose used is a fraction of the maximal tolerated dose in the animal
species found to be most sensitive in previous studies. The notion of using a "fraction" of
the median lethal dose has been abandoned. The initial dose used is often a third of the
maximal tolerated dose in the most sensitive animal species.

III.4 CONDUCT OF THE TRIAL

Each new experiment is based on the results of the preceding one, and the drug is
administered individual by individual. The first dose is given to a half-dozen subjects at
a time interval allowing evaluation of any late side effects. The dose is increased very
gradually until any signs of intolerance are noted. Subsequent increases are even more
gradual as the apparently toxic dose in the animal species is approached.

At this stage, it is possible to study the different administration routes and to begin
to give repeated doses in the same subject, which allows the development of the drug in
a form absorbed more easily or eliminated more slowly if the pharmacokinetics and
bioavailability are poor. Each step is followed by an analysis of the data, which
determines the continuation of the trial. The confirmation of each parameter requires
studies in a half-dozen subjects.

27
 In the case of zolpidem, 35 studies have been conducted in different countries in
healthy volunteers, and trials have been carried out in 4 ethnic groups: Europeans, North
Africans (Moroccans), Vietnamese and black Africans. The half-life of the drug proved
significantly longer in Vietnamese, which led to a greater clinical efficacy in this ethnic
group. At this stage, the debrisoquin test has been used to measure hydroxydation,
particularly differences in the hydroxydation of the drug according to individuals. The
dose inducing sleep has been studied in slow metabolizers, but this is exceptional insofar
as it is impossible to study the efficacy of an antidepressant or even an anxiolytic in the
same manner in the healthy volunteer. One requirement of the European Drug Agency
concerning psychotropic drugs is to study their interaction with alcohol. Drug
interactions are often investigated in phase I trials. However, as the cost of these studies
may be high if the drug proves active in phase II and III trials, it is always possible to
return to a phase I trial to investigate the most pertinent interactions, whether
pharmacokinetic or pharmacodynamic.

III.5 SPECIFICITY OF PHASE I TRIAL IN PSYCHIATRY

It is possible at this stage of development of a psychotropic drug to assess the
activity of such drug on cognitive performance. Mainly it is possible to perform
psychomotor tests as well as studies on car driving.
The following psychomotor tests are used:
Pictures test. This test is used to assess long-term memory. A set of 15 pictures is
presented to each subject who is allowed 10 seconds to name and memorize them. Thirty
minutes later, a free recall of the names of the pictures is performed, and the restitution
score is reported at intervals of 30 seconds over a total time of 2 minutes. A new set of
pictures is presented at each session.

Digit Symbol Substitution Test (DSST). This test is adapted from the Wechsler Adult
Intelligence Scale. On the top of the sheet is a list of symbols to be substituted for each
digit. The subjects are required to complete as many digit-symbol substitution as
possible in 90 seconds by writing down the appropriate symbol. The number of correct
substitutions is scored. Six parallel forms are used.

Choice Reaction Time (CRT). This test is used to assess sensorimotor performance and
was performed with an electronic automatized apparatus, the Leeds Psychomotor Tester
(LPT). Subjects were required to extinguish one of six red lights presented in a
semicircle and randomly illuminated by touching the appropriate response plot. From a
session od 50 stimuli, the mean score (in milliseconds) of three parameters was
automatically ested by LPT: the latency of the perception to the visual stimuli
(recognition reaction time, RRT); the time taken to extinguish the light (motor reaction
time, MRT); and the sum of the both measurements (total reaction time, TRT).

28
Critical Flicker Fusion (CFF). This test assesses central integrative capacity. The LPT,
which was positioned 1 meter away from the subject, showed four red diodes flickering
at an increasingly rapid frequency. When a certain frequency is reached, the signals
appear as a continuous light, i.e., they are fused. The frequency (measured in hertz) at
which the lights seem continuous was recorded for each subject. Individual thresholds
were determined by the psychologic method of limits on three ascending and three
descending values.

- Side effects questionnaire: This self-evaluation checklist of 26 items (e.g. nausea,

blurred vision, modification of appetite, dizziness) was given to subjects to record
frequency and severity of side effects to the treatment.

- Subjective rating scales: At the end of the session, subjects self-rated their feelings by a
mark across a series of three ungraded Visual Analogues Scales (VAS) of 100 mm lines
with opposite statements at each end (e.g. calmness/agitation, tiredness/dynamism, better
or worse capacity of concentration). Scores were measured in millimeters from the
middle of the lines to the mark.
These tests are administered in the same order throughout the experimental period. Each
test session lasted 30 minutes.

Statistical analysis. For the continuous variables, the normal probability distribution is
searched with the Shapiro-Wilk test (with a significant level p = 0.01) and the variance's
homogeneity was tested with the F-test (significant level p = 0.05). When the conditions
are required, analysis of variance (ANOVA) (unilateral) of one factor (treatment) or
ANOVA (bilateral) of two factors (time, treatment and interaction time treatment) could
be performed. If none of these conditions was applicable, one factor ANOVA
(unilateral) is replaced by the Mann-Whitney test. For the use of two factors ANOVA
(bilateral), the normality of the data is not a necessary condition, and the normality of the
remainder was verified. To study the standard deviation, a standard method is applied. If
the standard error presented too great a variation, a Friedman ANOVA (bilateral), i.e., a
nonparametric technique) is used. For the catagorcial values, the treated groupes was
analyzed by the Pearson c 2 test.

29
 PHASE II TRIALS

The purpose of the phase II trial is to detect pharmacodynamic activity in the

patient and determine the range of active doses. Phase III trials subsequently indicate
whether the pharmacodynamic activity is also therapeutic. Phase II is particularly
delicate since a range of truly active doses must be used to confirm whether the drug is
clinically efficient or not. On the basis of the findings of the phase I trial, tolerated doses
are studied in the healthy volunteer, generally over the broadest range possible, which
may require the participation of a considerable number of patients. Phase II trials are
generally conducted in parallel groups (for example, in psychiatry) in which three doses
of the drug (D1, D2 and D3) are studied versus a placebo and a control product. In any
event, it is absolutely necessary to use a placebo in phase II and to provide irrefutable
proof that the drug is more effective than the placebo. In the past, phase II trials were
often open, non-controlled studies involving few patients. This practice proved
unsuitable since the new drug seemed effective in the absence of comparison with a
placebo or control product. Except for special cases, the customary practice now is to
perform controlled, randomized studies in parallel groups in phase II and later trials. A
crossover approach can also be used in certain studies, although the conditions for
application are strictly limited.

I. PHASE II METHODOLOGY

The methodology of phase II trials differs only slightly from that of phase III. It
requires the use of selected patients, who are generally hospitalized, except for some
pathologies such as sleep disorders, anxiety and depression. The groups studied must be
homogeneous as to age, sex and the clinical form of the disease.

II. OBJECTIVES OF THE DOSE-EFFECT STUDY

The main purpose of studying the relation between drug dose and effect in man is
to define the limits of effective doses in relatively small groups of patients. A lower limit
or threshold of clinical effectiveness is determined, which is the minimal dose producing

30
a significant effect. An upper limit or toxicity threshold is the maximal dose that can be
administered without producing significant toxicity. The dose-effect study thus includes
an analysis of changes in effects as a function of the dose administered and possibly of
the drug concentrations in an easily sampled biological medium (most often plasma but
also urine or saliva).

The study of the dose-effect relation also suggests which administration route will
provide the expected effect, detects the possible presence of active metabolites of the
drug, reveals any phenomena of tolerance or sensitization of receptor sites and allows the
study of possible interactions among various drugs.

III. FACTORS OF VARIATION IN THE DOSE-EFFECT RELATION

Although the main purpose of the study of drug-effect relations seems simple in a
given patient, the situation is much more complex when the relations are defined in a
population of patients. The purpose of clinical trials of new drugs conducted with
relatively small groups of patients is to determine a general law applicable to the vast
majority of patients who will ultimately receive the drug. In fact, there is considerable
difficulty in applying this general law to individual treatment since the dose-effect
relation is subject to the influence of many factors:
1. The characteristics of patients: age, sex, weight, body surface area.
2. The pathologic state: etiology and course of the disease, associated pathology.
3. Interindividual variations in drug pharmacokinetics.
4. The presence of one or more active metabolites whose kinetics can differ from
that of the parent product; variation of effects depending on environmental factors,
schedules, food, living conditions, stress or endogenous factors (affinity or number of
cell receptors).
5. The possible presence of pharmacokinetic and/or pharmacodynamic drug
interactions.

All of these factors affect the individual relation between the dose administered
and the effect observed, which makes the dose-effect relation during phase II and III
clinical trials quite "fragile" and finally purely indicative. Any subsequent medical
treatment will require an individual adaptation of the dosage.

IV. DETERMINATION OF THE CLINICAL EFFECT

Determination of the clinical effect of a drug requires, first of all, that the

31
variation of a drug-related parameter be distinguished from variations related to a
spontaneous change in the state of the patient or to an error in measuring the parameter.
On the one hand, this implies that the spontaneous variability of the parameter is known,
either by measurement of the parameter both before and after drug administration or in
the same experimental conditions when patients receive a placebo. On the other hand,
determination of the clinical effect implies that the sensitivity and reliability of the
method used to ascertain the effect are known, which ensures that the error in
measurement is slight relative to variations of the drug-related parameter.
Subsequently, the method of measuring the clinical effect depends on the type of
effect observed. Schematically, two situations are possible:

IV.1 EFFECT ANALYZED ACCORDING TO A BINARY MODE

In this situation, the effect is either present or absent. This is true, for example, of
the therapeutic effects of antiepileptic drugs (presence or absence of seizure). The effect
can also correspond to a significance threshold dependent on spontaneous variability and
the pathologic situation. This is the case for ventricular extrasystoles in which the
antiarrhythmic effect corresponds to at least an 80% decrease in the number of
extrasystoles on the 24-h ambulatory ECG. When the effect is evaluated according to a
binary mode (all or nothing), the probability of the presence or absence of the effect is
studied for each dose. The dose-effect curve shows the proportion of subjects responding
to treatment for each of the doses studied. When a therapeutic effect is studied, it is
maximal when all of the patients are treated efficaciously. The dose-effect relation is
most often of sigmoid form.

IV.2 EFFECT ANALYZED ACCORDING TO A CONTINUOUS MODE

When the effect shows continous variation from 0 (absence of effect) to a
maximum during an increase of doses, the concentration-effect relation is defined by a
parametric model. In practice, it is rarely possible in man to measure a maximal effect,
and the effect is not always proportional to the blood concentration of the drug. The
dose-effect relation then most often assumes a sigmoid form whose middle part
corresponds to a linear relation between effect and dose. More complex models have
been proposed for the analysis of concentration-effect relations, either by using
logarithmic transformation of the concentration (corresponding to a linear approximation
of the hyperbolic model in the zone of effects representing 20 to 80% of the maximal
effect) or by integrating the pharmacokinetic and pharmacodynamic model by
calculating the concentrations of the drug at the "theoretical site of the effect."

32
V. METHOD OF STUDYING THE DOSE-EFFECT RELATION

Studies of the relation between the dose administered and the effect measured, as
well as the search for a range of effective and well-tolerated doses, are performed during
phase II clinical trials. These initial trials in patients come after phase I studies in healthy
volunteers during which the maximal limit of drug doses administrable to humans and
the pharmacokinetics of the drug have been determined.

VI.1 ADMINISTRATION OF SINGLE DOSES

During administration of a single dose to a group of patients, changes in the effect
and plasma concentrations of the drug are studied over a period of time. If the effect is
measured in binary mode, the proportion of patients who attain the efficacy threshold is
determined as well as the time required to reach this threshold and maintain it. The
plasma concentration corresponding to the efficacy threshold is also determined. In
continuous mode, the appearance of the effect is noted as well as the maximum reached
and the fall. The dose-effect relation can be studied by considering the maximal effect
observed for each drug dose. The study of the plasma concentration-effect relation can
be based on an analysis of the plasma concentration corresponding to the maximal effect
or on correlations between the area under the curve for plasma concentration time and
effect time.

Simultaneous measurement of the drug effect and plasma concentrations often

reveals a hysteresis phenomenon when (as is quite frequently the case after intravenous
administration) the effect persists during the fall in plasma concentrations. This
phenomenon can be related to the persistence of the drug at the activity site, the late
elimination of an active metabolite, or more rarely the sensitization of receptor sites
during the study.

V.2 ADMINISTRATION OF REPEATED DOSES

During repeated administrations of the drug, changes in effect are observed as
plasma concentrations gradually increase until a plateau is reached. The effect is then
measured in steady state after a period of administration equal to at least 5 times the
elimination half-life of the drug (cf. the chapter "Notions of Pharmacokinetics"). If the
effect is measured in binary mode, the number of doses and plasma concentrations
required to reach the efficacy threshold are noted. The proportion of "responders"
attaining clinical efficacy is determined for the steady state of plasma concentrations
corresponding to each dose. If the effect is measured in continuous mode, changes are
studied in terms of the time-points during administration of repeated doses when plasma
concentrations increase and then during the steady state of these concentrations.

33
 V.3 EXPERIMENTAL PROTOCOLS
Two types of experimental protocols are possible, depending on whether the drug
is administered in a single dose or repeated doses.

V.3.1 Protocol in parallel groups

The basal state of patients is determined during an initial study most often
performed single-blind with a placebo. The patients are randomly divided into parallel
groups and then, depending on the administration procedure, receive a single dose per
group or repeated doses for a period sufficient to reach the steady state of plasma
concentrations. Several groups of patients are thus composed (one per dose), while a
control group receives a placebo in the same experimental conditions if the pathology is
not too severe. When possible, a 5-arm controlled study is performed: three doses of the
compound are compared with a control drug and a placebo.

V.3.2 Crossover protocol

In this type of protocol, the patient is his own control. Basal state is determined
for each patient, and the different doses of the drug are administered successively and
studied for their effect. This protocol can be used for administration of the drug in a
single dose, in which case each dose is followed by a sufficient wash-out period, so that
all effects are dissipated before administration of the following dose. It can also be used
for administration of repeated doses, in which case each dose level is of sufficient
duration to allow the steady state of plasma concentrations to be reached. In these
crossover protocols, the order of the doses administered to each subject can be
determined (e.g. in increasing order) or randomized. Placebo periods can be included,
either during the protocol when administration is randomized or most often at the end of
the trial when doses are administered in increasing order. These placebo periods allow
the stability of the pathologic state of patients to be verified and demonstrate the possible
existence of a placebo effect related to administration of a therapeutic drug. In fact, this
type of protocol is very difficult to carry out, except with healthy volunteers in phase I
trials when some pharmacodynamic parameters are measured.

V.3.3 Practical problems

Regardless of the type of protocol chosen for determination of the range of
effective tolerated doses during phase II clinical trials, certain practical problems are
constantly encountered:

V.3.3.1 Criteria of patient selection

As the search for effective doses is carried out in small groups of patients, it is
advisable that their homogeneity be as great as possible concerning age, pathology,
course of the disease, etc. Intercurrent factors that could hinder interpretation of the

34
measured clinical effect should be eliminated.

V.3.3.2 Criteria of therapeutic efficacy

The criteria for judging the effect in phase II trials may not be strictly therapeutic.
However, if the measured effect is therapeutic in nature, the type of effect observed
(binary or continuous variation mode) influences analysis of trial results. It is thus
advisable to define the criteria of therapeutic efficacy initially and carefully. The same is
true for the criteria of clinical and biological tolerance of the drug.

V.3.3.3 Choice of doses

The drug doses to be studied in patients range from the minimal dose, most often
corresponding to that which has produced a measurable pharmacologic effect in healthy
volunteers during phase I trials, to a maximal dose generally lower than that tolerated in
phase I trials. The number of doses to be tested is variable, most often from 3 to 6, and
should remain within the limits of feasibility of the protocol.

V.3.3.4 Number of subjects

The number of patients receiving a drug dose (single or repeated) depends mainly
on the variability of the parameter considered for measuring the expected effect (and its
amplitude).

V.3.3.5 Definition of the minimum treatment period

During administration of repeated doses of the drug, the effect should be
measured after a steady state is reached for plasma concentrations. The treatment period
for each dose level should thus be equal to 5 times the elimination half-life of the drug.
This is not true when drug kinetics are not linear, the elimination half-life changes
during treatment, or active metabolites are eliminated over a long period of time. In these
cases, longer treatment periods are required, and measurement of plasma concentrations
of the drug and/or its metabolites is may be required.

VI. DIFFICULT PHASE II TRIALS

The classical phase II methodology described above is ideally applicable to
situations in which an effect can be easily demonstrated in man (whether a direct
therapeutic effect such as a drop in blood pressure or improved sleep, or a
pharmacological effect predictive of a therapeutic effect, e.g. bronchodilatation in the
asthmatic patient).

The determination of the optimal dose is much more difficult when the desired
effect is obtained late (e.g. an antidepressant effect), or when there is no readily apparent
therapeutic effect or predictive pharmacologic effect (e.g. in the treatment of arthrosis or

35
osteoporosis).
The difficulties are major when the treatment is intended to be preventive in the
long run. Thus, it would be difficult to define an optimal dose for an "anti-atheromatous"
drug that would not be hypolipidemic.

36
 PHASE III

I. INTRODUCTION

The main objective of phase III trials is to verify the therapeutic action of a new
substance in a large number of patients, essentially to determine the risk/benefit ratio.
Before phase III, the substance is not regarded as a drug, but after a positive phase III
trial it becomes a drug. In fact, the drug may then be approved for registration and
accepted by the authorities concerned. It can subsequently be offered to prescribing
physicians on the basis of valid arguments.

Phase III is thus the logical continuation of the previous phases of the drug trial in
man. Its purpose is to confirm the therapeutic effects of the drug. In this respect, the
notion of minimal benefit must be considered.

The objectives of phase III are the confirmation and extension of the results
relative to efficacy and safe use, evaluation of efficacy and safety in the medium- and
long-term, consideration of the most frequent adverse effects, and observation of other
specific characteristics of the drug (e.g. drug interactions of clinical importance and
factors such as age and sex that could modify the results).

Phase III trials thus require a greater number of patients and often a longer
treatment period.

II. METHODOLOGICAL BASES OF PHASE III TRIALS

These methodological bases are the classical ones for a clinical trial, insofar as it
is generally controlled, with random double-blind assignments between the treatment
and control groups, and includes a sufficient number of correctly analyzed patients.

Although the modalities differ depending on the substance studied, the protocol
must generally satisfy certain demands:

37
 II.1 CHOICE OF THE EXPERIMENTAL SCHEME
The choice of scheme depends on several factors such as the objectives of the
study, the number of participants and the number of stages in the study. The scheme
allows the comparison of two or more groups of patients, including a treatment group
and a group receiving a placebo or treatment with a reference drug. In fact, correct
evaluation of the drug effect requires comparison.

Among the various types of experimental schemes, the most common ones
involve a study in parallel groups. In this method, the patients are randomly divided into
two groups which by definition receive the planned treatment throughout the trial period.
The treatment of each group is different, except in the case of crossover trials when each
patient receives both compared treatments.

II.2 RANDOMIZATION
Randomization, the method of assigning a patient to a given treatment by chance,
is intended to reduce bias in the choice of treatments. If a difference is to be found
between treated and untreated groups, it is essential that both be strictly comparable,
except for the treatment received.

Randomization is necessary, and there are several methods for performing it.
However, two limitations may be noted in therapeutic trials: differences between groups
are not necessarily eliminated, and the choice of a suitable method can be complicated.

II.3 BLIND STUDIES

The efficacy of treatments can be assessed differently depending on whether or
not the patient knows that he belongs to the treatment or control group. To eliminate this
major difficulty and maintain comparable groups throughout the study, it is necessary to
implement a blind procedure: either simple blind (generally the patient does not know)
or double-blind (the patient and the physician do not know).

II.4 STATISTICS
The contribution of the statistician is essential. In fact, the groups represent only a
sampling of the general population which can vary. Only statistical tests (with risks of
first and second order) can ensure that the differences observed are meaningful. It is
desirable that the power of comparison be high, so that the probability of detecting a
difference between the treatments is maximal.

III. KEY ELEMENTS OF THE PHASE III TRIAL

38
 Several key points may be noted for these phase III protocols:

III.1 INCLUSION CRITERIA

The inclusion criteria define the requirements for entering a patient into the trial.
If the definition of these criteria is too vague, the patients included may compose a
heterogeneous group, therefore making interpretation of the results difficult and thus
compromising the objectives of the study. Conversely, if the inclusion criteria are too
restrictive, it is sometimes impossible to find a sufficient number of patients for the
study, and thus the results will be difficult to extrapolate to a larger population.

Depending on the substances studied, several trials are generally conducted during
phase III. During each of these different trials, a specific population can be studied (e.g.
elderly persons, patients with renal failure, etc.).

III.2 EXCLUSION (OR NON-INCLUSION) CRITERIA

Exclusion as well as inclusion criteria must be indicated in order to eliminate
patients for whom the trial represents an excessive clinical risk, or those whose follow-
up is uncertain, or those who would make the group too heterogeneous.

III.3 JUDGMENT CRITERIA

The choice of a judgment criterion or criteria is fundamental to attain the objective
of the study. Such criteria should be chosen in a judicious manner depending on the
pathology studied. In fact, judgment criteria are often intermediary choices.

III.4 ADVERSE (CLINICAL AND BIOLOGICAL) EFFECTS

Adverse effects should be determined by means of a questionnaire composed of
closed questions organized systematically with respect to possible symptoms indicated
on a pre-established list, or of open questions soliciting spontaneous complaints, or of
standardized questions.

III.5 NUMBER OF SUBJECTS REQUIRED

The number of subjects required is decided before the trial begins and determines
its length. In some cases, a multicenter study is necessary because of the large number of
subjects required. However, this quite essential calculation is restrictive and complicates
the trial. Studies are being conducted to try to reduce the number of subjects needed,
which would be of interest to patients (the drug would be available sooner), registration

39
authorities and manufacturers.

IV. OTHER INFORMATION PROVIDED BY PHASE III TRIALS

Although the benefit-risk estimation is the major objective of phase III trials, other
secondary objectives allow useful knowledge to be obtained for the prescribing
physician. These include the conditions for monitoring treatment, patient characteristics
requiring an adjustment of dosage, length of treatment, modalities for discontinuing
treatment, the profile of the responding patient (i.e. the target of the treatment),
interferences with other drugs, and optimal conditions for the dose. It is also necessary to
define the criteria of efficacy. The main criterion corresponds best to what the patient
expects in terms of the prognosis for survival, good health or quality of life.

V. GENERAL CONDITIONS FOR PHASE III TRIALS

V.1 CHOICE OF KEY ELEMENTS FOR THE PHASE III TRIAL

It is essential to recognize that a very large number of evaluation criteria can
apply to the same patient and the same pathologic situation. Thus, in evaluating the
efficacy of an antithrombotic treatment, the main criterion could be one of the following:
a change in the biological data for blood coagulation; a change in imaging data, e.g. for
Doppler ultrasound; a change in phlebography data; a change in clinical data, e.g.
clinical diagnosis of phlebitis; a search for complications, e.g. clinical diagnosis of
pulmonary embolism or of the beginning of post-phlebitic trophic disorders; systematic
imaging for pulmonary embolism, e.g. lung scintigraphy or angiography; occurrence of
death by pulmonary embolism; etc.

These criteria relate to the same disease but are obviously quite different in their
significance. Moreover, some can be easily demonstrated in all patients without great
expense, whereas others are invasive, raise ethical problems, involve considerable
expense or are only observed in a few patients.As a result, large series of patients are
required.

The choice of the "level" of proof provided by the main evaluation criterion is
crucial.

It is evident that the different key elements are directly related, since the inclusion
criteria should help determine the main evaluation criterion. The number of subjects
required is related to the frequency of occurrence of the event searched for and the

40
difference expected between the groups.

The drafting of a phase III protocol should aim at obtaining total coherence among
the different key elements. This coherence depends on the question which the trial is
intended to answer.

V.2 PHASE III: AN "EXPERIMENTAL SITUATION"

The main objective of managers concerned with drug development in the
pharmaceutical industry is to convince the registration authorities in the different
countries of the efficacy and safety of their new product. Phase III trials, which are
important since they occupy a large part (often 3 to 5 years) of the clinical development
period, should be designed to demonstrate the qualities of the new drug as clearly as
possible. The experimental plan and the monitoring of patients should be conducive to
this purpose. The techniques of the clinical trial (which will be described later on)
constitute an "experimental situation."

It is often useful to chose a very homogeneous group of patients and to establish

monitoring conditions which "oblige" the patient to follow his treatment faithfully and
perform the essential examinations. No patients should be included who are likely not to
respond favorably to the treatment: those who are too young or too old, sometimes those
who are too severely or too slighly affected, and often those with several diseases or
using several drugs, etc.

In fact, the results of these trials are only valid for the population chosen and the
monitoring conditions defined.

V.3 OTHER QUESTIONS TO BE RAISED

When the results are favorable for the drug studied, a series of questions still
remains unanswered: Will the results observed in experimental conditions prove valid in
routine therapeutic conditions? Will the results observed in highly selected patients be
similar in ordinary ones (for example, patients with an associated disease or taking a
combination of drugs)? Can the results observed during a very special type of
monitoring be corroborated in routine therapeutic conditions?

Recent experiments have shown that undesirable effects observed during

treatments in uninformed, non-volunteer patients, who were sometimes taking several
drugs or had defects, could be much more intense than during therapeutic trials. For
example, this was the case with hypoglycemic episodes in elderly subjects and

41
gastrointestinal disturbances in subjects receiving non-steroidal anti-inflammatory drugs
when the customary precautions applied in therapeutic trials were not used in routine
therapeutic conditions.

The safety data for certain groups at risk (elderly or very elderly subjects, persons
with hepatic, renal and sometimes respiratory failure, etc.) should be evaluated in
separate studies if such patients have not been included in the main trials.

V.4 APPROVAL FOR DRUG REGISTRATION

After the phase III trial, the efficacy and the safety data of the new drug should be
defined. A file, including pharmaceutical data and the results of preclinical studies and
the three phases of clinical trials, should be prepared and submitted to the registration
authorities of the different countries. This file should establish the major criteria:
pharmaceutical quality, efficacy and safety. It should also provide answers to all possible
questions concerning the choice of patients to be treated and the modalities of
prescription. In practice, the file should provide all the data for the "summary of product
characteristics" which appears in the official information sent to all health professionals.

42
 PHASE IV

I. DEFINITION

Phases I, II and III are essential steps in the development of a drug for approved
registration. For certain drugs, phase IV begins as soon as this approval is obtained,
whereas for others it comes after marketing has started and throughout the commercial
life of the drug.

By definition, phase IV includes all the trials undertaken to study a drug in the
strict context of the indications and dosage approved at the time of registration. These
phase IV trials are intended to provide better knowledge of the usefulness of the drug for
the patient and society. An indication of the advantages of a drug, a more complete
collection of epidemiologic data, and a strategy of evaluation adapted to the particular
circumstances of each pathology should lead to greater efficacy and utility, better quality
of life and improvement of the cost-benefit ratio.

New data needed to improve the medical services offered and assess therapeutic
needs require continual observation and evaluation of the drug and its environment from
initial marketing to the end of its commercial life. It is obviously in ambulatory practice
that a drug can best be observed in its ordinary environment, improved with respect to its
indications and precautions for use, and judged (observed and analyzed) in terms of its
role in everyday circumstances.

The results of a phase IV clinical trial can give rise to new phase II and III studies
in order to enlarge the indications, modify the dosage and elaborate new galenic forms.
Any study undertaken to change the conditions in which drug registration was obtained
should in fact be considered as a phase III clinical trial.

II. USEFULNESS OF PHASE IV TRIALS

Phase IV clinical trials are essential for two reasons:

43
 II.1 IMPROVING SCIENTIFIC KNOWLEDGE
The knowledge of a drug is still often incomplete at the end of a phase III trial
because the number of patients studied was inadequate, the patients were too carefully
selected, the protocols were too rigorous relative to routine medical practice, the
treatment period was too short and/or intermediary evaluation criteria were used.

The information collected during phase III is by definition limited in time and
space. The therapeutic norms (particularly the indication and dosage) established for a
small homogeneous population will be extrapolated in phase IV to all patients regardless
of their social or pathologic situation. Thus, these patients will differ from those of phase
III.

II.1.1 Patient heterogeneity

In practice, disease is heterogeneous because it occurs within a non-uniform
genetic inheritance and environment. Thus, the indication and dosage need to be
adapted. It is necessary to carry out specific studies in subpopulations to which the
prescribing physician can refer in order to define the safest conditions for application
and to ensure that therapeutic trials are as plausible as possible. These subpopulations
can be defined as a function of age, sex, ethnic origin and morphology. Age can clearly
modify the pharmacokinetic and pharmacodynamic constants of a drug. The
pharmacokinetic behavior of men and women of the same age can differ greatly, and the
same is true for the pathology and the pharmacodynamic response. The therapeutic
response can also differ depending on the race. Finally, the pharmacokinetics of a
product can be modified by obesity.

II.1.2 Associated pathology

Renal or hepatic insufficiency can modify the pharmacokinetics of a drug and
favor its accumulation, thereby inducing toxic manifestations.

II.1.3 Dosage
The dosage proposed at drug registration is broad enough to be adjusted to the
needs of different patients and will thus be gradually redefined and generally lowered
(minimum effective dose). It is based on the pathology of the hospitalized patient who is
usually severely afflicted, whereas the ambulatory patient often has a different and less
threatening condition of a more chronic nature requiring an adjustment of the dosage.

II.1.4 Drug interactions

In everyday practice, a physician is often led to prescribe two or more drugs for
patients. As the combinations are infinite and cannot be studied in advance, trials are
necessary. On the whole, phase IV studies should search for the optimal conditions of

44
drug use for individual application.

II.2 ECONOMIC PURPOSES: FACILITATING PRODUCT PROMOTION

Once drug registration has been achieved, the new product begins its commercial
life in an environment that will probably change in scientific, sociocultural and
economic terms. In fact, the knowledge of pathologies improves, prescription strategies
are developed, and consumer needs change (contraception, prevention of menopause
disorders, etc.). In this environment, it is necessary to obtain the longest possible life
cycle for the drug, which implies the following goals for the pharmaceutical firm:

II.2.1 Familiarizing the greatest number of physicians with the product from
the moment it is launched on the market
The pharmaceutical firm needs to make physicians aware of the product and its
optimal conditions for use. In particular, reliable information based on rigorous scientific
study can assist physicians in making correct therapeutic decisions. A better knowledge
of the drug and of the subject to whom it is to be administered will reduce the frequency
of adverse events, many of which occur when a drug is prescribed in less than ideal
circumstances.

The pharmaceutical firm attempts to collect the maximum of quantitative and

qualitative information on the therapeutic behavior of its new product, which is
beneficial to the practitioner who of course has no experience in prescribing the drug.

The practitioner is required to develop and improve his knowledge in order to

maintain his therapeutic potential at the highest scientific level. Thus, he must determine
the true value of the new drug within his "therapeutic arsenal."

II.2.2 Confronting the competition

Generic products may be expected to appear once the patent on a drug has
expired.

III. DIFFERENT TYPES OF PHASE IV TRIALS

For a pharmaceutical firm, research in phase IV trials involves the medical and
marketing departments and pharmacovigilance. It is thus possible to define three
different types of activity in phase IV: clinical research, pharmacovigilance and seeding
trials.

45
 III.1 CLINICAL RESEARCH
A manufacturer develops a research plan based on a line of inquiry and recruits
investigators, in which case the French Huriet law is generally applied.

III.2 INDEPENDENT CLINICAL RESEARCH

In certain cases, a trial may be requested by a physician who during his
professional activity is confronted with difficulties, limitations and failures concerning
the drug or who feels that improvements are needed.

The promoters of these studies may be public authorities, state health insurance
offices, patient associations, groups of physicians, etc. In fact, few studies of this type
are undertaken since budgeting is not provided.

III.3 PHARMACOVIGILANCE
This section is developed elsewhere.

III.4 SEEDING TRIALS

One of the objectives of phase IV is to promote the commercial development of a
drug. Although the purpose of the trial may be to communicate concepts or knowledge
about the new product, certain studies known as seeding trials serve essentially to
familiarize physicians with the drug.

III.4.1 Clinical seeding trials

These studies allow the physician to become accustomed to prescribing a recently
approved drug, possibly in consideration of certain incentives. However, some clinical
seeding trials are justifiable if they are scientifically serious and correctly monitored.

III.4.2 Prescription studies or pseudo-trials for commercial purposes

The real intention of a pharmaceutical firm in conducting a phase IV trial may be
to ensure that physicians prescribe the new drug. This is often accomplished by
compensating participating physicians (i.e.investigators) for the treatment of patients.
The drug is in fact purchased on prescription by patients and reimbursed by the social
security system, generating a certain activity.

Payment to the investigator can consist of fees that are often proportional to the
number of packages of the product prescribed or take the form of benefits not directly
related to medical practice. This activity may only appear to have a scientific objective.
In this case, it is not a free therapeutic act or an instance of valid research but simply a
means of transferring money from the pharmaceutical firm to the prescribing physician

46
and then from the patient back to the firm via the pharmacy.

Unlike true phase IV studies monitored by clinical research assistants, these

seeding trials often make use of medical representatives and entertainment events to
promote the relation between the pharmaceutical firm and the physician.

Although these types of trials are currently decreasing in number, the commercial
development of a product is still quite conceivable as an objective. In fact, scientific
knowledge, development and promotion are complementary objectives which can be
achieved simultaneously.

47
IV. PHASE IV TRIALS AND THE INSTITUTIONAL CONTEXT

IV.1 PHASE IV AND THE FRENCH LAW

Initially, the French law was intended to reply to questions raised by trials
conducted before drug registration (I, II and III). Phase IV trials have no legal definition,
which may account for certain deviations and abuses.
Phase IV trials must now conform to the requirements of the French law of
December 20, 1988, which modified the practices of manufacturers, or of ethics
committees. However, compliance with these regulations is not a sufficient guarantee
that a study will be considered as a clinical trial. The form is in fact less essential than
the content when it is a question of obtaining the approval of a regional ethics
committee.

As soon as freedom of prescription is called into question by the protocol of the

trial, or the usual therapeutic relations between the physician and patient are modified
and replaced by relations between the promoter and the investigator, or a new
hypothesis or a new risk appears, the law is totally applicable. Thus, phase IV trials
intended to enlarge the indications of a product (i.e. to reply to a question concerning the
drug which was not answered during the period before approval) may be considered as
veritable biomedical research in terms of the law. A hypothesis is formulated and a
clinical trial is designed around precise objectives leading to the development of a
clinical research protocol.

Conversely, epidemiologic research in general and studies relating to

pharmacovigilance do not correspond to a new hypothesis, and no new risk is
encountered by the patient since the drug is prescribed in the indication validated by the
registration procedure. Likewise, the usual therapeutic relation between the physician
and his patient is not changed. The drug is purchased in the pharmacy, and the studies
are not included within the field of application of the law of December 20, 1988.
However, it is preferable that monitoring be performed by clinical research assistants
independently of the activity of medical representative in order to ensure that the the
study is free of any commerical concerns about the new drug. The term "clinical trial" is
usually reserved for research relative to the French law concerning phases II and III and
not involving promotional studies. When a clinical trial is planned in compliance with
the French law, the promoter must submit the protocol to an ethics committee and obtain
their approval. This procedure includes the following items: an application to the Drug
Agency; a monitoring plan in accordance with good clinical practices (i.e. follow-up
ensured by clinical research assistants and monitors independent of the activity of the
firm's medical representatives); packages of product(s) supplied free of charge; an
insurance policy covering trial contingencies; an indication of the fees for investigators;
and an informed consent form for patients.

48
 IV.2 PHASE IV AND GOOD CLINICAL PRACTICES
Good clinical practices are intended to ensure the quality of the trial, verify that
the patients exist, and confirm that the data used for the analysis are in accordance with
the source document.

IV.3 PHASE IV AND THE FRENCH LAW CONCERNING VARIOUS

SOCIAL MEASURES (VSM)
The problem of paying investigators for the work performed during a clinical trial
has always been a sensitive point. This payment actually depends on various factors such
as the importance of the work performed and the skill and sometimes the reputation of
the investigator. It is thus obvious that certain practices, abuses and deviations have been
observed, such as the purchase of prescriptions or exaggerated payments for trivial
studies or counselling activity for the pharmaceutical firms.These uncertainties
concerning benefits accorded to members of the medical profession arouse suspicion,
whereas openness and clarity are highly desirable.

During the close of the parliamentary session at the end of December 1992, the
VSM law (also known as the "gift" or "anti-corruption" law) was voted and then
published in the official French journal on January 27, 1993. These various social
measures, adopted without any consultation with the main interested parties, were
intended to achieve a new openness and clarity by supplementing controls at the national
level prohibiting gifts or benefits accorded to members of the liberal professions.

This law recalls the principle of forbidding these benefits and specifies the nature
of agreements between the pharmaceutical industry and medical practitioners:

1. Any pharmaceutical firm is concerned once it produces and markets products

reimbursed by the state social security system. The medical professions involved are
physicians, dentists, midwives, nurses, physical therapists, speech therapists and
orthoptists.
2. All benefits in the form of gifts (equipment, various objects, pleasure trips), use
of equipment free of charge, lending material or objects, and offers of money are
forbidden.

3. These prohibitions do not apply to benefits relative to agreements between

members of the medical profession and firms when the explicit objective and the true
purpose of the activities are scientific research and evaluation, when they are submitted

49
to the opinion of the regional council of the French Medical Association and when
payments are not proportional to the number of products prescribed. Biomedical
research in phase I, II and III clinical trials is excluded from the field of application of
this law.

4. The text increases penalties not only for members of the medical corps but also
for directors of firms participating in these operations.

50
 INTRODUCTION AND PRESENTATION OF
MODULE II

A therapeutic trial is generally conducted to determine a new treatment or

improve therapeutic applications. Several crucial questions should be considered before
the trial is undertaken:
- What treatments are to be compared?
- What type of population should be studied?
- What are the judgment criteria?
- What is the most suitable experimental scheme?
- How many patients should be included?
- What statistical procedures should be implemented (single analysis, intermediary
analysis, serial analysis)?

THE CHOICE OF PATIENT SELECTION CRITERIA

Which criteria will govern patient selection if this choice is to take various
requirements into account and if the key problem is to obtain homogeneous groups in
order to reduce variability in response and yet provide representative samples of the
affection studied?

The means of selecting patients will be defined by inclusion and exclusion

criteria, which should be as explicit as possible. All these criteria are defined during the
drafting of the protocol. This module provides an example of a protocol concerning the
clinical study of anxiolytic drugs to illustrate the complexity of these inclusion and
exclusion criteria.

THE CHOICE OF EVALUATION CRITERIA IN A CLINICAL

TRIAL

Strictly speaking, the judgment criteria should be clinical criteria. However, in

some types of pathology, e.g. arterial hypertension, the judgment criteria concern either

51
the evaluation of blood pressure or the occurrence of cardiovascular accidents. Blood
pressure is not a clinical criterion, but epidemiological studies have shown that an
increase in blood pressure is an important risk factor. It may thus be considered that
blood pressure is currently a pertinent intermediary criterion (sometimes referred to as a
criterion of substitution). However, one should be cautious about intermediary criteria
that have not been validated, particularly in psychiatric pathology in which it is difficult
to make reasonable correlations as to the course of a disease on the basis of purely and
strictly biological criteria.

EXPERIMENTAL SCHEMES

All therapeutic trials are governed by experimental schemes, which most often
involve the creation of parallel groups. The groups can be completely randomized, i.e.
determined by the drawing of lots. Though this process is simple to perform, it is
apparent that each subject of each group is not strictly comparable with the subjects of
other groups nor with each of the subjects of the other groups. It is thus necessary at the
outset to ensure the comparability of the groups. Other experimental approaches
(crossover schemes, factorial schemes or serial trials) have been proposed but are
difficult to carry out in the most common clinical trials (i.e. phase III trials). Admission
to a trial involves the drawing of lots, according to methods described below. Moreover,
it is necessary to ensure that possible differences can be demonstrated between
treatments and that the number of subjects is sufficient. As our presentation here is
focused especially on phase III trials, what is involved (as indicated above) is a
comparative controlled clinical trial, which implies the inclusion of a large number of
subjects determined beforehand in an effort to answer the following questions: Is the
drug more efficient than a placebo? Is the drug as efficient, more efficient or less
efficient than a reference product?

ELEMENTS FOR COMPARISON

The efficacy of a treatment is determined by comparing it with another already

validated. Moreover, it must not be forgotten that many diseases cure spontaneously.
Thus, a group of treated patients should be compared with a control group given a
validated (reference) treatment and with another group receiving a placebo (if ethically
possible). The rates of spontaneous cure should be known as well as those obtained after
treatment. In population samples, it is only possible to compare values that differ more
or less from true ones, a condition related to the fluctuation of the sample. It is thus
necessary to suppose that the value for the rate of cured patients is the same with two
treatments. The probability of obtaining a difference at least as great as the observed one
is then calculated. It is generally considered that a difference is significant when the

52
calculated probability is less than 5%, which is related to what is classically known as
the null hypothesis. It is also possible to show that two treatments do not differ in their
efficacy, which does not mean that they are actually effective. Such ambiguity is often
found in reports of clinical trials. All things considered, a difference is significant if the
probability of observing a difference of this magnitude by chance is less than 5%.

DRAWING LOTS

The drawing of lots to determine which treatments are administered to patients is

necessary to give the maximum possibility of the groups being comparable. The
demonstration of a significant difference in treatment efficacy between two groups must
be based on their comparability from the beginning of the trial. Thus, lots are drawn
before patients are entered into the trial, e.g. it is decided that patient No. 1 will receive
treatment B, patient No. 3 treatment C, patient No. 2 treatment A, and so on. This
technique, known as randomization, means that each patient has a treatment assigned by
the drawing of lots. In addition, subrandomization can be performed, so that a given
investigating physician will not have too many patients receiving the same treatment
(placebo, in particular). There will thus be blocks of treatments depending on the number
of treatments compared (blocks of 3 or a multiple of 3 for 3 treatments, blocks of 4 or a
multiple of 4 for 4 treatments). It is unusual to compare more than 5 treatments in the
same trial (placebo, reference drug and 3 different doses of the drug under study),
although this can occur in phase II when the effective dose or doses are studied.

NUMBER OF SUBJECTS

For obvious economic reasons, it is impossible to perform clinical trials involving

a very large number of subjects. However, to ensure that a comparison is valid, the
number must be sufficient. As these two requirements are contradictory, it is necessary
to determine before each trial the number of subjects which will allow the detection of a
possible difference between treatments. To ensure an adequate number of subjects, it is
essential to perform multicenter studies which include various investigators from
different centers who follow the same protocol. A greater number of patients must be
recruited when the difference between treatments is small. The statistical test used in the
trial is not an indication of certitude but only of probability, which entails two risks:
either to conclude that the treatment is effective when it is not (a risk), or ineffective
when it is (b risk).

A difference of 20% between treatments is usually required to ensure clinical

relevance. The procedure described above relates to a trial with parallel groups, i.e. each
possesssing sufficient homogeneity to allow valid comparison. It is theoretically possible

53
to reduce the number of subjects by using the crossover technique in which each subject
is his own control. However, this approach is not easy to apply when time can be a factor
in improving or worsening the pathology. Finally, with the sequential method it can be
determined before the end of the trial whether the difference observed is important or
not. This practice is used especially in oncological trials.

The number of subjects required is proportionally lower when the expected

difference in efficacy becomes greater, as in trials using a placebo. For example, 40 to 50
subjects per group will be required for the study of an anxiolytic compared to a placebo
and a control drug, whereas 120 subjects per group will be necessary if the comparison
is made with a reference group alone (without a placebo group).

54
 CRITERIA OF PATIENT SELECTION

The selection of patients for a therapeutic trial involves many often contradictory
requirements. In particular, subgroups of patients are selected, whereas the drugs are
intended for a large population. Moreover, rapid results are needed, which justifies the
recruitment of patients with a high degree of homogeneity. Finally, the selection criteria
should involve as few risks as possible for the patients. The contradiction is thus
between the rigor required and the desire for representativeness.

The selection process is based on five requirements: 1) isolating a group for which
there is a greater or lesser chance of detecting a possible difference between the
treatments compared; 2) establishing a homogeneous group in order to reduce the
variability of response, thus making statistical comparison more sensitive and decreasing
the risk of bias due to the constitution of non-homogeneous groups; 3) obtaining
representative samples of the affection studied; 4) defining the rules corresponding to
realistic recruitment; and 5) respecting ethical obligations.

I. GENERAL POINTS

As selection should favor measurement of the expected difference between two

treatments, the objective needs to be defined. It may be to evaluate the variations in
blood pressure caused by two antihypertensive agents regardless of their pharmacologic
class, or to define the nosologic situation if diuretics are studied in the context of arterial
hypertension, or to delineate the clinical form clearly in order to determine whether it is
symptomatic or progressive (an episode, complication or recurrence) or a matter of
pathogenesis. Special attention should be paid to borderline cases which may involve
important variations. In fact, everything needs to be considered, including the chances of
success for the treatments compared (particularly the rapidity of cure).

II. SELECTING A HOMOGENEOUS GROUP

The patients selected should be likely to have a nearly comparable spontaneous

55
course during the trial and especially a nearly identical sensitivity to the treatment
compared. Otherwise, there is a risk that the groups will not be comparable, with a
resulting variability of responses which would make the conclusions relatively unclear.
Too vague a definition of the type of patients included would inevitably lead to a
heterogeneous selection, providing discordant results and making the trial impossible to
reproduce. Thus, it is advisable to determine the following points precisely: the
nosologic situation, the possibility of an associated pathology (comorbidity), and the
social, demographic and, of course, physiologic characteristics which could influence the
result.

The nosologic situation, if defined precisely, should include an indication of

symptom intensity. This will most often require numerical assessment, whether by
laboratory examinations or scales (for psychiatry). A patient could thus satisfy the
diagnostic criteria of DSM IV-R relative to depression and only be included if his score
on the Montgomery Asberg scale was more than 20. The same is true for intermediary
criteria such as blood pressure which should be clearly determined. A concomitant
pathology should be considered if it is likely to have an influence on the course of the
disease, the judgment criteria and the metabolism of the drugs to be compared in the
study. Thus, subjects at risk because of hepatic or renal insufficiency are often excluded
from a trial if the drugs are eliminated mainly through the kidneys or if hepatic
metabolism is an important factor. Finally, demographic, social and physiologic
characteristics should also be considered for their possible influence on the results of the
trial. This concerns essentially age, gender, weight and height, especially if the trial
involves a fixed dosage. The patients should also understand the protocol, which may
not be the case if there is a problem of language or of intellectual level in the event that
self-evaluation scales are used.
III. SELECTING A REPRESENTATIVE SAMPLE OF THE
AFFECTION STUDIED

Theoretically, the results of an experiment can be extrapolated if they relate to a

representative sample of a hypothetical population corresponding to all of the patients
with the pathology in question.
Obviously, the sample is not truly representative since it does not depend on
drawing lots from the total population. Moreover, it is not random since the physicians
participating in the trial do not represent the entire profession, nor the individuals
included the totality of patients. Finally, this sample excludes age categories as well as
all comorbidities. In practical terms, a problem arises the other way around when an
attempt is made a posteriori and empirically, on the basis of the patients included, to
identify a pathological context theoretically corresponding to the population studied.
It is necessary in preliminary studies to envisage a sufficiently broad
representation of a given pathological state and then, if possible, conduct studies on
more homogeneous subgroups. In any case, it must be kept in mind that the requirements

56
of homogeneity and representativeness are perfectly contradictory. A group is less
representative to the extent that it is more homogeneous, and realistic compromises are
not always possible.

IV. ENSURING A REALISTIC RECRUITMENT

When an investigator is consulted about his recruitment practices in a given

pathology, the replies are always overestimated. In fact, the problem is twofold: the
pathology considered to be frequent is often less so, particularly at certain seasons, and
the investigator more or less assumes that he will be able to recruit all the patients
needed with this type of pathology.

In fact, the possibilities for recruitment are limited. The inclusion criteria may
exclude subjects, for example, whose pathology is not exactly that desired or who
present a comorbidity. The exclusion criteria very often eliminate individuals not
satisfying the age requirement. This overestimation is also related to the fact that some
patients may refuse to enter the trial since it is not always easy to convince them of the
notion of the placebo. Moreover, it is not reasonable to include a patient who is not well
known by the investigator—who, for example, is being seen for the first time. The
recruitment procedure corresponds roughly to a very simple law, i.e. that only 10% of
the patients with the pathology in question who are seen regularly by the investigator are
likely to be included in the study.

V. RESPECTING ETHICAL CONSIDERATIONS

It is difficult to include patients for whom the best treatment is uncertain, even
though the risk is quite minor. Of course, the value of proven therapies must not be
overestimated, nor that of the placebo underestimated. In many cases, the placebo has an
appreciable effect, particularly in the treatment of anxiety, depression or even a
gastroduodenal ulcer. The problem can be raised by even temporary administration of
drugs capable of causing teratogenic risks. It is particularly difficult to include patients
with good equilibrium for a chronic disease who would be required to stop an effective
treatment. This is the case notably for schizophrenic patients for whom achievement of
therapeutic equilibrium is often a long process. However, failure to include
schizophrenics resistant to current therapies would introduce a considerable bias for the
development of new drugs. In fact, all of the staff members taking part in a trial must
recommend inclusion and exclusion criteria that are specific, sensitive and reproducible.

57
 A last problem concerns patients lost to view. In fact, this concept should not be
applied to therapeutic studies insofar as a patient lost to view is considered as "dead" for
purposes of statistical analysis. It is absolutely essential for an investigator to know his
patients perfectly well. If the patient does not show up for a visit, it should be possible to
reach him easily by telephone and ask why he does not wish to continue his treatment.
This notion of a drop-out must not be confused with the requirement to exclude a
participating patient after the trial has started.

58
 CHOICE OF EVALUATION CRITERIA IN A
CLINICAL TRIAL

The purpose of a trial is to assess the efficacy of a new treatment, which is

measured by a criterion or criteria of judgment. Thus, the conclusions of the trial will
depend, among other factors, on the criteria by which the efficacy of the compared
treatments is judged.

I. JUDGMENT CRITERIA

I.1 NATURE OF THE JUDGMENT CRITERION

The judgment criterion is clearly defined in the protocol and should be relevant to
the disease and the mechanism of action of the drug and appropriate to the purpose of
the trial. A single criterion is preferable but not always possible. There may be a main
judgment criterion and accessory ones or a "composite" criterion.

The judgment criterion may be subjective (anxiety or pain) or objective

(laboratory tests). However, a certain subjectivity may enter into the interpretation of the
"objective" results of some complementary examinations (e.g. radiographic ones).
Doubtful examinations should be repeated. Moreover, there is a risk of using an
objective examination for indirect assessment of a very subjective symptom. For
instance, bone scintigraphy, which appears to be a very objective examination, is a poor
means of evaluating a disease such as rheumatoid arthritis.

The judgment criterion can be direct or indirect, provided that it has been
validated in a preliminary study.

The judgment criterion is considered to be sensitive if it allows the detection of

very significant improvements or deteriorations of the patient's condition. It is essential
to check the sensitivity of a new criterion before accepting a negative result. The
criterion is regarded as specific if it does not detect supposed improvements (false-
positive results) due to outside factors. Consistency relates to the reproducibility of
measurements made by the same observer and to the concordance of measurements
made by different observers. It is necessary to employ the same trained instructors. The

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criterion is considered to be stable if there is no variation over time in a given individual,
or labile if there is variation. It is sometimes useful to calculate means (e.g. for blood
pressure).

I.2 DIFFERENT TYPES OF JUDGMENT CRITERIA

Criteria may indicate the presence or absence of a variable. A clinical scale
provides a scoring system for answers to questions concerning a parameter: 0 = normal
or absent, 1 = mild, 2 = moderate, 3 = severe, and 4 = extremely severe. A visual analog
scale allows the quantification of subjective results (pain, anxiety, pruritus, hunger,
vigilance, etc.). The patient may also keep a diary according to a preestablished form,
which can be useful for certain drugs (e.g. antidiarrheals or antiepileptics). Diagrams,
figures and drawings are useful in certain circumstances such as ophthalmologic
pathologies and Parkinson's disease. Finally, criteria of relativity are measurements by
specific tests of more or less direct parameters of treatment efficiency.

I.3 CHOICE OF CRITERIA DEPENDING ON THE TYPE OF

TREATMENT
For preventive treatment, the criterion must relate to the frequency of occurrence
of the pathologic state in question (primary or secondary prevention), which raises the
problem of the detection method to be used and the length of the disease course.

The objective of curative treatment is to shorten the course of a disease. The

criterion can be either disease duration (which supposes the problem of normality and
cure) or the occurrence of a complication.

The purpose of symptomatic treatment is to relieve a symptom without affecting

the course of the disease. The judgment criterion depends on the intensity of the
symptom or the duration of the effect achieved.

The objective of palliative treatment is to delay the unavoidable progression of the

disease toward death. The judgment criterion is the time of occurrence of this event (rate
of survival).

I.4 CHRONOLOGY OF MEASUREMENTS

With respect to measurements before and after treatment, the judgment criterion is
the variation in a measurement or the intensity of a symptom. The effect is noted on the
absolute difference or the percentage of improvement. Interpretation can sometimes be
difficult.

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 Repeated measurements before treatment allow a better assessment of the basal
state if the criterion of choice is labile (e.g. blood pressure). Repeated measurements
during treatment allow assessment of changes in criteria and the influence of the time
factor as well as time/treatment interactions. An overall analysis is performed.

II. INTERMEDIARY CRITERIA

Determination of the efficacy of a treatment is most often based on clinical

criteria, but it is frequently necessary to use a non-clinical or intermediary criterion.

The purpose of therapeutic trials (phase III) is to demonstrate the efficacy of a

given treatment. The criteria chosen are generally either those of patient inclusion or
disease progression. In fact, the most relevant judgment criterion would be mortality or
morbidity, although it is rarely chosen since very long studies in a large number of
subjects and patients would be required.

The intermediary criterion should be reliably and precisely measurable. It should

be more prevalent than the corresponding clinical criterion, and its variation more rapid.
The use of an intermediary criterion requires a greater number of patients, so that the
trial becomes longer and more costly, in which case there is a risk that medical advances
might make it useless. Moreover, the power of the trial is not as great. Thus, rapidity is
the most important quality of an intermediary criterion since it increases the power of the
trial and reduces the cost, requiring the inclusion of fewer patients. The period before
drug registration is shortened.

The intermediary criterion should be equivalent to the morbidity and mortality.

This implies the description of a physiopathologic model of the disease, including the
intermediary criterion; the performance of epidemiologic studies demonstrating the
relation between the reference clinical criterion (morbidity and mortality) and the
intermediary criterion; and the performance of therapeutic trials in which the effects of
treatments on both criteria are compared.

The intermediary criterion should have good metrological qualities, reliable

variability, good reproducibility and good discrimination between normal and disease
states.
Intermediary criteria should be pertinent concerning the relation with the clinical
criterion (morbidity and mortality) and capable of being substituted to compare the effect
of several treatments.

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 II.1 ARTERIAL HYPERTENSION
The judgment criteria for arterial hypertension relate either to the level of blood
pressure or the occurrence of cardiovascular events. Blood pressure is the main criterion
if the purpose of the trial is to lower it, and the intermediary criterion if the purpose is to
show the usefulness of lowering it (in which case the main criterion is the occurrence of
a cardiovascular event or coronary mortality).

WHO standards allow a definition of normality and arterial hypertension

depending directly on the interindividual variability of blood pressure level in which two
elements are involved. First, a biological component relates to an increase in blood
pressure in the event of exercise or stress, so that it is essential to achieve normality
through rest, abstention from alcohol, etc. Secondly, measurement errors can occur,
although there are many recommendations for preventing them. These two elements lead
to variations in normotensive subjects (20%), which may explain why 30% of such
patients react to a placebo.

Multiple ambulatory measurements provide a better assessment of the blood

pressure of patients, allowing a better classification relative to non-patients. This reduces
intraindividual variability and thus the number of subjects required, which can drop from
250 to 67 for delta = 5 and alpha = beta = 5%.

According to Perloff (JAMA 1983, 249, 2792-98), ambulatory measurement of

blood pressure is a better indicator of cardiovascular risk. Moreover, it is better
correlated with left ventricular hypertrophy.

WHO standards distinguish between a normal state with a PAD below 90 and
arterial hypertension with a PAD above 95. However, this concerns a continuous
variable, whereas no precise standard exists for ambulatory blood pressure.

There may be a link between the intermediary criterion and the clinical criterion
(mortality and morbidity). Therapeutic action on the intermediate criterion should
correspond to that on the clinical criterion.

Although there is a clear advantage in clinical pharmacology for ambulatory

measurement, it is not performed routinely in clinical trials.

Ambulatory measurement of blood pressure may be a selection criterion for

inclusion but cannot be used for monitoring of the trial. In fact, it is always useful to
record morbidity and mortality.

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 II.2 HEART FAILURE
Heart failure is defined as the inability of the heart to pump blood at an adequate
rate for the needs of the organism. Numerous etiologies and very many clinical features
are involved. There are two types of relevant judgment criteria, namely morbidity and
mortality or functional state and the quality of life, both of which raise metrological
problems.

There are many intermediary criteria. Clinical signs vary depending on the
pathogenesis (and can differ because of the use of diuretics), e.g. hepatomegaly
("calques") and pulmonary rales. Hemodynamic data are of course more precise, but
physiological and psychological variations can occur. Moreover; the method is invasive
and involves a single measurement. Ejection fraction can be measured by a
hemodynamic, angioscintigraphic or ultrasonographic approach. The measurement is
reproducible, but interpretation can be difficult in the event of akinetic zones. Ergometric
data can be obtained with a bicycle, treadmill or measurement of VO2 max. However,
this raises a problem as to the reliability and determination (20 to 25% variation), the
effect of training and the fact that VO2 max is rarely attained in cases of heart failure.
Heart size is a simple measurement but difficult to reproduce. Finally, a rhythm disorder
can occur.

Discrimination between normal and disease states is difficult for clinical signs and
even for objective signs. In fact, the zone of non-normality cannot correspond directly to
the existence of heart failure. For the choice of inclusion criteria, there is a predicament
relative to the facility of performing the study and the subsequent generalization of the
results.

Intermediary criteria are numerous, and all raise problems. For clinical signs,
there is no correlation with mortality and morbidity. Hemodynamic study is invasive,
and there is little correlation with functional signs. Measurement of the systolic ejection
fraction in case of heart failure concerns the heart and the peripheral sector, for which
there is no clear correlation. For ergometric tests, this correlation is rather good, but the
correlation with mortality and morbidity and with quality of life is not clear. For heart
size, the correlation is non-linear, and for rhythm disorders there is little correlation.

II.3 CHOLESTEROL
The problems raised by hypercholesterolemia, which are similar to those of
arterial hypertension and heart failure, can be illustrated by the results of three studies.
The LRC-CPPT study showed that cholestyramine induces a decrease in cholesterol and
a reduced rate of infarction but not in mortality. Similar results were found for the
Helsinki study with gemfibrozil. The WHO study indicated that clofibrtate reduced

63
cholesterol and the rate of infarction, but that there were more deaths in the treatment
group.

II.4 QUALITY OF LIFE STUDIES

There are several questionnaires intended to study the quality of life, including the
QVS (Quality of Life and Health), the PQVS (Profile of the Quality of Subjective Life),
the OCAPI (Optimization of the Choice of Antihypertensives in First Intention), and the
APQV (Quality Adjusted Life Years). The APQV questionnaire is particularly efficient
and can be used as an economic tool. A single figure indicates the length and quality of
survival. For example, the length of life that an individual will sacrifice to obtain a better
quality of life can be estimated. An additional year of life = +1, and a year of life with
disease manifestations < 1.

II.5 DISCORDANCE BETWEEN THE INTERMEDIARY AND THE

CLINICAL CRITERION
In the absence of treatment, the relation between the intermediary and the clinical
criterion depends on the type of correspondence between the two criteria. If the relation
is causal, the correspondence between the two criteria is verified. However, this
correspondence is often unknown, in which case epidemiologic or multivariate (multiple
risk factors) studies may be useful.

During treatment, discordances can be related to the effect of chance, errors in

physiopathology between the intermediary and the clinical criterion, a slow effect of the
treatment (cholestyramine) or treatment leading to an iatrogenic pathology.

The possibility of an error due to chance should always be considered.

III. CONCLUSION

The choice of intermediary rather than clinical criteria is warranted for practical,
economic or ethical reasons. A serious preliminary study of the relation between the
intermediary and the clinical criterion is required. It is also necessary to obtain validation
even after drug registration.

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 PLANNING CLINICAL TRIALS

The planning of a clinical trial involves a succession of steps intended to develop

a protocol providing a clear and unbiased answer to a precise therapeutic question. This
chapter considers briefly the main points to be resolved at each planning stage.

I. FORMULATION OF THE QUESTION

The planning of a clinical trial supposes two prerequisites: the formulation of a

clear, precise and relevant therapeutic question and the certainty that the reply to this
question has not already been given in earlier studies.

First of all, this step requires careful reflection about the wording of the question.
Experience has shown that an initial therapeutic question often includes a series of
questions that must be analyzed to determine the most important one. The objective at
this stage is to obtain a sufficiently precise question, i.e. which clearly defines the
pathology and the type of patients studied, the therapeutic modalities envisaged, the
modes of comparison, and the judgment criterion on which the evaluation will be based.

Secondly, exhaustive bibliographic study is needed to be sure that the question has
not already been resolved. If the question is truly pertinent, it is likely that other
investigators have already considered it and attempted to find an answer. If the literature
does not indicate that the question has been resolved, it is desirable at this stage, in the
light of published works on the same subject, to reconsider its pertinence. If it still seems
of interest, then the feasibility of the study must be ensured. A maximum of data must be
obtained to understand the most recent developments in the subject, the methodological
choices, the problems encountered, etc.

It is important at this stage to consider that a clinical trial can answer only one
question precisely. As the number of therapeutic trials that can be performed is limited,
they should relate to the most important questions to be resolved. The protocol must
define the means needed to reply to the question, and particularly the number of subjects
to be included in the study. The carrying out of the trial implies the means to recruit the
number of subjects needed. Otherwise, it is preferable not to attempt it.

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II. THE EXPERIMENTAL PLAN

Three simple principles govern the procedure ensuring an unbiased reply to the
question:

1. The need for comparison

When a patient receives a treatment, the effect observed after a given period of
time depends on the natural course of the disease, the fact of being treated (placebo
effect) and the pharmacologic activity of the drug. The spontaneous variability of the
course of most diseases and the often relative results of therapy mean that the effect of
any new treatment should be evaluated by comparing a group receiving treatment with
one that is not. Moreover, it is necessary to use a control group receiving a placebo to
evaluate the contribution of the pharmacologic activity of the treatment to the therapeutic
effect observed.

2. The need for initial comparability of groups

If an observed difference is to be attributed to the therapy studied, the treatment
and control groups must be comparable before the beginning of the trial. Otherwise, it
would be impossible to distinguish between the effect of the treatment and what is due to
the initial difference between groups. Several procedures have been proposed to
determine the treatment to be attributed to a patient. All involve the constitution of
groups that are more or less comparable. The only means of obtaining truly comparable
groups relative to all the individual characteristics of the patients is to draw lots
(randomization). In practice, this means that each patient receives the treatment assigned
by a random procedure. This method of composing the groups has the added advantage
of ensuring the validity of the statistical tests used to compare the groups.

3. The need to maintain the comparability resulting from randomization

throughout the study
If an observed difference is to be attributed to the therapy studied, the treatment
and control groups must remain comparable throughout the trial. Otherwise, it would be
impossible to distinguish between the effect of the treatment and what is due to external
factors. The awareness of the physician and/or the patient as to the type of treatment
administered would be likely to introduce a bias. A physician who knows that he is
giving a patient a placebo or a supposedly active treatment may have a very neutral or
highly enthusiastic attitude that could influence the response of the patient negatively or
positively. Likewise, the response of a patient may be influenced negatively or positively
if he knows that he is receiving a placebo or a supposedly active treatment. In this
context, the only means of maintaining the comparability resulting from randomization
throughout the study is to perform a double-blind trial. This procedure requires that the

66
different treatments be totally indiscernible and that the modalities of administration be
absolutely identical. When a double-blind trial is not possible, a single-blind procedure
can be considered in which only the physician is aware of the treatment administered. In
this case, and even when the single-blind approach is impossible, the judgment criterion
should be evaluated by a physician unaware of the treatment the patient is receiving.
This blind procedure avoids a possible bias in evaluating the effect of the treatment
administered.

These three simple principles (comparison, randomization and double-blind

procedure) can be applied systematically in most therapeutic trials. Though the first two
principles are intangible, the double-blind procedure must sometimes be abandoned
because it raises ethical or technical problems or involves high additional costs. The bias
potentially induced by the physician's and/or patient's awareness of the treatment should
be estimated according to the question posed, the judgment criterion chosen, etc.

The second phase is to define the experimental scheme used to compare

treatments, which can be either a trial with parallel groups or a crossover trial. The
former consists in assigning each patient only one of the two treatments (as determined
by randomization), so that the two resulting groups are composed of different patients.
The latter depends on each patient serving as his own control, i.e. each patient receives
both treatments successively. In this case, randomization determines the order in which
the treatments are received rather than assignment to a specific treatment group. Both
groups are composed of the same patients, thereby reducing the number of subjects to be
included. The crossover trial supposes that the treatments do not allow the disease to be
cured definitively (for instance, treatment of symptoms) and are rapidly effective and of
short duration. These conditions suppose that the basal disease state at the beginning of
the second sequence is comparable to that at the beginning of the first sequence and that
the judgment criterion may be readily obtained. Finally, for purposes of simple and
unequivocal interpretation of the results of the comparison, there must be no interaction
between the treatments studied and the two different periods, i.e. that the difference
between the two treatments is the same whether they be administered in the first or
second period.

As a result of all these constraints, the crossover scheme is rarely used in phase III
trials, but rather in phase I or II. However, it is possible to consider it for phase III in
certain specialties such as ophthalmology, when the pathology concerned involves both
eyes, or dermatology, when several lesions exist simultaneously, provided that the
treatments studied involve no systemic route.

Experimental schemes allowing comparison of more than two treatments

Among the experimental schemes allowing comparison of more than two
treatments, the 2 x 2 factorial approach is of particular interest since it provides

67
evaluation of the distinctive effects of two treatments (versus placebo) and of the
possible interaction of these two treatments (i.e. that the overall effect of the two
treatments is greater or lesser than that obtained simply by adding up the particular
contribution of each treatment). In the absence of interaction between the treatments, this
type of experimental scheme allows an evaluation (versus placebo) of the distinctive
effects of two treatments using the same number of subjects as would be necessary for
the comparison of just one treatment with a placebo.

The 2 x 2 factorial approach defines 4 modalities:

A A

B Placebo A
B B A+B

one group receives neither A nor B (placebo group),

one group receives only treatment A,
one group receives only treatment B,
and one group receives both treatments A and B.

At the end of this study, and in the absence of interaction between treatments A
and B, the distinctive effect of A is evaluated by comparing the patients who received A
(those of groups A and A+B) with those who did not receive A (those of the placebo and
B groups). The distinctive effect of B is evaluated by comparing the patients who
received B (those of groups B and A+B) with those who did not receive B (those of the
placebo and A groups). Interaction is evaluated by comparing the patients of the placebo
and A+B groups with those of groups A and B.

III. CHOICE OF THE POPULATION

The population included in the trial should be representative of that intended to

benefit from the new therapy but uniform enough to demonstrate its efficacy. These two
requirements are apparently contradictory since representativeness implies a broad range
of differences in the population included. In fact, the selection criteria for patients must
be defined to provide the best compromise.

Inclusion criteria define which patients are ideal for the trial, i.e. those who would
best demonstrate the effects of the treatment studied. They include demographic criteria
(sex, age, weight, etc.), nosologic criteria defining the diagnosis of the disease, criteria

68
indicative of the severity and progressive nature of the disease, criteria defining the
conditions for informing and observing patients, and possibly criteria concerning
treatments previously administered.

Exclusion criteria define patients who correspond to the inclusion criteria but
whose presence in the trial would make it more difficult to demonstrate the effects of the
treatment studied. These patients may show poor understanding of the protocol or poor
compliance with treatment or present a difficulty for evaluation of the judgment
criterion. They may run a greater risk in undergoing the treatment because of renal,
hepatic or respiratory insufficiency, heart failure, pregnancy, breast-feeding, etc. They
may have a particularly severe clinical form of the pathology studied, or associated
pathologies that introduce particular risks. There may be contraindications to the
explorations in the protocol, or to one of the treatments studied. Certain therapeutic
indications may be forbidden, or particular dangers may be involved relative to the
treatments studied.

The following points are important to recall at this stage:

1. The selection criteria should be precise and unequivocal, so that each

investigator can determine whether a given patient is capable of being included in the
trial.

2. The selection criteria should define patients who are representative of the
eventual treatment population to which the results of the trial can be extrapolated.

3. The results of the trial can in fact be extrapolated to the population from which
the participating patients are derived. When the selection criteria are determined, the
relative frequencies of given patients presenting particular characteristics should be
considered.

4. Less restrictive selection criteria allow simpler and more rapid recruitment and
easier extrapolation of results but can also increase the number of subjects required and
make it difficult to demonstrate efficacy when the treatment is not the same for different
disease classes.

5. More restrictive selection criteria make recruitment more difficult and slower
and limit the scope of the results but can also decrease the number of subjects required
and make it easier to demonstrate the efficacy of the treatment.

IV. CHOICE OF THE POPULATION

69
 The treatments considered are those studied in the trial as well as previous and
associated ones.

IV.1 TREATMENTS STUDIED IN THE TRIAL

The treatment to be evaluated

Phase I and II trials should have defined the galenic form of the drug, the
administration route, the dosage and the optimal modes of administration required to
obtain the expected therapeutic effect or the best compromise between efficacy and
tolerance. The choices made are indicated in the protocol. In addition, it is necessary to
specify the length of treatment (if for a set period) or the criteria allowing discontinuance
of treatment (if for a variable period). In certain cases, an adaptation of the dosage
should be considered either from the start of treatment, if the dosage is based on the
particular characteristics of the patient (age, weight, body surface area, creatinine
clearance, etc.), or during treatment, depending on the patient's response as evaluated by
precise criteria of efficacy and/or tolerance.

Treatment given to the control group

In practice, the control group can be given no treatment or receive a placebo or a
reference treatment. The first procedure should only be chosen if the other two are
impossible since it does not allow the performance of a double-blind trial. The choice
between a placebo and a reference treatment depends on the therapeutic purpose
(evaluation of the "absolute" or the "relative" efficacy of a new treatment). Ethical
reasons sometimes require the choice of a reference treatment which should be clearly
effective versus placebo and recognized by the scientific community. Moreover, the
galenic form, administration route, dosage, modes of administration and length of
treatment should be optimal to obtain the expected therapeutic effect or the best
compromise between efficacy and tolerance.

When a blind procedure (single or double) is planned, the treatments compared

should be totally indiscernible as to presentation, form, color and taste and be
administered according to the same modalities. When the control group receives a
reference treatment, it is often simpler to produce a "placebo" in galenic form for each of
the treatments studied and give each patient the treatment assigned by randomization and
the placebo of the other treatment (double-placebo technique).

IV.2 PREVIOUS TREATMENTS

Previous treatments can be considered in determining inclusion and exclusion

70
criteria (cf. 3) and may affect the conduct of the trial by inducing a wash-out period. This
period, which can be obtained without treatment, or under placebo, or sometimes by
symptomatic treatment, allows evaluation of the state of patients without active
treatment and can also be used, on the basis of specific criteria, to select the pre-included
patients who will finally be included in the trial.

IV.3. ASSOCIATED TREATMENTS

Associated treatments intended for the treated patient

It is essential to have a preceise definition of the associated treatments which may
be approved and the circumstances and their administration modes. This is a delicate
problem in all cases since it is difficult at the time of evaluation to distinguish between
the effect due to the studied drug and that due to the associated treatment.

Associated treatments intended to combat an intercurrent affection

It may be necessary to have a precise definition of the associated treatments
approved for treatment of an intercurrent affection and of their administration modes.

V. RANDOMIZATION

The purpose of randomization is to compose groups comparable for all factors

(known and unknown) characteristic of the disease, in particular those which could
influence response.

Two types of randomization can be considered: fixed randomization, which gives

each included patient the same likelihood of receiving one of the treatments, regardless
of the time of inclusion in the trial; and adaptive randomization, which gives each
included patient the likelihood of receiving one of the treatments, depending on the time
of inclusion. The latter allows the correction of a possible imbalance in the number of
patients or in the initial disease characteristics compared. Only fixed randomization will
be considered here.

The simplest form of randomization

This approach consists in determining the treatment to be assigned to the patient at
each inclusion by the toss of a coin. If the coin is correctly weighted, the repetition of a
great number of tosses inevitably leads to the composition of two groups of very similar
size. To avoid the toss of a coin, random number tables can be used in which 0 to 9

71
appear at random regardless of how the tables are read (by lines or columns). One
treatment can then be assigned to certain numbers (e.g. even ones) and the other
treatment to other numbers (e.g. odd ones). The amount of numbers used depends on the
number of patients to be included. Moreover, this approach makes it easy to create
randomization lists to obtain a different ratio between treatments (e.g. to include twice as
many patients in treatment A as in treatment B, numbers 1 to 6 are attributed to A, 7 to 9
to B, and 0 is excluded). More than two treatments can also be distributed in this
manner. For example, if an equal number of patients is to be included in 3 treatments A,
B and C, A can be attributed to 1-2-3, B to 4-5-6, C to 7-8-9, and 0 is excluded. The
major drawback in this randomization method is that it can cause imbalances between
the groups, especially when the number of patients is low.

Block randomization
This approach involves the use of random number tables in which series of
numbers appear (e.g. 1 to 6) according to the sequences defined (by lines or columns).
The order of these numbers within a sequence is completely random. The rules for
assigning treatments from successive numbers are the same as above. The advantage of
this method over the preceding one is the creation of balanced groups at the end of each
sequence. For example, if a permutation table with 6 elements is used and A is to be
assigned for numbers 1-2-3 and B for numbers 4-5-6, it is certain that 3 out of 6
successively randomized patients will receive each of the treatments. In the worst of
cases, there would be an imbalance of 3 patients between the two treatments at the end
of the study. To make the balance perfect between the treatments studied, it is only
necessary to choose a rule that provides an exact division of the number of subjects to be
included. However, this method used in this fashion does not ensure a perfect balance of
patients between different centers (in the case of a multicenter study) and of the essential
prognostic factors of the disease between the treatment groups.

Stratified randomization
This approach is most often a block randomization (though the method can also be
applied to the simple form) in which the randomization list is by level of the
stratification variable. For example, in a multicenter study, the center is always a
stratification variable. Or a prognostic factor which supposedly has an important
influence on response can be a stratification variable. The advantage of stratification
applied to block randomization is to create balanced groups for each level of the
stratification variable.

Finally, it is possible to stratify the randomization with respect to several variables

(e.g. the center and 1 or 2 essential prognostic factors), although it is apparent that the
number of resulting randomization lists depends on the number of levels of each
variable. For example, the desire to statify randomization on the center, in the case of 4
centers and 2 prognostic factors with respectively 2 and 3 different levels, would lead to

72
the creation of 6 distinct randomization lists per center for a total of 24. Besides the great
complexity involved in the practical achievement of this type of randomization (a
complexity which may also cause mistakes), certain combinations of stratification
factors may introduce difficulties in recruitment possibilities. In practice, the best
compromise should be found between the benefit of creating balanced groups for one or
two essential prognostic factors and the feasibility of the procedure.

VI. JUDGMENT CRITERION

The choice of the judgment criterion is crucial in a therapeutic trial since it allows
an unambiguous reply to the question posed and determines the number of subjects
required, thereby partially affecting the feasibility of the study.

VI.1 CONDITIONS DETERMINING THE CHOICE OF A JUDGMENT

CRITERION
The criterion must be medically pertinent. For example, the choice of measuring
transcutaneous oxygen pressure after exercise to evaluate the supposed efficacy of a
treatment in arteritis of the lower limbs is certainly less pertinent than measuring the
walking perimeter. The criterion must also be currently accepted by the international
scientific community. A therapeutic trial is intended to convince all physicians of the
validity and benefit of the results, which is much easier if the methodology is
irreproachable and the criterion used is widely accepted for the pathology studied. The
criterion must be measured in the same manner regardless of the center and the
investigator but also, and especially, of the treatment administered. It must be sensitive
(allowing detection of slight improvements or worsenings) and specfic (varying only
through the effect of the treatment).

Moreover, the measuring instrument used to evaluate the criterion should possess
metrologic qualities such as sensitivity (the aptitude to reveal minimal variations induced
by the treatment), specificity (the aptitude to measure only the judgment criterion),
repeatability (the aptitude to give the same result if the measurement is repeated by the
same observer in the same conditions within a short period of time), and reproducibility
(the aptitude to give the same result if the measurement is repeated by two different
observers in the same conditions at two different times).

VI.2 INTERMEDIARY CRITERIA

In certain cases, the most pertinent judgment criterion cannot be evaluated until
after a considerable delay, e.g. the efficacy of an antihypertensive treatment on

73
cardiovascular mortality. It is then possible to use other types of judgement criteria
known as intermediary criteria, provided that there is a demonstrated relation between
the intermediary criterion and the most pertinent judgment criterion and that therapeutic
action on the intermediary criterion leads to a demonstrated therapeutic effect on the
pertinent criterion. In the example just cited, blood pressure could serve as an
intermediary criterion.

VI.3 DIFFERENT TYPES OF JUDGMENT CRITERIA

Objective or subjective criterion?

The choice between an objective criterion (which, like blood pressure, can be
determined directly with a measuring device) and a subjective criterion (which, like pain
or the moment for resorting to a final treatment, can be left to the discretion of the
patient or physician) must be based above all on the answer to the question posed. If the
choice is possible and the two criteria are of equal pertinence, preference will probably
be given to the objective criterion which may be assumed to have a lesser spontaneous
variability.

Qualitative, quantitative or censured criterion?

The choice between a qualitative criterion (which evaluates the quality of the
patient's response, e.g. success or failure of the treatment), a quantitative criterion (which
evaluates the patient's response on a graded scale, e.g. blood pressure) and a censured
criterion (which evaluates the occurrence or not of an event and the delay in its
occurrence, e.g. death) must be based above all on the answer to the question posed. If
the choice is possible and two or three criteria show the same pertinence (which is
unlikely), preference will probably be given to the judgment criterion for which the
number of required subjects is lowest.

Main or secondary criterion?

The answer to the question posed requires a definition of the preferential
judgment criterion which will allow determination of the number of subjects to be
included in the trial. This preferential criterion is the main one in the trial.

As a therapeutic trial is often a complicated and prolonged procedure, it is

desirable to evaluate treatment response relative to other criteria than the main one.
These secondary criteria must be clearly identified as such, and their number limited
(less than 10 to 15) to avoid poor evaluation and, more importantly, any deterioration in
the assessment of the main criterion. Their choice depends on the same rules as those for
the main criterion. The possibility of detecting differences in these criteria is not
controlled a priori since the number of subjects required depends on the main criterion

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alone.

VI.4 THE MOMENT FOR MEASURING THE CRITERION

The judgment criterion can be measured at the end of the treatment period, or
before and after, or before and then repeatedly during the treatment period. When the
criterion is measured before and at least once after the beginning of treatment, the
variation calculated is either absolute (the difference in parameter values before and after
treatment) or relative (the percentage of variation between the values before and after
treatment). Once again, the choice depends on the question posed. However, it is always
beneficial to remain as close as possible to the measured value, particularly in order to
convince the scientific community of the pertinence of the results observed. Repeated
measurements should only be considered in phase III trials when there is good evidence
that the effect and therefore the difference between the treatments is likely to change
with time, even though a state of pharmacokinetic equilibrium has been reached.

VII. THE NUMBER OF SUBJECTS REQUIRED

Calculating the number of subjects required is a determinant step after the choice
of the main judgment criterion since it has a partial influence on the feasibility of the
trial. This simple step involves establishing the value of four parameters: the minimum
benefit of clinical interest relative to the main judgment criterion, or the benefit that
has the best chance of being detected if it exists; the variability of the judgment criterion
s in the selected population; the first species of risk a of the statistical test, i.e. the risk of
finding the study treatment more effective than the control treatment, whereas efficacy is
actually the same; and the second species of risk ß of the statistical test, i.e. the risk of
finding the study treatment less effective than the control treatment, whereas efficacy is
the same or better.

The value of must be determined realistically. As a result of an obvious

overestimation, the trial would very likely show no difference between the treatments
studied, whereas an underestimation would produce too slight a benefit to prove of
clinical interest and convince the scientific community. Moreover, this second
misestimation would lead to an unnecessary increase in the number of subjects included
in the study.

The value of s must be carefully determined on the basis of values in the literature
for patients similar to those in the protocol and for a measurement device identical to
that used in the protocol. Precise knowledge of the variability of the judgment criterion
is all the more likely if a currently used classical criterion is chosen. The estimation of s

75
determined from the literature must be compared with estimations provided by the
investigators drafting the protocol on the basis of experience with their own patients.

The value of a and ß risks is defined by the statistician participating in the drafting
of the protocol. In practice, a is 5% and ß can range between 5 and 20%. Accepted a ß
risk above 5% allows the number of subjects in the trial to be reduced, although this is
likely to decrease the probability of demonstrating the efficacy of the treatment. When ß
= 20%, there is one chance in 5 of not detecting a difference in efficacy between the
treatments equal to.

VIII. STATISTICAL ANALYSIS

The use of statistical analysis must be considered from the planning phase in order
to avoid any bias that could be introduced by the choices made in terms of the results of
the study.

The classical approach for a therapeutic trial is to perform a single statistical

analysis for all randomized patients once the number of expected subjects has been
reached. The statistical tests used depend on the nature of the judgment criterion: the chi-
square test for a qualitative criterion (comparison of percentages), Student's t-test for a
quantitative criterion (comparison of means), and the Log rank test for a censured
criterion (comparison of survival distributions). If the statistical test, when performed in
these conditions, shows a significant difference between the treatment groups relative to
the main judgment criterion, and if the trial has been carried out according to the
methodological principles discussed in section 2 (randomized, comparative double-blind
trial), the difference observed can be attributed to the treatment.

In practice, statistical analysis of a therapeutic trial is often much more

complicated than the classical approach would suggest because of deviations from the
protocol, the possibility of imbalances in certain prognostic factors between the
treatment groups which require adjustment strategies, and possible interactions between
treatment results and certain covariables (e.g. time). Moreover, the possibility of
analyzing the data during the trial in order to discontinue it if a difference or a lack of
difference in efficacy is clearly apparent leads to the implementation of sequential-type
statistical methods which have their own limitations.

The strategy for statistical analysis of a therapeutic trial is almost necessarily

complex, which implies the participation from the planning stage of a statistician

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experienced in the methodology of clinical research.

IX. CONCLUSION

The planning of a therapeutic trial involves a succession of steps from the

formulation of the question to the choice of statistical analysis to be performed once the
trial is finished. This series of steps, which leads to the elaboration of a protocol, is often
long and requires the participation of various individuals including specialists in the
pathology considered, clinicians, biologists, a pharmacologist and a biostatistician. It is
important to take the time needed to develop a good protocol since the improvised
resolution of problems occurring during the trial by the investigators themselves is likely
to bias the results of the study.

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 RECOMMENDATIONS FOR DRAFTING STUDY
PROTOCOLS
IN BIOMEDICAL RESEARCH

I. INTRODUCTION

The French law of December 20, 1988, concerning the protection of subjects
taking part in biomedical research and the subsequent decrees for its application
(published in the state journal on September 29, 1990) require the drafting of a protocol
for any study involving humans and its submission to a state ethics committee for
approval. The very general recommendations presented here facilitate the preparation of
these protocols but need to be adapted to each particular situation.

II. TYPICAL PROTOCOL FOR A BIOMEDICAL RESEARCH STUDY

The following points and procedures are required for the preparation of the
protocol:

1. The title of the study.

2. Identification of the investigator in charge and the promoter of the study (dates
and signatures).

3. The plan of the project.

4. A synopsis of the project: a 1- or 2-page typed summary providing the key

points of the study protocol.

5. Justification of the study.

A review of the literature is provided (bibliographical references in an annex) and
an explanation of the scientific problem, indicating the interest of performing the study
in humans and showing that the problem has not been solved by previous studies. It is
important to summarize the experimental research performed in animals and any clinical
studies.

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 6. The objectives of the study should be indicated in terms of the justification of
the study.

7. Characteristics of the subjects.

Inclusion criteria: The characteristics of the subjects to be included in the study
should be indicated in detail (age, sex, weight, size, case history, activity, biological
data, etc.).

Exclusion criteria: The demographic, medical, clinical, biological and/or

administrative reasons for not including subjects in the study should be indicated, e.g.
the impossibility of obtaining clear information, the possibility that the subject will be
unable to complete the study, difficulty in obtaining health insurance coverage, or
refusal to sign the consent form.

8. Number of subjects.
The number of subjects to be included in the study depends on the type of
protocol (preliminary or definitive study), the purpose of the study, the parameters
considered as major criteria and the spontaneous variability of these parameters. The
advice of a biostatistician can be useful in solving these problems.

9. Presentation of the products.

When a drug or biological or physiological reagent (hormone, neuromediator,
etc.) is to be administered to humans, the physical, chemical or galenic characteristics as
well as the administration mode must be indicated.

10. Study protocol.

Experimental scheme:
- open, single-blind or double-blind trial;
- comparative or not;
- involving a reference product or placebo;
- parallel groups, crossover technique, etc.

General organization of the study:

- reception of the subjects;
- schedule for performing the study and obtaining samples of biological fluids;
- conditions for clinical supervision;
- description of the parameters recorded;
- complementary examinations (functional investigations).

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 Criteria for discontinuing the study: A description of the reasons for stopping the
study and the procedures to be followed in case of an unforeseen interruption.

11. Biology: the conditions for obtaining and processing samples (centrifugation,
freezing) of biological fluids; the means of transport and storage; and the assay methods
as well as the site of analyses and identification of the persons in charge (details on the
assay methods are given in annexes).

12. Analysis of results

- analysis of clinical and biological parameters;
- methods of statistical analysis;
- software (if used).

13. Adverse effects

- method of determination and treatment:
- procedures to be followed in case of a severe side effect: persons to be informed;
steps to be taken, etc.

14. Procedures
Ethics committee:
Indicate the location of the ethics committee that analyzed the protocol application
as well as its members and include a copy of the definitive approval as an annex (the
committee receives a request for approval from the investigator and not the promoter).
The investigator must advise the promotor that definitive approval has been accorded.

Informing subjects and obtaining a consent form

Complete and reliable information must be provided to subjects in understandable
terms, and a form must be given to them indicating the objectives of the study, the main
constraints of the protocol, the possible risks involved, the safety measures taken, etc.
This form, which specifies that a subject can at any time and without personal prejudice
withdraw his consent to the study, is signed by the subject who thereby gives his
informed consent. A copy is given to the subject, and another is kept by the investigator.
This form must be submitted to the ethics committee for approval.

The following points must be specified relative to the protocol: compliance of the
subjects, amendments to the protocol, monitoring of the study by a clinical research
assistant or other qualified person authorized by the promoter, binders or sheets for
observations, conditions for respecting the anonymity of the subjects taking part in the
study, and consultation of the national list of healthy volunteer subjects (especially if a
drug is used).

15. Length of the study (i.e. the presumed length).

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 16. Site of the study.
It should be noted that a drug trial with no direct individual therapeutic benefit for
the subjects can only be performed in a center approved by the Ministry of Health.

17. Insurance.
The promoter must take out an insurance policy covering the risks encountered by
subjects during the period of the trial. This insurance covers all persons involved in the
research. If the promoter is also the investigator, he must be certain that his professional
civil liability insurance covers this type of study.
18. Financial contract.
The budget for the trial and any financial contracts are to be presented in annexes.
They must be signed by the investigator. In the context of a trial in a hospital
environment, a financial contract covering the expenses of the trial must necessarily be
concluded between the promotor, the investigator and the hospital administration.

19. Storage of trial records: the investigator must store the data for 15 years.

20. Publications.
If a scientific paper is planned for publication at the end of the trial, it may be
necessary to indicate whether the promoter's approval will be required before publication
and whether the promotor has the right to contest the publication of the results (for
specified reasons).

21. Annexes.
The annexes include the bibliographical references, the information and consent
form for subjects, the location and membership of the ethics committee, a copy of the
definitive approval accorded by the ethics committee, a description of the assay methods
to be used, a copy of the French law of December 20, 1988, and copies of the budget and
financial contracts for the trial.

III. COMPENSATION FOR PARTICIPATING SUBJECTS

The promoter must compensate all persons participating in research and not
receiving any direct individual benefit (Article L. 209-15 of the law of December 20,
1988) for the constraints experienced, with the exception of minors, majors under
guardianship, and persons admitted to a health-care or social establishment.

The total amount of compensation that an individual can collect during a given
year is limited to a maximum set by the Ministry of Health.

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 No person can participate simultaneously in several biomedical research projects
not providing direct individual benefit (Article 20-15). An "exclusion period," the length
of which is determined by the investigator, is set for each trial in order to prevent
volunteers from taking part in another research project not providing direct individual
benefit. An investigator wishing to include a given subject in a trial can check the end-
date of a possible exclusion period by consulting a national file kept by the Ministry of
Health.

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 INTRODUCTION AND PRESENTATION OF
MODULE III

The first concern once the protocol has been established is to determine which
physicians have suitable patients for the trial and which of these patients could be
included. A realistic target for mean recruitment per investigator is then set and an
inclusion period defined. In fact, the number of patients that an investigator is likely to
include represents no more than a tenth of those with the pathology in question. Despite
all the precautions taken, experience has shown that the objective set is often excessive
and that at least 20 to 30% of the investigators who agree to participate will actually not
recruit any patients. Moreover, the production of treatments intended for a clinical trial
raises many practical problems for manufacturers, particularly with respect to placebos.
A six-month period is often necessary for long-term trials, and problems of expiry dates
may arise during the trial and should therefore be anticipated. This problem in producing
the drugs often leads to a delay in getting the trial under way, requiring the investigators
to wait beyond the date originally set for the beginning of the study.

As the data collected provide a basis for analysis at the end of the trial, the
procedures for their acquisition are fundamental. It is important to collect only those
which are necessary for the analysis. The investigators must not be given useless tasks,
even though there is a risk that information of major importance will be lacking at the
end of the trial. The binders used for recording observations are important documents
requiring the careful attention of the team in charge of the study. The ideal binder is self-
explanatory and should guide the investigator from the beginning to the end of the trial,
providing answers to his questions and preventing mistakes. The information can be
transmitted in several ways. The least satisfactory is to collect each file when complete.
It is far better to send the data obtained at each visit to a coordinating center. Addressed
envelopes with prepaid postage can be used, although it is preferable to transmit the
information by telematics (Internet or an equivalent system). Once the data reach the
coordinating center, they can be computerized for subsequent analysis. It is thus
extremely important that they be correctly identified (number of the investigator, number
of the patient, initials of the patient, date, type of information) for easy retrieval in the
computer files. Although single-center trials cause few problems of this sort, it is
essential in multicenter trials that everyone receive the same information at the same
time and that the circulation of data between the investigators and the coordinating
center be accomplished without loss or excessive delay. Theoretically, the use of

83
telematics avoids postal delays, provided that the investigators keyboard the data in real
time. This approach is virtually essential for randomization and enables the coordinating
center to follow patient recruitment day by day. In large trials, good communication
depends on the establishment of committees which meet regularly. The use of
committees permits a clear designation of the persons in charge, and the minutes of the
meetings are official documents ensuring the communication of information and the
enforcement of the decisions adopted. It is essential to predict the length of each phase of
the trial, e.g. the starting phase and even the date of publication of the results which
serves as an objective to be reached. It is clear that these forecasts become more and
more approximate as the event in question is farther from the beginning of the trial.
However, they are necessary to keep the trial from getting bogged down.

Setting up the trial, the final phase of preparation before the start, involves an
effective implementation of all the procedures decided on in the planning stage, so that
the trial can be carried out according to the protocol. The last administrative formalities
must be taken care of, i.e. the declaration to hospital directors and hospital pharmacists
and the signing of the contract by the investigators, with the approval of the governing
body. The procedures should be tested, i.e. through the use of binders concerning
imaginary cases, computerization of the data thus obtained, and verification of the
equipment and transmission systems.

The investigators should receive training together in one or more sessions, at

which time they are instructed in trial procedures. Clinical research assistants make visits
to set up centers and distribute various documents to each investigator relative to the
application of the French law of December 20, 1988, and to good clinical practices. The
investigators are then supplied with products and equipment for the trial. Once the initial
excitement has died down, it is necessary to maintain the attention and interest of the
investigators so that they recruit patients and respect the schedule. After one or two
months, it is generally possible to determine the rate of inclusions and compare it with
the theoretical predicted rate. Experience has shown that results are rarely better than, or
even equivalent to, what was planned, and that this tendency will need to be rectified.
Clinical research assistants must frequently intervene to pinpoint and solve problems,
and it is quite often necessary to recruit additional investigative centers.

The rate of patient recruitment in a therapeutic trial is often sluggish at the

beginning and then usually accelerates before slowing down after six months. The
enthusiasm at the start dies down once the most accessible patients have been included.
Other activities sometimes divert investigators from the trial. It is necessary to maintain
a certain pressure on the participating physicians and ensure that the trial is always one
of their main concerns. This is a major task of the clinical research assistants, but it is
also the role of in-house newsletters and support sessions. Any new scientific
information relative to the trial should be communicated to the investigators, who should

84
also be informed of the progress of the trial, the problems encountered and the personal
objectives to be reached.

The expression "garbage in, garbage out" is an excellent justification of the need
for quality control. Regardless of the sophistication and perfection of a protocol and an
analysis, the results will be worth no more than the data on which they are based. Quality
assurance in the United States developed progressively from the beginning of the 1970s,
leading to good clinical practices. In France, this approach was rapidly adopted by some
teams influenced by the North American model and then officially recognized in 1987.
Initially, this recognition took the form of recommendations which were followed in
trials supporting an application for drug registration but were not an absolute
requirement in other cases. It is currently considered that respect for good clinical
practices is essential to all biomedical research performed in humans. Article R-51-17 of
the French decree of September 27, 1990, in application of the law of December 20,
1988, indicates that trials should be performed in accordance with good laboratory and
clinical practices. Finally, the concept of European good clinical practices has been
applied since July 1, 1991. These good clinical practices define in general terms the
respective responsibilities of the promoter and the investigator. Some officials of
pharmaceutical firms have cited the need to conform to the standards of the U.S. Food
and Drug Administration and have therefore elaborated much more specific and
demanding procedures that are sometimes difficult to apply.

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 SELECTION AND RECRUITMENT OF
INVESTIGATORS

The promoter of a clinical trial needs to recruit investigators, who may be

physicians working in hospitals or in general practice. The first step is to prepare a list of
candidates based on several criteria: their qualifications as investigating physicians and
in the speciality required by the trial (as attested by publications or studies), the
adequacy of their workplace for good performance of the trial, their availability for the
trial, and an assessment of the capacity of their patients to comply with the proposed
treatment.

Once this list is established, various problems should be explored during an

information meeting with the investigators, preferably at the site where the trial is to be
performed. The following discussion points should be established in advance, and a
report of the proceedings made:

1. The clinical experience of the investigator in his discipline should be evaluated

and his previous experience with trials. It may be of interest to discuss any problems that
he encountered in a similar trial.

2. The situation in the investigator's department should be discussed, i.e. the staff,
equipment, possibility of conducting biological examinations, and the way in which
drugs are distributed.

3. The nature of the investigator's medical environment and his role, for example,
in a hospital, should be determined. It is necessary to judge the overall motivation of the
investigator, his team and the health-care staff.

4. Will the investigator collect and record the data himself or delegate a part of his
work to a colleague (for example, a head resident or resident)?

5. Financial aspects should be discussed.

6. It should be indicated that the protocol will be submitted to an ethics committee

and that each patient will be asked to give his free informed consent.

7. The situation with regard to publications should be clearly defined. In general,

the preliminary agreement of the promoter and the investigators is required for any

86
publication.

8. The possibilities for recruitment of patients as well as their origin, i.e. whether
hospitalized or outpatients, should be determined.

The recruitment of patients generally falls off rapidly after the beginning of the
trial and regains its initial level at the end.
It is necessary to ensure that the investigator is fully aware of his responsibilities,
which concern several levels:
Before the trial, the investigator, in agreeing to follow good clinical practices,
accepts certain responsibilities: a knowledge of the protocol and a commitment to
respect all of its aspects; his qualification as an investigating physician; a knowledge of
the product(s) studied; his own availability and that of his team for performance of the
study; the existence of adequate space and equipment for performance of the study; the
recruitment of a sufficient number of patients satisfying the inclusion criteria; obtaining
the written informed consent of each participating patient; obtaining the approval of the
ethics committee; his own written acceptance of the contract specifying the general
conditions, insurance and financing of the trial, and a signed commitment to respect
good clinical practices; and the forming of a medical and paramedical team for optimal
performance of the trial.
During the trial, the investigator is committed to respecting the protocol and its
annexes, providing accurate and reliable collection of the necessary data, managing the
products well, dealing with critical events and informing the promoter when necessary,
and being available for the performance of the trial.

After the trial, the investigator should ensure that the records are properly filed.
He may or may not take part in the drafting of the final trial report which in any case he
must sign.

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 SPECIFIC REQUIREMENTS OF THE
MULTICENTER TRIAL

The multicenter trial has a common protocol conducted by several centers

(hospitals or individual physicians) and leading to an overall analysis.

Whenever a clinical trial is to be performed for a rare disease or in a very limited

category of patients, or when a large number of patients is involved, it is not sufficient to
recruit a single investigator. Several participants are necessary (several physicians or
several hospital departments). This not only allows a broader recruitment of patients but
also a greater representativeness because of the peculiarities of each center. The
generalization of the results will thus be more valid.

I. SPECIAL REQUIREMENTS

The centers must be comparable in their equipment, staff, timetables and

recruitment. Only examinations performed in identical conditions and providing results
of similar reliability can serve as a criterion for the evaluation of a multicenter trial. The
equipment used to assess the results should be standardized and easily available. The
availability of staff and their training in conducting therapeutic trials should be similar
for each center. The schedules for meal distribution, examinations and drug
administration should not differ greatly. The recruitment of patients should be uniform in
all centers.

II. A COMMON PROTOCOL

The recruitment, the way of assessing results and the assay methods for biological
studies should be identical. As any difference in the interpretation of the protocol can
lead to a defect in homogeneity, it should be considerably more detailed than when
applied by a single center. In-depth discussions with all of the staff in each center
involved in the trial are highly desirable.

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III. A COORDINATING CENTER

The composition of the coordinating center team varies according to the trial but
generally includes one or two clinicians not participating in the performance of the trial,
a statistician, a pharmacologist and a representative of the organization that has
requested the trial. There should be sufficient facilities such as secretarial services,
means of calculation and easily accessible telephone lines.

The role of a coordinating team may differ from one trial to another but generally
includes the following:
- Elaboration of the protocol and discussion with interested parties.
- Organization of preliminary meetings.
- Drafting of the definitive protocol.
- Motivation of the participants:
• a legitimate desire for scientific renown, which can be satisfied by an
equitable listing of the authors of a publication;
• an equitable distribution of credits among the participants at all levels
based on the portion of the work performed;
• the advantage of belonging to a work group allowing participation in
training events.
- Preparation or control of the randomization procedure, the packaging of products
intended for the trial, and the binders or sheets for observations.
- Informing participants about the trial procedure.
- Centralization of data for each patient.
- Checking adherence to the protocol and noting any deviation from patient
selection criteria, conduct of the treatment, dates of examinations, etc.
- Checking the recording of individual observations.
- Rejection of inadequate observations.
- In an extreme case, exclusion of a participating center because of a lack of
reliable data.

IV. PARTICULAR SITUATIONS ENCOUNTERED DURING

INTERNATIONAL TRIALS

In international trials there can be a diversity of languages and concepts. It is

essential to use translations of protocols, but a reference version should exist in a
language understood by all participants. Differences in nosology are sometimes
involved.

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V. A WISE PRECAUTION: THE PRE-TRIAL

It is desirable to request each center to conduct a pre-trial relative to a few cases.

This provides an idea of the recruitment of each center, the feasibility of the study as
planned, the quality of the information collected, the comparability of the centers, the
acceptability of the treatments and their tolerance, and, if possible, the variability of the
results. The great inconvenience of the pre-trial is the "consumption" of patients before
the real trial begins.

VI. ANALYSIS OF THE RESULTS

Several special problems of multicenter trials should be considered:

A particular element known as the center factor should be taken into account
when the results are analyzed by a suitable statistical method. This factor allows
intercenter variability to be deducted from residual variability, thereby improving
sensitivity in the detection of differences between treatments.

It is also important to check whether differences between treatments (other than

random variations) have been found in all the centers. If important differences exist, they
can be revealed by a significant "treatment per center" interaction test. The cause of such
discrepancies could be a difference in the initial characteristics of subjects from one
center to another; an abnormal proportion of drop-outs or non-observers in one or more
centers, which could be due to laxity in interpretation of the protocol or inadequate
motivation of investigators in these centers; and/or a real variation in differences
between treatments in one or more centers.

In practice, the "treatment by center" interaction is especially disturbing if the

difference between treatments detected for the trial as a whole is actually due to a single
center, or if there is a "crossover" interaction, with distinct differences and contrary
findings among the centers (one treatment better than another in some centers, and the
opposite for other centers). In the latter case, it is also necessary to take the number of
centers into account.
Finally, the number of patients recruited by each center must to be taken into
consideration. Ideally, the contribution of the centers should be uniform.
VII. ENSURING THE GOOD FUNCTIONING OF CLINICAL TRIALS

90
 The responsibility for the good functioning of the study is shared between the
organization requesting the trial (represented by a coordinating group or a supervisor)
and the team(s) involved. First of all, it is necessary to keep all the investigators
participating in the trial informed by meetings, periodic visits, telephone calls, letters and
mailings. The investigator should in turn inform the patients through explanations about
the trial and by providing them with reminders, lists of dates and appointment times, and
examination programs. The protocol must also be explained to the care staff who should
be made aware of the interest of obtaining the data. The family doctor of the patient
should also be informed.

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 MONITORING THE CLINICAL TRIAL

A clinical trial is a time-consuming and costly undertaking requiring effective

coordination. One of the most important needs when the trial is initiated is to define the
monitoring strategy. The quality of the protocol will ensure the scientific value of the
trial, but monitoring guarantees the reliability of the data and the performance. Although
monitoring may focus on certain special aspects of the trial, four basic points require
periodic control: that the trial is proceeding according to the protocol, that the means
implemented are adequate, that the investigator and all other participants in the study are
fulfilling their various obligations scrupulously, and that the data are relevant and
complete.

A sophisticated protocol can never compensate for poor quality of the data.
Monitoring is thus of major importance, requiring a coordination and management of
field organization compatible with good clinical practices. The results can only be
validated (or not) once all these obligations have been satisfied.

I. THE COORDINATOR AND CLINICAL RESEARCH ASSISTANTS

The coordinator, generally a physician selected and empowered by the promoter,

is responsible for ensuring the management and supervision of the trial.

The position of clinical research assistant (CRA) was created in the early 1970s in
France. The pharmaceutical industry has made frequent use of CRAs to supervise
clinical trials under the direction of the coordinator. As the essential role of the CRA is
to ensure the quality and authenticity of the scientific data collected, he must have an
excellent knowledge of trial methodology. Accordingly, a program leading to an
interuniversity degree was created several years ago to train CRAs.

The CRA should detect any problems that might occur for investigators, provide
solutions and especially explain and apply the protocol as well as all the procedures and
decisions of the trial coordinator. The CRA is essential to the management of a clinical
trial since he can very quickly detect any divergences.

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II. THE MONITORING FUNCTION

The coordinator's role begins well before the stage at which the various
investigators are involved in the trial. The protocol must be developed in agreement with
the different partners. The methodologists, statisticians, pharmacists and investigators
must be represented, which is generally ensured by the coordinator. Once the protocol
has been elaborated, the investigators should give their opinion before the definitive
version is written up in order to be sure that the conditions for carrying out the trial are
applicable in all centers and that no overly complicated or unnecessary requirements
exist relative to the main objective. If this procedure is followed, it is to be hoped that
each of the partners participating in the definition of the objectives of the study and the
means to achieve them will be more motivated and respect the protocol better. As the
CRAs are more involved in field work and thus closer to the investigators, they should
be present during the first meetings in which the trial is worked up.

III. TRAINING AND INFORMING INVESTIGATORS

The choice of investigators, although within the competence of the promoter (as
indicated by good clinical practices), is generally made by a local coordinator with a
good knowledge of the investigators. The choice can also be made by an organization
which may however recruit investigators whose abilities are not always known. The
coordinator, accompanied by the CRA, will first inform the investigator of the
prerequisites, the protocol and especially the obligation to conform to the procedures to
be followed, including those pertaining to severe side effects. The role of the
coordinator, and generally that of the CRA, is to provide a detailed explanation of the
binders or data sheets used for observations to ensure that the investigator understands
everything perfectly well.

The coordinator should also ensure that all members of the team participating in
the trial with the investigator (i.e. other physicians, nurses and secretaries) are familiar
with their respective tasks. If in the context of a hospital trial the investigator
(department head) cannot be personally responsible for conducting the trial, someone
within his team must be designated as the representative for contacts with the CRA. It is
the role of the coordinator and the CRA to obtain the written acceptance of the
investigator to abide by good clinical practices and to accommodate the regular visits of
the CRA. It is necessary to organize information and training sessions for investigators
before the trial begins (cf. the section on selection and meetings with investigators). The
essential role of the CRA is now to supervise the investigators for whom he is
responsible throughout the trial, beginning with the start-up visit. The first step is

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administrative since the CRA must determine whether the administrative file is in order.
The protocol must be signed and the investigator's curriculum vitae attached. The CRA
draws up a schedule with the investigator which may relate to telephone contacts but is
essentially concerned with future visits. The CRA provides the invesigator with the
products necessary for conducting the trial, consisting of the drug packages, the
envelopes for randomization and the materials necessary for performing biological
assays. The CRA must ensure that the communication of information between analytic
laboratories and/or the different specialists is performed correctly (e.g. in the event of
additional X-ray or cardiologic examinations). In the case of a hospital trial, the CRA
must be sure to inform the pharmacist and be certain that he has received the products.

IV. MONITORING THE TRIAL ITSELF

The role of the CRA is essential to the conduct of the trial. As indicated above, he
must perform regular visits to investigators as scheduled. However, he can make
additional visits on his own initiative or at the request of an investigator. The CRA must
ensure the application and respect of good clinical practices, particularly strict adhesion
to the protocol. The CRA collects the trial data after having consulted the files and
checked their authenticity and coherence. Access to patient files may raise ethical
problems insofar as the CRA is not a physician. Nonetheless, he is subject to the code of
professional secrecy. In the event of a dispute, additional procedures may be necessary.
In particular, the coordinator, who is a physician, or another physician designated by the
promotor, can check a file when required. Access to files makes it possible to confirm
the existence of patients and to verify that they have given their written informed
consent. It must also be determined that the randomization order has been respected.
Further explanations will be necessary if a physician has failed to do so. An error in
randomization could cause an imbalance in one of the treatment groups in the event of
an untimely discontinuance of the trial or of non-inclusion of some patients. It is also
necessary for the CRA to check that the coordinating center is informed of each patient
inclusion, which can be done quite simply by the use of reply cards or e-mail. The CRA
must be sure that recruitment is regular to avoid any divergences. As disregard for
deadlines can lead to deviations prejudicial to the trial, the CRA should regularly remind
investigators of the date for the end of inclusions and encourage them to recruit as
rapidly as possible. The CRA should also encourage the slower centers and particularly
attempt to know why inclusions are not following the planned pace. It is also necessary
to check the relevance of inclusions, which must not only concern those patients who
satisfy the inclusion and exclusion criteria. The CRA must not only check the
authenticity of the data but also their quality by ensuring that the binders are well kept
and that the records are readable and indelible. In the event of a mistake in data
recording, the investigator must make the necessary rectifications, which are then

94
checked and approved (signed) by the CRA. The CRA should request any data that have
been omitted. He also assists in filling in questionnaires for which he sometimes ensures
the codification and data acquisition. The role of the CRA is thus to avoid mistakes,
omissions and acts of negligence in the monitoring of patients, particularly in the nature,
frequency and regularity of appointments. The CRA does everything possible to limit
and identify deviations from the protocol. He encourages investigations concerning
patients lost to follow-up and attempts to obtain good observance of the protocol.

While respecting confidentiality, the CRA ensures that all critical events have
been detected and correctly handled. He keeps the coordinator informed, records the
events and verifies them for future validation. He inquires about the opening or not of
the treatment code by the investigator, which must of course be done as a last resort. The
CRA must also ensure the conservation of drugs in suitable conditions and the storage of
documents. He is concerned with the collection and conveying of certain samples for
analysis and assay at a central point. For multicenter trials, the CRA is generally
responsible for writing the information sheets which allow investigators to follow the
progress of the trial. He keeps up-to-date a file containing all of the documents
concerning his role, whether the content of telephone calls, reports of visits to
investigators or different types of mail. The CRA must ensure that all participants in the
trial other than the investigators, i.e. nurses, biologists and specialist physicians, are
competent and that they are informed about the nature of the trial. The CRA must be
capable of assessing the quality of the work performed in the center for which he is
responsible, whether it is a question of collecting data (missing or mistaken data) or of
the delay before data are communicated after each visit (which should be relatively
short). He must also ensure the observance of treatment and in particular must count the
number of treatment units returned. He should also note the number of visits (and
possibly examinations) for which the date was changed or the patient did not show up.
He must also ensure that the investigator has made an effort to determine what has
happened to drop-outs in order to limit the number of patients lost to follow-up. Finally,
the CRA can immediately prevent any deviations by ensuring the regularity of
inclusions.

V. ROLE OF THE CLINICAL RESEARCH ASSISTANT AT THE END

OF THE TRIAL

Ultimately, the CRA must perform end-of-trial or center-closing visits, during

which he collects the drugs and other trial materials which have not been used. He sees
that the last sheets and binders are reviewed and completed and checks that the
investigators have filed their documents correctly. A meeting is held at the end of the
trial, after the blinding has been lifted, to inform each investigator of the treatment

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received by his patients during the trial.

VI. MONITORING FROM THE POINT OF VIEW OF THE

INVESTIGATORS

Monitoring, long regarded by investigators as a police action, is increasingly

considered to be a form of assistance. The clinician has come to realize that his
diagnostic and treatment skills are not sufficient to ensure adherence to a rigorous
methodology. The CRA should not supervise the investigator but help him to perform
his various tasks correctly. In fact, the clinical trial is a paid scientific activity, and the
manufacturer, like the drug registration authorities, expects a service of high quality. The
CRAs are demanding because they are the watchdogs of the procedure. The investigator
should realize that it is not demeaning to rely on the competence and availability of a
CRA who necessarily knows the procedure better than himself. The CRA should be
regarded as a partner and not as a policeman. An investigator who refuses to allow the
CRA to examine his files on the pretext of professional secrecy or, what is worse, on the
assumption that the CRA is not scientifically qualified, should withdraw from the trial.
In fact, the monitoring of a trial requires coordination and standardization, which are
only possible when good relations exist among the different partners. Therefore, the
terms and conditions of the trial, which actually constitute the protocol itself, must be
based on good clinical practices and determine the respective tasks accepted by all
participants. The objectives of monitoring are the good functioning of the study and the
reliability of its results, which are absolutely essential to ensure that statistical analysis of
results is not based on false data.

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 THE AUDITOR IN CLINICAL TRIALS

I. INTRODUCTION: DEFINITION AND ROLE

The term "audit,"long used to refer to the checking of financial accounts, has
recently been applied to clinical trials. The role of the auditor as a person outside the
system is to testify that the information contained in reports is credible, i.e. that it has
been generated, collected and processed according to the rules of the art. This supposes
that the rules (procedures) have been determined and that they respect the laws and
regulations in force( in France, the Huriet law and French and European good clinical
practices). The auditor is a witness within the process of quality evaluation.

The quality of a trial depends in part on the assurance and internal control
provided by the promoter. Quality assurance is intended to define and establish the
conditions or rules for conducting a trial. These procedures are especially concerned
with what is to be done, how it is to be done and the way records are to be kept. There
are particular procedures for each stage in the process of performing a clinical trial. The
investigators need to know the procedures for recording observations in data sheets and
binders and managing serious events, treatment units, etc. Quality control ensures that
these procedures are carried out. The audit testifies to their application. It is essentially
an administrative process which assures the promoter and state supervisory agencies that
the rules have been respected and that the data are thus credible.

II. SETTING UP THE AUDIT

II.1 THE OBJECTIVE

As the audit is intended to verify what has taken place, its form depends on the
mission of the auditor, i.e. on the objective in question. It can be a system audit of the
promoter or an aspect of the trial such as the galenic files of the treatment units, the
maintenance of records, the biometry, or the work of clinical research teams. Or the
audit can be conducted on site by a systematic assessment of the work of the
investigators, or by random sampling, or, in case of suspected fraud, by the service
company in charge of the trial. Laboratories conducting biological or complementary
examinations can also be audited.

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 Thus, the choice is large and must necessarily be limited. System audits are most
often performed regularly to assess the general situation without any specific reference
to a clinical trial. However, on-site audits relate directly to a clinical trial and are
conducted especially to improve the credibility and thus the admissibility of the trial by
the state supervisory agencies.

II.2 PRINCIPLE OF THE AUDIT

The auditor should verify that the working rules envisaged by the firm have been
applied. These are expressed through procedures which constitute sets of directions
relative to all the actions undertaken to reach a goal indicated by the type of procedure in
question. Thus, a procedure for record-keeping will indicate who is responsible, who
applies the procedure, how the documents should be filed, etc. In addition, it determines
the rules for consulting the records and borrowing and duplicating them. Any participant
should be able to store records, look for and find a document simply by following the
procedure without consulting a succession of persons to obtain explanations.

The auditor, in this case, will verify the existence of the procedure, determine that
records have been filed as indicated in the procedure and, if necessary, test the procedure
on an outsider to be certain that it is valid.

The auditor can be asked to evaluate the relevance of the procedure to its
objective. Naturally, procedures are not intended to gratify the ego of their designers but
to assure those responsible for an action that it can be carried out effectively.
Nevertheless, procedures need to be in accordance with the laws of the country and with
good clinical practices. If requested, the auditor can give his opinion about the relevance
of the procedures and their adequacy in terms of the intended objective. In fact, the
procedures are not a guarantee of quality but the description of working practices.
Procedures may be similar from one firm to another but not identical because of
differences in the environment and working practices.

II.3 AUDIT RULES

An audit cannot be performed secretly as it is an important act for firms. The
question or questions raised by an audit must always be indicated in advance since they
determine how it will be carried out:

1. The firm must advise all the teams concerned of the decision to perform an
audit by an individual or a team.

2. The auditor must clearly understand the objective of his mission, i.e. what must

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be audited and why. He makes sure that the persons involved are clearly aware
of the purpose of the audit.

3. The auditor familiarizes himself with all the information required for his work.

4. With the assistance of the sponsor,the auditor draws up an operating plan and
an evaluation scale.

5. In practice, the auditor conforms to the accepted plan and evaluates compliance
with the working rules (procedures).

6. The auditor keeps records of his meetings, draws up a general report of what he
has observed and finally gives his opinion about compliance with the procedures
he has investigated and their admissibility by state supervisory agencies. The
auditor expresses a clear judgment but does not make a decision. His judgment
should be factual since it may be contested by others. In addition to the audit
itself, the firm can request advice and opinions about the effective operation of a
department, although these observations must not be included in the report.

III. THE SYSTEM AUDIT

The system audit is both easy and difficult. It is generally easy since most of the
persons involved are present on the site, but it is difficult as well since all of the actions
of the teams are not codified (unwritten practices are the rule). The persons in charge of
quality assurance and control are overworked and generally do not concentrate on the
essential elements expressed in official texts. Finally, the units or departments in a firm
are not isolated, even if there is little communication among them (as is generally the
case). Interdepartmental interfaces are vital and yet difficult to manage because of the
overlapping of responsibility. System audits are generally intended to accomplish the
following:

1. To check that all actions have been performed in accordance with the laws and
regulations and that the administrative documents are complete.

2. To ensure that no document essential to the operation of a department is lost

and that it is used, checked and filed in an acceptable manner.

3. To determine that it is impossible in the operation of the departments to modify

an essential piece of information without leaving an explicit indication.

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Consequently, the auditor should verify that no fraud is possible or, if detected,
that it is reported to the highest authorities concerned and given special
attention.

It is not the role of the auditor to make a judgment about the organization of
departments, which relates to another type of mission. However, it is his duty to indicate
the inadequacy of procedures or their possible absence. The auditor should generally
comment on the disparity between the description of the procedure and the true state of
operations. In fact, procedures should reflect reality and may thus be modified. For this
reason, the system audit is often used by managers to improve the operations of
departments and check their adequacy in terms of the requirements of authorities, in the
event of an official inspection of a particular trial.

IV. ON-SITE AUDIT

The on-site audit is performed to check the work of the investigators and often of
the monitoring team in a particular trial. This audit is intended to provide the trial with
an attestation of conformity and thus make it more credible in the eyes of the authorities.
The auditor makes a judgment about the compliance of the teams with the rules initially
set forth. The audit is announced and described during the meetings with investigators
before the trial.

When the plan of the audit is developed, the procedure will be described,
indicating in particular what will be verified on-site. This procedure should be sent to all
investigators before the audit takes place so that they can become familiar with the rules
to be followed, the number of sites audited and the actual date of the audit.

The following elements define the plan of action of the audit:

- the protocol and the data sheets and binders;

- the procedures for starting up the trial, the meetings of investigators, the
pre- investigation visits, the setting up of the trial, the follow-up and the closing
of the centers, as well as the procedures for administrative management of the
trial within the firm;
- the list of centers;
- for each center audited, the observations already noted as well as the reports of
visits.

The investigator is advised of the auditor's visit, which occurs independently of

that of the monitoring team. The auditor checks all the data required and the way in

100
which they were obtained. In particular, he ensures that the patients included in the trial
exist, have given their informed consent and have been seen at the times indicated in the
binders.

He determines whether the investigator and his team are performing the clinical
trial according to the protocol and the established rules of evaluation. If there are
procedures specific to the trial, the auditor ensures that they are understood and
followed.

After the visit, the auditor prepares a report which is sent to the promotor and, if
previously agreed, to the investigator. In his report, the auditor indicates all the failings
noted and evaluates patient by patient, and then in terms of the center, the degree of
credibility that can be accorded to the trial data. After the audits of all the sites have been
performed, the auditor writes a general report indicating his opinion on the credibility of
the trial.

V. CONCLUSION

The audit provides an independent evaluation of the activity of one or more of the
trial teams relative to the established rules and generally on the basis of administrative
documents. In this respect, there is no direct relation between the quality of a trial and
the audit, although the absence of administrative conformity is an indication of poor
quality. However, it is possible to extend the notion of quality to the entire trial by taking
into account all the elements involved, and notably the way in which the trial data were
obtained.

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 DATA COLLECTION

In a clinical trial, the data collected are recorded in a binder provided for this
purpose. Precise information should be given for all aspects of the protocol:
identification of the patient, the pathology, treatments, etc. The binder entries should be
written clearly and effectively to facilitate data collection. Entries must be carefully
recorded, if possible always by the same person. The data should be checked to avoid
any mistakes or omissions.

I. BINDER DESIGN

Each page generally includes a standard part where the initials of the patient are
written as well as his identification number and the number of the center in the case of
multicenter studies. The title of each page should be clearly identifiable at first glance. A
terminology familiar to all physicians should be used.

The amount of data to be recorded is a critical consideration since there is a risk of

collecting too many or too few. The protocol can be simplified to make it easier to carry
out, but this may provide too few data for meaningful statistical analysis, so that the
objective of the trial cannot be reached. On the other hand, an excess of information
complicates the trial as well as the processing of data and statistics.

Open or closed questions can be used in the binder. In the closed system, a pre-
established list is provided, and it is only necessary for the investigator to check the
corresponding square, which facilitates data processing and statistical analysis
considerably. However, the risk with too closed a system is to overlook interesting data.
On the other hand, open questions allow each investigator to complete the questionnaire
in his own way, thereby increasing the difficulties of analysis.

In practice, the two systems actually co-exist. A minimum number of closed

questions is required, but a "Remarks" section is generally provided.

The forms generally provide for two or three copies by means of automatic
duplication. The sheets are kept in a binder or a file, so that certain elements can be
added, such as the results of complementary examinations. In general, dividers with tabs

102
are placed between the different sections, so that handling is clear, easy and
understandable to everyone.

II. BINDER SECTIONS

1. Identification of the subject: It should be possible to identify the subject

clearly, especially in the event of unforeseen effects: last name, first name, date of birth,
and sometimes place of birth. The confidentiality of the data should be ensured.

2. Clinical examination: It should be rigorous and serve in particular to verify the

comparability of groups: age, sex, height and other trial parameters intended to define
the disease.

3. Complementary examinations: It should be noted whether the assays are done

by the same center; if not, it is necessary to indicate the units of measurement used by
the laboratory. The standardization of these examinations (other than biological ones)
must be ensured.

4. Treatments received: Data concerning previous and associated treatments must

be very clear. Drug or other treatment must be described in the protocol, notably
indications of doses and the administration timetable. Observance must be noted
systematically.

5. Parameters of efficacy: These generally relate to the judgment criterion and

must be determined with precision and in a reproducible manner.

6. Adverse effects: They may be recorded using a system of open or closed

questions (involving the respective disadvantages considered above). Biological
tolerance is also noted.

7. Discontinuing the protocol: The details must be given, together with the reasons
for stopping the protocol.

III. QUALITY CONTROL OF DATA

Ideally, data should always be recorded by the same person. However, in the
event of absence, a trained replacement should be available.

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 The person who records the binder entries need not always have the highest
medical rank. It may be advantageous to choose someone for the task who is particularly
meticulous.

It is essential to verify the data as soon as possible (when the patient is still
hospitalized) or when the investigator still has a clear memory of the patient. The
observation should never be recorded before all the data are available and checked.

Three problems may arise during the statistical study:

First, data may be lacking. In fact, it is rare and even a bit suspect if no data are
missing. However, the trial could be invalidated if too many are missing. A position
must be adopted before the opening of the code (in the event of a blind procedure) about
how the missing data are to be treated (particularly if they are important) and whether
the observation should be deleted or not.

Secondly, there may be aberrant data, in which case an attempt should be made to
understand the cause and, if possible, correct them. Otherwise, they should be considered
as missing data.

Thirdly, there may be deviations from the protocol, which can sometimes
constitute veritable violations. Two actions are possible: either to exclude these
observations since they are prejudicial to the initial objective of the trial, which was to
answer a precise question; or retain them since the groups were composed by random
selection and the initial consideration was to compare "the intentions of treating."

IV. CONCLUSION

The composition of the binders used to record data may appear to be a trivial
consideration, but it is essential to ensure the good conduct of the trial. The proposed
version of binder contents should be studied by the different participants in the trial
before the definitive protocol is adopted.

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 CONCLUSION

The performance of the protocol offers the investigator an opportunity to test his
theoretical concepts against everyday reality, often leading him to search for a
compromise between what should be done and what is usually done. The room to
maneuver left by legislation and methodology is limited, which makes the task more
difficult and complex than in the past and justifies the increasing professionalization of
the clinical trial.

The requirements for the trial weigh on investigators insofar as it is difficult for
them to find the time needed to recruit patients for the study. These constraints also
involve training since most of the trials are multicenter and require meetings to ensure
the coordination and instruction of the investigators. The good conduct of the trial is
initially the responsibility of the promoter, who is often represented by a service firm or
a coordinating group. The investigators are then informed by regular visits and should in
turn inform their patients correctly by explaining the nature and objective of the trial and
possibly providing them with reminders. The clinical trial is difficult and time-
consuming, which is why the coordinator and especially his clinical research assistants
are needed to assist the investigators. The clinical research assistants are now well-
established participants in clinical trials, and their relations with the investigators are
generally excellent. In any event, monitoring must not be confused with trial inspection,
which has intentionally been omitted from discussion here. The latter is not yet the rule
in France, though appropriate legislation exists.

The activity of the clinical research assistant is fundamental for the good conduct
of the trial. His regular visits to investigators ensure the good quality of the data
collected. Thus, investigating physicians should accept the notion of quality control, so
that procedures are not ignored or applied incorrectly. It is the auditor who judges this
application.

As discussed in this chapter, the role of the auditor is to determine to what extent
the trial has been adequately performed, whether in terms of the galenic activity of
treatment units, record-keeping or the work of clinical research teams. Considerable
progress has been made in the French health-care system through the auditing function
of clinical trials. The investigators, who are most often general practitioners or
specialists, have increasingly accepted the notion that their activity can be evaluated and
that they can even benefit from the advice of the auditor. The collection of data, which is

105
increasingly facilitated by pharmaceutical firms, is fundamental insofar as it influences
the subsequent analysis of results. This task often seems tedious, but it is absolutely
necessary for the investigator to record data. The efficacy of the product can be
demonstrated and any adverse effects detected early. The verification of binder entries
can reveal possible deviations from the protocol and help set things straight for the
investigator.

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PROTOCOL FOR A CLINICAL TRIAL

107
INTRODUCTION

The derivative BOU-093 has shown efficient anxiolytic, anti-aggressive and anti-
convulsant properties when administered to rodents. Although BOU-093 has no
chemical relationship to benzodiazepines or other anxiolytic substances, its mechanism
of action appears to be mediated by the benzodiazepine receptor. In comparison with
diazepam, the sedative and muscle-relaxant effects of BOU-093 are minor in the
experimental animal. Its anxiolytic and anti-convulsant effects last significantly longer
than those of diazepam.

No habituation to BOU-093 was noted when it was administered daily for two
weeks in an anti-conflict test (Vogel's conflict test). M-II (or BOU-094, a metabolite of
BOU-093) also showed an anxiolytic effect in Vogel's test. Ro 15-1788, a
benzodiazepine receptor antagonist, suppressed the anxiolytic and anti-convulsant
effects of BOU-093. BOU-093 tends to potentiate the anxiolytic and anti-convulsant
effects of diazepam.

It has been shown that BOU-093 is a powerful competitive inhibitor of the

binding of tritiated diazepam to benzodiazepine receptors. The affinity of BOU-093 for
these receptors was 20 times that of diazepam. Moreover, the affinity of BOU-093 for
these receptors was not enhanced by the presence of GABA. There is a considerable
difference between the doses of BOU-093 producing anxiolytic effects (5 mg/kg) and
those inducing sedative-hypnotic and muscle-relaxant effects (160 mg/kg). These results
suggest that BOU-093 possesses more selective anxiolytic properties than
benzodiazepines.

No signs of dependence were observed in the rhesus monkey when BOU-093

doses of up to 200 mg/kg were administered.

Two studies have helped determine the choice of the dose. A quantified EEG
study showed that a 2-mg dose of BOU-093 was equivalent to 10 mg of diazepam, and a
study conducted in 307 patients with generalized anxiety showed that the minimal
effective dose was 1 mg and that 2 mg gave the best ratio of efficacy to tolerance in
comparison with higher doses.

Thus, this study should include patients with generalized anxiety (DSM-IV).

The length of this trial was set at 3 months, in consideration of the need for long-
term administration of anxiolytics and the existence of a French directive (November 21,
1991) limiting the period for which they can be prescribed to 12 weeks.

108
109
I. PURPOSE OF THE STUDY

The trial is intended to evaluate the efficacy of and tolerance to BOU-093 at a

dose of 2 mg twice daily in comparison with alprazolam and placebo in patients with
generalized anxiety during a three-month treatment period. A difference between the two
active compounds and between BOU-093 and placebo will be looked for after 1 and 3
months of treatment. A difference equal to or greater than 4 in the score of the Hamilton
Anxiety Rating Scale (HAMA) will be considered significant. In addition, tolerance will
be studied in a minimum of 49 patients treated for three months with BOU-093 (cf.
section IX.4).

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II. RISK-BENEFIT ASSESSMENT

Preclinical studies such as those performed to date show that the risk encountered
by patients participating in this study is low. This has been confirmed by the good
tolerance of BOU-093 in clinical studies conducted in Japan, the United States and
Europe.
Available data suggest that the products tested (BOU-093, alprazolam) in this
study are efficient against generalized anxiety and that their tolerance is good. Only a
few disorders of higher functions such as somnolence, vertigo and ataxia have been
observed, whereas no major clinical problems have occurred to date. Therefore, the
therapeutic benefit of BOU-093 is far greater than the potenital risk which theoretically
would be encountered by patients in this study. The risk-benefit ratio is thus favorable.

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III. STUDY METHODOLOGY
This comparative, randomized, double-blind multicentric study will be performed
on three parallel groups of patients receiving BOU-093, alprazolam or placebo.

Two hundred and sixteen ambulatory patients with a generalized anxiety

syndrome will be selected in approximately 36 investigative centers in general
practitioner medicine: 72 will be given BOU-093 2 mg twice daily, 72 alprazolam 0.375
mg three times daily, and 72 placebo. The number of patients included in a given center
will range from 6 to 18.

After a weaning period of 5 to 7 days on placebo, patients will be randomly

assigned to receive BOU-093 or alprazolam or placebo for a three-month period. This
will be followed by a second randomization procedure. For the first week, half of the
patients in each group will then continue the same treatment, while the other half will
receive placebo. For the second week, all patients will receive placebo.

Accordingly, both patients and doctors will be in double-blind status at the

beginning of the post-treatment period. The last two weeks will constitute a period
without treatment.

Selection Day 0 Day 15 Day 30 Day 90 F 1 F2 F4

BOU-093
placebo

placebo placebo placebo

placebo

alprazolam

1st randomization 2nd randomization

F = follow-up visit

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IV. SELECTION OF PATIENTS

IV.1 INCLUSION CRITERIA

Patients included in the trial should meet all of the following criteria:
- ambulatory status.
- male or female, 18 to 65 (years of age).
- a diagnosis of generalized anxiety based on DSM-IV criteria.
- a score at the time of selection equal to or greater than 18 on the HAMA scale.
Scores on this scale at inclusion (day 0) should not differ more than 20% from
those obtained during the selection visit. Thus, those patients will be eliminated
who show possible signs of wash-out from a previous treatment, as well as those
responding to placebo.
- the patient should have presented with a Covi score higher than the Raskin score
at the time of selection.
- a negative pregnancy test is required for all women still genitally active.
- patients accepting the study protocol will give their informed written consent.

IV.2 EXCLUSION CRITERIA

Patients with any of the following conditions should not be included in the trial:
- those with panic disorders, agoraphobia or social phobia within the previous six
months (as diagnosed by DSM-IV criteria).
- those with schizophrenia, bipolar disorders, mania, obsessive-compulsive
disorders (according to DSM-IV criteria).
- those with major depression during the previous six months.
- those with a history of epilepsy.
- those with problems occurring only during a humoral or psychotic disorder.
- pregnant women or those not practicing efficient contraception during the trial
(pill, intra uterine device) or undergoing breast-feeding.
- insulin-dependent diabetic patients or those with severe allergies requiring
chronic treatment.
- those who received alprazolam within a month before the trial.
- those with a known allergy to alprazolam.
- drug addicts or drug-dependent persons, or those with a history of drug addiction
within two years before selection.
- alcoholics or alcohol-dependent persons, or those with a history of alcoholism
within two years before selection.
- those with a concomitant organic disease likely to interfere with the present trial,
or a decompensated associated pathology (renal failure, hepatic insufficiency,
heart failure, diabetes).
- those with abnormal laboratory results (a difference of more than 30% with the
norms of the central laboratory).

113
 - those who took a drug in the context of a therapeutic trial within three months
before selection.
- those who in the opinion of the investigator will not be suitable for the trial
protocol.
- a second patient belonging to the same nuclear family.
- those who underwent anticancer chemotherapy within six months before
selection.
- those receiving a treatment forbidden by the protocol.

IV.3 INFORMED CONSENT

Written consent should be obtained from each patient or his legal representative
before treatment is undertaken. According to the Helsinki Declaration, patients should be
totally informed about the purpose of the study, the nature of the therapy, the possible
adverse effects, and their right to leave the trial at any time and for any reason.

IN ALL CASES, THE INVESTIGATOR SHOULD INDICATE ON THE

APPROPRIATE SHEET THAT THE WRITTEN CONSENT OF THE PATIENT OR
HIS LEGAL REPRESENTATIVE HAS BEEN OBTAINED.

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V. PRESENTATION OF THE PRODUCT

V.1 PRODUCT
BOU-093 is an original substance derived from Boupharma Research.
Pharmacologic experiments on animals have shown that BOU-093 possesses an
anxiolytic activity more selective than that of benzodiazepines. This product has already
been administered to 200 healthy volunteers without any serious undesirable effects.
Alprazolam is a benzodiazepine derivative for which therapeutic efficacy in generalized
anxiety has been validated.
V.2 STUDY MATERIAL AND SUPPLY

V.2.1 BOU-093
2-mg capsules
Code name: BOU-093
Galenic form: capsule
Dosage: 2 mg twice daily
Batch No.: E 23270101
Packaging unit: Boupharma, Brussels, Belgium

V.2.2 Alprazolam
0.375-mg capsules
DCI name: alprazolam
Galenic form: capsule
Dosage: 0.375 mg three times daily
Batch No.: E 23270101
Packaging unit: Boupharma, Brussels, Belgium

V.2.3 Placebo
Name: placebo
Galenic form: capsule
Batch No.: E 23270101
Packaging unit: Boupharma, Brussels, Belgium

The products are prepared in capsules according to the double-blind procedure

required by the protocol. They are strictly identical in appearance and thus totally
indistinguishable. Samples will be stocked by Boupharma, Brussels, Belgium, and
available within 24 h.

V.3 PRODUCT CONSERVATION

The Boupharma Laboratories should inform the investigator about the conditions
for product conservation, in accordance with good pharmaceutic practices. The

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investigator should then advise patients that they are responsible for the products and
should protect them from heat damage and store them at room temperature in a dry place
away from sunlight and artificial light.

V.4 DOSAGE AND ADMINISTRATION

• BOU-093 is prepared in white 2-mg tablets.
The daily dosage will be 4 mg (2 tablets per day).
• Alprazolam is prepared in white 0.375-mg tablets.
The daily dosage will be 150 mg (3 tablets per day).
• The placebo is indistinguishable from the other two products.

All three products will be placed in opaque light-blue capsules (size 0) and
administered three times daily after meals.

For the group receiving BOU-093, administration will be as follows:

- 1 capsule of BOU-093 morning and evening;
- 1 capsule of placebo at noon.

For the group receiving alprazolam, administration will be as follows:

- 1 capsule morning, noon and evening.

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 V.5 ASSIGNMENT OF TREATMENT AND PRODUCT PACKAGING

V.5.1 Assignment
As soon as a patient has been selected for the trial, he will receive a quantity of
product (placebo) sufficient for 5 days of drug weaning, and a number will be assigned
to him. Upon inclusion and after randomization, a treatment number (= inclusion
number) will be assigned. A sufficient quantity of product will be delivered for use until
the next visit. During the second visit, the same quantity of product is delivered, and this
procedure is then followed for subsequent visits.

V.5.2 Packaging
All the products needed to conduct the trial will be supplied by Boupharma
Laboratories and distributed to each general practitioner in packaging consistent with the
randomization list and the phase of the protocol. Each box will contain labeled blister
packs containing a sufficient number of capsules to meet treatment needs until the
following visit. Additional capsules will be available in the event that a patient is
temporarily unable to attend an evaluation visit. The label, in addition to the legally
required information, will indicate the number of the study and the number of the
patient. Labeling will respect the double-blind procedure throughout the trial. When a
physician distributes the drugs, he must write the patient's initials on the label and the
date they were given.

V.6 CONCOMITANT TREATMENTS

V.6.1 Authorized treatments

All treatments not expressly forbidden are permissible during the trial, provided
that the patient has been in stable status on a given treatment for at least three months
before inclusion.

V.6.2 Forbidden treatments

The forbidden drugs include antidepressants, other drugs with an activity on the
central nervous system (such as beta-blockers, hypnotics and HI antihistamines), and
anticancer chemotherapeutic drugs (administered within 6 months before selection). In
case of previous treatment with an anxiolytic, a minimum weaning period of 7 days will
be required, and a maximum dosage of 3 mg/day of lorazepam or an equivalent drug
will then be given.

V.6.3 Discontinuance of forbidden drugs

The requirements will be as follows when a forbidden treatment can be stopped to
allow inclusion of the patient:

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- neuroleptics with prolonged action: discontinuance for at least 6 months.
- other neuroleptics: discontinuance for at least 3 months.
- classic antidepressants and monoamine oxidase inhibitors: discontinuance for 1
month, except for fluoxetine (6 weeks).

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VI. PERFORMANCE OF THE TRIAL

PREREQUISITES
The investigator can only begin the trial once written approval is given by the
ethics committee. All data must be recorded in patient binders in black ink with a
ballpoint pen. Each page in the binder consists of three sheets (including two carbon
copies). The first two sheets are returned to Boupharma Laboratories, and the third is
kept by the investigator.

VI.1 QUALITY CONTROL

Each trial coordinator will validate each file independently of the investigator. A
scientific committee composed of all the coordinators will meet regularly to consider
contentious observations.
VI.2 PROCEDURES
Six regional coordinators will each work with a group of general practitioner
investigators who recruit the patients. During the trial, each regional coordinator will
meet with these investigators to consider the protocol and to ensure the use of uniform
evaluation procedures, particularly psychometric scales. These deliberations will be
recorded and eventually included in the final report.

The evaluation tools to be used are the following:

- Laboratory analyses: a single central laboratory will be used:
- NFS, a complete hepatic study, glycemia, uric acid, blood urea, creatinine,
cholesterol, trigylcerides (T3, T4, TSH at selection), a blood
ionogram, proteinemia.
- A pregnancy blood test.
- Urinary analysis for barbiturates, benzodiazepines, glucose, proteins, ketone
bodies, pH.
- Samples will be obtained at the patient's home or a laboratory and then sent
directly to the central laboratory, so that the physician-investigator can
receive the results within no more than 7 days.

- Psychometric scales:
- The Hamilton Anxiety Rating Scale (HAMA);
- The Raskin/Covi scale;
- The anxiety self-evaluation scale (HAD);
- The Lader-Bourin scale;
- The Cassano scale;
- CGI crossed with side effects.
The frequency of visits: evaluations will be performed at day 15, 30, 60 and 90,
and at follow-up visits 1, 2 and 4. A difference of 2 days more or less is allowed for the

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visit at day 15 and 30, 1 week more or less at day 60 and 90, and only 24 h more or less
for follow-up visits 1, 2 and 4.

VI.3 SELECTION VISIT

The selection visit, which will be conducted by the investigator responsible for the
trial, is intended to check the inclusion criteria and stop the use of drugs forbidden by the
protocol. The patient will be given a placebo to replace an anxiolytic.

Selection will take place no earlier than 7 days before randomization and no less
than 5 days before the inclusion visit.

Before any other trial evaluations, the patient must meet all the inclusion criteria,
have signed the informed consent form and not be affected by any of the exclusion
criteria. The investigator will inquire about the use of any concomitant drugs.

A selection number will be assigned to the patient.

The patient will be evaluated clinically according to DSM-IV criteria for anxiety.

The Raskin/Covi scale will be completed (the Covi score must be higher than the
Raskin score).

The investigator will evaluate the eligibility of the patient for inclusion in the trial:

- Previous drug use, concomitant treatments and treatments stopped for puposes of
inclusion.
- A complete physical examination: weight, height, rectal temperature, systolic
and diastolic blood pressure when seated and radial pulse. A checklist will be filled in.

Blood and urine samples will be taken for laboratory determinations.

Patients whose laboratory parameters are not normal, but can be considered as
non-significant from a clinical point of view, may be recruited for the study, provided
that the investigator gives his approval.

The investigator will give the patient Drug Box No. 1 and make a suitable
notation on the dispensation sheet. The patient will be asked to take the trial medicine
each day according to the following schedule: one capsule after each of 3 meals.

The patient will be advised that drugs excluded by the protocol cannot be taken
during the trial period. No anxiolytic drugs are to be taken between the selection visit

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and the initial visit. If changes in the patient's drug use occur after the selection visit, the
name and dosage of the product, the date of beginning or discontinuing its use, and the
reason for treatment will be indicated in the binder.

After the selection visit (if the patient is preincluded), the investigator will arrange
an appointment within 5 days (+ 2 days in the event of previous anxiolytic treatment) for
the inclusion visit. The patient will be reminded to take the trial drug every day and to
return the box and all aluminum blister packs at the inclusion visit.

VI.4 INCLUSION VISIT (DAY 0)

The patient will see the investigator again for the inclusion visit and be assigned a
number.
The investigator will question the patient concerning any possible undesirable
events that may have occurred or any drug that he may have taken since the previous
visit. Patients who have taken forbidden drugs, who no longer meet all the inclusion
criteria, who are now affected by any of the non-inclusion criteria, or who have
experienced a severe undesirable event since visit No. 1 will be excluded from the trial.
The investigator will perform a complete physical examination.

The investigator will see that the following psychometric tests are performed:
- The 14-item HAMA scale. The patient should achieve a score equal to or greater
than 18.
Baseline HAMA scores should not differ from those obtained during selection by
more than 20%.
- The CGI.
- The anxiety self-assessment scale (HAD) will be completed by the patient at
each visit.

The normality of the biological examinations will be checked.

A urine sample will be obtained to check for the absence of barbiturates and
benzodiazepines.

The investigator will collect Box No. 1 and count the number of capsules
remaining in order to assess compliance with the treatment.

The investigator will give the patient Box No. 2 and make a suitable notation on
the dispensation sheet for the trial drug.

The investigator will remind the patient to take the trial drug every day according
to the following schedule: one capsule after each of 3 meals.

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 The investigator will arrange an appointment for the visit at day 15.

VI.5 TWO-WEEK VISIT (DAY 15)

The investigator will question the patient about any undesirable events and
concomitant drug treatments.

The investigator will see that the following are performed:

- A complete physical examination.
- The HAMA scale.
- The CGI.
- The HAD scale.

The investigator will collect Box No. 2 and count the capsules remaining in order
to assess compliance with the treatment. He will then return Box No. 2 to the patient.

The investigator will arrange an appointment for the one-month visit. He will
remind the patient to continue taking the drug three times per day according to the
recommended schedule and to bring back the box of drugs and all blister packs at the
next visit.

VI.6 ONE-MONTH VISIT (DAY 30)

The investigator will question the patient about any undesirable events and
concomitant drug treatments.

The investigator will see that the following are performed:

- A complete physical examination.
- The HAMA scale.
- The CGI.
- The HAD scale.

Blood and urine samples will be taken for laboratory tests.

A urine sample will be obtained to check for the absence of barbiturates and
benzodiazepines.

The investigator will give the patient Box No. 3 and record a suitable notation on
the dispensation sheet.

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 The investigator will collect Box No. 2 and count the number of capsules
remaining in order to assess compliance with the treatment.

The investigator will arrange an appointment for the two-month visit. He will
remind the patient to continue taking the trial drug three times per day according to the
recommended schedule and to bring back the box of drugs and all blister packs at the
next visit.

VI.7 TWO-MONTH VISIT (DAY 60)

The investigator will question the patient about any undesirable events and
concomitant drug treatments.

The investigator will see that the following are performed:

- A complete physical examination.
- The HAMA scale.
- The CGI.
- The HAD scale.

The investigator will give the patient Box No. 4 and record a suitable notation on
the dispensation sheet.

The investigator will collect Box No. 3 and count the number of capsules
remaining in order to assess compliance with the treatment.

The investigator will arrange an appointment for the three-month visit (day 90).
He will remind the patient to continue taking the trial drug three times per day according
to the recommended schedule and to bring back the box of drugs and all blister packs at
the next visit.

VI.8 THREE-MONTH VISIT (DAY 90)

The investigator will question the patient about any undesirable events and
concomitant drug treatments.
The investigator will see that the following are performed:
- A complete physical examination.
- The HAMA scale.
- The CGI.
- The HAD scale.
- The Lader-Bourin scale.
- The Cassano scale.

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 Blood and urine samples will be taken for laboratory tests.

A urine sample will be obtained to check for the absence of barbiturates and
benzodiazepines.

The investigator will give the patient Box No. 5 and make a suitable notation on
the dispensation sheet.

The investigator will collect Box No. 4 and count the number of capsules
remaining in order to assess compliance with the treatment.

The investigator will arrange an appointment for the following visit. He will
remind the patient to continue taking the trial drug three times per day according to the
recommended schedule and to bring back the box of drugs and all blister packs at the
next visit.

VI.9 FOLLOW-UP VISIT No. 1 (F1)

The investigator will see the patient one week after the previous visit.

The investigator will see that the following are performed:

- A complete physical examination.
- The HAMA scale.
- The CGI.
- The HAD scale.
- The Lader-Bourin scale.
- The Cassano scale.

The investigator will question the patient about any undesirable events and
concomitant drugs.

The investigator will give the patient Box No. 6 and make a suitable notation on
the dispensation sheet.

The investigator will collect Box No. 5 and count the number of capsules
remaining in order to assess compliance with the treatment.

The investigator will arrange an appointment for one week later.

VI.10 FOLLOW UP VISIT No. 2 (F2)

The investigator will see that the following are performed:
- A complete physical examination.

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 - The HAMA scale.
- The CGI.
- The HAD scale.
- The Lader-Bourin scale.
- The Cassano scale.

A urine sample will be obtained to check for the absence of barbiturates and
benzodiazepines.
The investigator will question the patient about undesirable events and
concomitant drugs.

The investigator will collect Box No. 6 and count the number of capsules
remaining in order to assess compliance with the treatment.

The distribution of the trial drug stops at this point.

The investigator will arrange an appointment for two weeks later.

VI.11 FOLLOW UP VISIT No. 3 (F4)

The investigator will see the patient two weeks after the previous visit.
Exceptionally, if the patient is unable to attend this visit, he can be questioned by
telephone, in the context of the CGI, to determine whether the patient resumed treatment
with anxiolytics.

A urine sample will be taken to check for the absence of barbiturates and
benzodiapezines and to screen for beta HCG.

VI.12 FINAL ANALYSIS

The investigator will give his opinion on the efficacy of the treatment and its
tolerance.

The regional coordinator, independently of the investigator, will perform a quality

control for each of the observations.

VI.13 MANAGEMENT OF OVERDOSES

To date, no cases of overdosage have been observed.

BOU-093 and alprazolam have been administered to patients at doses significantly

higher than those used in this trial. These doses have been tolerated perfectly well,

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without significant side effects. No specific antidote is known. In the event of an
overdose problem, appropriate and timely symptomatic therapy should be given.

VI.14 EMERGENCY IDENTIFICATION OF THE PRODUCT STUDIED

ONLY IN EMERGENCY CONDITIONS, when the identification of the

product is absolutely necessary, can the investigator open the sealed envelope (given to
him with the corresponding package) which contains the identification of the product.
Once the envelope has been opened, the investigator must make an entry to this effect in
the patient's binder. As the blind code has been broken, the investigator must inform the
trial supervisor directly by telephone and then in a written report. The report should
indicate the name of the person who broke the code, the date and time, the circumstances
responsible for this decision, and any treatment administered to the patient.

If possible, the responsible individual and/or the study coordinator should be

contacted before the code is broken. The code must not be broken in a routine situation,
but only when serious or unexpected side effects occur, and only if a knowledge of the
treatment is necessary. If the code is broken, the patient must stop his participation in the
trial, and the procedures for his withdrawal must be performed (cf section VIII.
Withdrawals from the trial).

VI.15 COMPLIANCE OF THE PATIENT

During ambulatory oral treatment, the investigator should count the number of
unused products at each visit.

VI.16 RETURN OF THE PRODUCTS

All packaging used in the trial (boxes and blister packs), whether empty or still
containing unused drugs, should be returned to the supervisor for Boupharma
Laboratories, who keeps the "product count record" up to date.

VI.17 PRODUCT COUNTS AND COMPLIANCE

The investigator or another responsible person will keep an inventory indicating
the description and quantity of product supplied throughout the study as well as the
number of capsules brought back by the patient at each visit. Compliance is considered
acceptable if the difference from theoretical use of the product does not exceed 10%.

At the end of the trial, the investigator must draw up a final inventory of the
products. The original copy of the inventory is sent to Boupharma Laboratories, and

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another copy is kept in the investigator's records.

According to instructions, the investigator will return to Boupharma Laboratories

the products not distributed during the trial or brought back by patients.

The investigator agrees to deliver products only to patients participating in the

trial.
VI.18 TREATMENT PERIOD AND END OF THE TRIAL
The total treatment period is three months. For a given patient, the trial is finished
either after four months or upon withdrawal before the scheduled end.

A one-year inclusion period is foreseen from the time the first patient is selected.

The study ends once Boupharma Laboratories has received all the patient binders
necessary for analysis of efficacy (patients who completed the trial or those who
withdrew early because of lack of efficacy or because of intolerance).

VI.19 TRIAL MATERIALS

Boupharma Laboratories will provide investigators with the protocol, the
investigator's booklet, the patient binders, and the products for experimentation.

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VII. JUDGMENT CRITERIA

VII.1 BASIS FOR ASSESSMENT OF THERAPEUTIC EFFICACY

The score on the Hamilton Anxiety Rating Scale provides the major judgment
criterion.
The secondary criteria are the anxiety self-assessment scale (HAD) and the CGI.

VII.2 BASIS FOR ASSESSMENT OF TOLERANCE

VII.2.1 Clinical criteria

- Data from the physical examination and side effects reported spontaneously
during each visit.
- The Cassano and Lader-Bourin scales.
- The crossed CGI.

VII.2.2 Biological criteria

- NFS, ionogram, urea, creatininemia, transaminases, gamma GT and
bilirubin.

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VIII. WITHDRAWALS FROM THE TRIAL

The following procedures relate to the investigator and do not concern statistical
analysis:
In the event of withdrawals from the trial for any reason, no replacements will be
made. The investigator should proceed as follows:

a) Request the patient to report on the treatment prescribed in the context of the
trial and/or other elements (complementary examinations for which the investigator is
responsible).

b) When possible, complete all the examinations included in the protocol of the
final visit, either at the time the patient withdraws from the trial or at a later follow-up
visit (not included in the trial) within two to three weeks. The purpose of this later visit is
to inform Boupharma Laboratories as to whether the patient's clinical state is unchanged,
worsened or has returned to the initial condition (before participation in the trial).

c) Complete all the appropriate sheets in the patient's binder, including the one
concerning early withdrawal from the trial, indicating the date and reason and whether
treatment was administered or not.

d) When necessary, arrange an appropriate medical follow-up of the patient and

note the results (for Boupharma Laboratories) on the corresponding sheets of the binder
or an additional sheet. If adverse effects are reported, the supervisor must be informed
immediately.

Major discrepancies with the protocol will be examined by the scientific

committee, notably in the following cases:
- Use of anxiolytics and/or hypnotics for at least three successive days between
two visits.
- If urinary screening for barbiturates and benzodiazepines is positive, the
investigator should question the patient and perform a urinary control within 48 h. If the
control is also positive, the patient should withdraw from the trial.

If anxiolytics and/or hypnotics are used occasionally, either three times between
two visits but not on successive days or a single time 24 h before an evaluation, the
patient will be kept in the trial.

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IX. STATISTICAL ANALYSIS

Data for all patients will be sent to the R&D Center of Boupharma Europe in
Brussels as soon as they are available. Keyboarding and data management will be
performed by Loire-Monitoring-Nantes during the trial.

Biometric analysis will be managed by the Biometry Department of Boupharma

Europe.

After double keyboarding of the data, logic and statistical plausibility will be
checked. All data used in the final analysis will be obtained from lists of raw data.

Patients who do not meet the inclusion criteria will be excluded from later
analyses, except the safety analysis; data relative to these patients will be presented case
by case.

All violations of the protocol will be documented and discussed with the main
clinical investigator in order to exclude the patient, if necessary, from later analyses.

For each step in the analysis, a detailed list of evaluable patients will be provided
(e.g. in diagram form).

Analysis will be performed both "with intent to treat" and "according to the
protocol." Thus, ineligible patients or those lost to sight will be excluded. For each safety
analysis, all available data should be taken into account, whether or not the patient has
remained in the trial until the end.

The particular statistical methods used for analyses are described here or in the
references cited.

IX.1 DESCRIPTIVE STATISTICS

All measured and derived variables will be presented in terms of the treatment
group according to standard procedures (using suitable estimators of localization and
dispersion or absolute and relative frequencies, depending on their distribution).
Time changes in the main variables will be presented in graph form (e.g. mean
and standard deviation).
For each center, the essential variables will be described, in particular for the
HAMA, HAD and CGI scales.
Undesirable events will be coded using WHO terminology for unfavorable
reactions and presented in appropriate contingency tables. A coding list "according to the
report" will be included systematically.

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 IX.2 EXPLORATORY STATISTICS
The homogeneity of treatment groups at baseline will be assessed by suitable
statistical tests. Structural homogeneity as well as the homogeneity of observations will
be analyzed.
The comparability of the treatment groups will be assessed by the Fisher exact test
extended to quantitative variables, by unilateral analysis of variance or by the Kruskal-
Wallis test (as a function of effective distribution) for quantitative variables, and by
Cochrane-Mantel-Haenszel methodology for data arranged by categories.
For laboratory data, the mean values at the beginning and end of the study, as well
as the frequency of aberrant values (relative to reference tables or according to the
physician's clinical judgment), will be compared and tested respectively by Student's t-
test and the Wilcoxon or chi-square test.
Variations in HAMA, SAS and CGI scores between baseline and later visits will
be assessed using Student's t-test or the Wilcoxon test (according to effective
distribution).
For all treatment groups, a responder-nonresponder analysis will be performed
after three months of treatment, so that patients, for all pertinent variations in HAMA
scores, will be assigned to one of three classes: "improvement," "stable," or "worsening."
The tables (3 x 3) thus obtained will be tested using the Mantel-Haenszel method.
All p values calculated will be interpreted according to an exploratory analysis of
the data and not as a true test of the initial hypothesis.
A safety analysis at three months and an analysis of weaning phenomena will be
added.

IX.3 CONFIRMATIVE STATISTICS

The main judgment criterion will be the change observed between selection and
the normal evaluation visits at day 30 and 90.
Comparison of the three treatment groups will concern the "before and after"
difference in the HAMA score between selection and visits at day 15, 30 and 90.
The comparability of the three treatment groups will be assessed by unilateral
analysis of variance concerning the treatment factor and, if needed, the adjustment of
covariables.
If the analysis of variance is significant at 5%, the groups will be compared
pairwise using Student's t-test.
The global risk of type I error will be ensured by the use of Bonferroni
procedures.

IX.4 CALCULATION OF SAMPLE SIZE

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 The primary final point of the confirmative tests will be the HAMA score after
one and three months of treatment.
The main objective is a simple pairwise comparison between the treatment groups,
which will provide the basis for calculating sample size. As the power of the global test
(analysis of variance) is higher, it is necessary to ensure sufficient power for this type of
comparison.

Hypotheses:

a = 0.025 Type I error

ß = 0.1 Type II error
∆=4 Significant minimum difference in HAMA scores
s = 5.5
n1 = n2 = n3 = 49

In view of these basic hypotheses for the comparison of treatment groups using
the test statistic, the required size of the sample is 49 evaluable patients per group after
three months of treatment.

IX.5 BIOMETRIC CONCLUSION

The statistical report will include a biometric discussion and conclusion.
If the null hypothesis cannot be rejected, the power of the test will be calculated a
posteriori, and the basic hypotheses of the trial will be reevaluated.

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X. SURVEILLANCE OF THE STUDY

The investigator agrees to the periodic visits of the representative of Boupharma

Laboratories, in accordance with Good Clinical Practices. During each visit, the
investigator and the supervisor will check on the progress of the trial and its conformity
with the protocol and discuss any problems that have come up.

The representative of Boupharma Laboratories will examine the patient binders

and check the following:

- that all data have been written in black ink with a ballpoint pen.
- if an error occurred during the recording of data, the correction will be made by erasing
the erroneous entry and writing in the correct data (authenticated by the initials of the
correcter and the date of correction).
- when the study is finished for a patient, or voluntary or compulsory withdrawal has
occurred, the report sheet will be reviewed by the investigator, whose signature will
certify that it is complete.

X.1 IF SERIOUS UNDESIRABLE EFFECTS OCCUR

The investigator should report any serious undesirable effects within 24 h, either
by telephone or directly, to persons of the medical department whose names appear on
the flyleaf of the binder and fill in the appropriate sheet. This information should be sent
to Boupharma Laboratories as soon as possible. The list of serious undesirable effects
appears in annex 2.

In case of emergency, one of the following persons should be contacted:

either at Boupharma Laboratories: 16 (1) 00-00-00-00
or at their home number:
Dr. A. Dupont: 00 (1) 11-11-11-11
Dr. B. Durand: 00 (1) 22-22-22-22

X.2 PROCEDURES
In case of serious adverse effects, the information should be sent to Boupharma
Laboratories on the very first day if the effects
- are life-threatening,
- are due to an overdose,
- lead to hospitalization,
- lead to permanent disability, a congenital anomaly, cancer, or death.

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 The initial report should provide the following information:
- a concise description of the undesirable effect and the reason why it is considered
serious,
- the number of the study and of the patient,
- the name and telephone number of the investigator.
The following minimal data should be provided using accepted medical
terminology:
A description of the undesirable effect:
- its nature,
- intensity and duration,
- date of occurrence,
- treatment required, course, and relation with the trial product.
The time since the last administration of the trial product.

Information concerning the hospitalization, if necessary (or prolonged hospitalization for

patients already hospitalized).
The measures taken with respect to the trial product.

Indication as to whether the code has been broken.

All undesirable effects observed (including laboratory results) should be followed
up until the end of the trial and afterwards (if necessary). They should be recorded until
their complete disappearance or after the sequelae have been evaluated by the
investigator.

The results of any complementary examinations, such as laboratory tests, ECG, or

X-rays, should be added to the patient's binder and dated.

The investigator should evaluate each undesirable effect and give his opinion
about its possible relation to the trial product. For this procedure, the investigator should
make use of the definitions provided in annex 2.

X.3 AMENDMENT TO THE PROTOCOL

Neither the investigator nor Boupharma Laboratories can modify the protocol
without obtaining the written agreement of the other party. Any change in the protocol
will be recorded in an "amendment to the protocol" prepared by the trial supervisor. This
amendment will then be submitted to the ethics committee for approval.

All approved amendments to the protocol will be recorded on an amendment form

signed by Boupharma Laboratories and the investigator.

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 X.4 PROTOCOL VIOLATION DUE TO AN EMERGENCY,
UNDESIRABLE EFFECT OR FAILURE OF THE PATIENT TO COMPLY
WITH THE VISIT SCHEDULE
An emergency situation can justify a failure to comply with the protocol. The
investigator or other duty physician in case of an emergency should get in touch with
Boupharma Laboratories on the same day. The investigator should describe the protocol
violation in the patient's binder, indicating the reason.

X.5 RECORDS
French law requires the investigator to maintain information concerning the
product, informed consent, and approvals by the ethics committee. He is required to keep
copies of binders, correspondence, dates of visits, and results. These obligations are valid
for a 15-year period after the end of the clinical trial.

X.6 MINISTRY OF HEALTH

The investigator is advised that local health ministry representatives can check the
progress of the trial. He agrees to facilitate all their visits required for the trial and to
review the data with them.

X.7 CONFIDENTIALITY OF THE PATIENT

To ensure the confidentiality of the patient, the only identification reported to
Boupharma Laboratories will be the patient's initials and the number assigned to him
during the trial. This confidentiality cannot be maintained for any patients who might
experience a severe side effect or be hospitalized during the trial.

135
XI. USE OF THE RESULTS

XI. USE OF TRIAL DATA AND RESULTS

All data concerning BOU-093 and the activity of Boupharma Laboratories, such
as research, formulas, manufacturing procedures, and basic scientific data or information
provided by Boupharma and not yet published, are considered to be confidential and
remain the property of Boupharma Laboratories..
The investigator agrees to use this information only for the accomplishment of the
trial and not for other purposes, unless express written consent is obtained from
Boupharma Laboratories. Exceptionally, information may be given to official
representatives such as those from the Ministry of Health.
The investigator agrees that the information resulting from this clinical trial, as it
relates to the development of BOU-093, can be used by Boupharma Laboratories and
requested by other investigators and government authorities.
To facilitate the use of information from the clinical trial, it is essential that the
investigator send the complete results of examinations and all the data developed during
this trial to Boupharma Laboratories.

XI.2 PUBLICATION OF RESULTS

The publication of the final study will be carried out under the authority of the
members of the scientific committee designated in the protocol. The individual
investigators are free to publish the results independently, but they must have the
approval of the other participants in the trial whose data are used in the publication.
It is understood that no part of the study will be reported before the complete
publication of the trial has appeared.
Manuscripts for publication must be submitted to Boupharma Laboratories, if
possible four weeks before their submission to the organism responsible for their
publication.
The results of this clinical trial can be freely used by the supervisor, notably for
inclusion in a registration file or in documentation intended for the medical corps, in
summaries, or during presentations at scientific meetings or publications in specialized
journals.

XI.3 TRIAL REPORT

The final trial report will be prepared by the national coordinator in collaboration
with Boupharma Laboratories. It will be discussed with the regional coordinators before
being finalized.
The report must be signed by the coordinators and responsible individuals of
Boupharma Laboratories.

136
137
XII. EXTERNAL TRIAL AUDIT

In accordance with the quality control described in Good Clinical Practices,

Boupharma Laboratories reserves the right to have a systematic control conducted by an
external organism.

138
XIII. INSURANCE

Boupharma Laboratories acknowledges that it is covered by an insurance contract

underwritten by Zurich International France (Contract No. XX85-893) relative to the
civil liability of the investigators and promoters working in the context of therapeutic
research.

139
ANNEX 1

PATIENT INFORMATION SHEET

Dear Sir or Madam,

You are suffering from anxiety, and your physician has asked you to take part in a
therapeutic trial during which you will be given either a new drug known as BOU-093,
or alprazolam, or a pharmacologically inactive product (but not without therapeutic
effect).
The purpose of this study is to assess the benefit of BOU-093 treatment on
anxiety.
The Ethics Committee of the Pays de la Loire Region has approved this trial.
BOU-093 is a new drug not belonging to the benzodiazepine family which may
have a favorable effect on anxiety. It has already been administered to 200 healthy
volunteers, none of whom experienced any undesirable effects.
To participate in this trial, you are requested to follow the instructions that your
physician will give you.

The trial will be carried out over a four-month period.

- examinations will be performed during the first seven days, and you will be wash-out
from unapproved medicines;
- treatment will be administered during the next three months;
- a subsequent two-week period will allow the treatment to be tapered off;
- the last two weeks will serve as an observation period without treatment.

You will take the drug regularly after each of three meals.

Nine visits to your physician will be necessary.

Three blood tests and six urine analyses will be performed in your home.

It is absolutely essential to follow your appointment schedule strictly.

If you are a woman, you should take every precaution (pill, intauterine device) to
avoid pregnancy during the trial.

140
 There will be no cost to you for the examinations and visits included in this trial.

The drug you shall be taking, like any other, may sometimes cause undesirable
reactions which are generally benign and familiar to your physician. These effects
include nausea, dizziness, somnolence and fatigue.
You should also be prepared for a possible change in alertness while driving an
automobile or using dangerous machines. The effects of drinking alcohol may also be
enhanced.
Alprazolam can cause the same type of reactions.
If you observe these effects, telephone your physician who will be able to give
you information about this trial.
You have given your consent to take part in this trial, but you are free to withdraw
at any time without any negative consequences for the quality of the care that may
subsequently be given to you.
Finally, if you see another physican during the treatment period, please advise him
that you are participating in this trial, so that he can get in touch with the physician who
is administering this treatment.

We thank you for your participation.

141
PATIENT INFORMED CONSENT FORM

BOU-093 TRIAL

ASSESSMENT OF THE EFFICACY AND TOLERANCE OF BOU-093

COMPARED TO ALPRAZOLAM DURING TREATMENT OF GENERALIZED
ANXIETY

Subject No.: Center No.:

I, the undersigned,

Last Name ............ (first three letters only)

First Name .................................

declare that I give my consent freely and with full knowledge of the facts to take part in
the biomedical research project conducted by Prof. (or Dr.) ..................................

I recognize that I have the right to refuse to participate in this project or to

withdraw my consent at any time without incurring any responsibility, and I realize that
such a decision would not affect the management of my treatment by Prof. (or Dr.)
..................................

The purpose of the research project and the conditions and length of the trial have
been clearly explained to me, as well as the possible constraints and risks, including
those relating to the project being stopped before its normal term.

I have been advised that the information collected will remain anonymous.

Place and date of signature: .................................................................

142
Signature of the investigator Signature of the patient

143
ANNEX 2

144
UNDESIRABLE EFFECTS

1. DEFINITIONS

1.1 Undesirable effect

An undesirable effect is an unusual event occurring in a healthy volunteer or a
patient, which coincides with the administration of a drug under development or on the
market, regardless of whether it is considered to be due to the drug or not.
An undesirable effect includes any unusual event which produces subjective or
objective symptoms of an intercurrent disease, accidents, biological changes, effects
leading to the discontinuance of the drug, drug interactions, effects of overdosage (as
assessed by the physician), abuse, or dependency.
Unusual events occurring during phases under placebo or in the comparison group
are also included.

1.2 Product-related effect

A side effect for which the trial drug is considered to be responsible is regarded as
product-related.
Unless such a relation has been established, the undesirable effects observed
during a clinical trial should not be designated as product-related.

1.3 Intensity (severity)

Low: The undesirable effect is transient and well-tolerated by the patient.

Moderate: The undesirable effect causes the patient discomfort and affects his
usual activities.

Severe: The undesirable effect causes the patient considerable discomfort in

his usual activities, may be disabling, or may be life-
threatening.

1.4 Serious/non-serious
A serious side effect is any event suggestive of a significant risk, a
contraindication, a side effect to be mentioned, or a precaution.
For humans, serious side effects include any event associated with death,
hospitalization or prolonged hospitalization and permanent sequelae, as well as all the
events that are life-threatening or the cause of a congenital anomaly, a coma or
overdosage.

145
 Non-serious side effects are all others than those described above.

1.5 Expected/unexpected
For drugs under development, the effect is considered expected if its nature,
intensity, frequency and specificity correspond to any of the side effects indicated in the
investigator's booklet. (For drugs already on the market, the effect is considered expected
if described in the VIDAL or the drug package insert.)

In all other cases, the effect is considered unexpected.

146
2. ASSESSMENT OF SIDE EFFECTS

Definitions are given below on the basis of a five-level scale used by the
investigator to rate the relation between the side effect and the drug.

Definite (very probable):

A side effect which occurs within a time period compatible with drug
administration (including after drug weaning) and meets one of the following criteria:
- reappearance of a similar reaction after another administration of the drug
(reintroduction);
- positive results on product senstivity tests (lymphocyte transformation test, skin
test, etc.);
- toxic concentration of the drug in the blood or in other organic fluids.

Probable:
A side effect which occurs within a time period compatible with drug
administration (including after drug wash-out), for which other causative factors can be
excluded, such as an underlying disease, complications and concomitant treatments other
than the drug tested.

Plausible:
A side effect which occurs within a time period compatible with drug
administration (including after drug wash-out), for which the role of the drug cannot be
excluded*, even though other factors may be responsible, such as an underlying disease,
complications and concomitant treatments other than the drug tested.
*for example, the existence of similar indications attributed to the suspect drug or
its analogs, or reactions attributed to the pharmacologic effect.
Unknown:
This category should be reserved for a side effect for which the data are
inadequate to provide an evaluation (refused judgment).

Apparently excluded:
A side effect which does not occur within a time period compatible with drug
administration or which can be reasonably explained by another factor, including an
underlying disease, complications and concomitant treatments.

DIAGNOSTIC CRITERIA FOR GENERALIZED ANXIETY DISORDER

147
A. Excessive anxiety and worry (apprehensive expectation) occurring more days than not
over at least a six-month period and relating to a number of events or activities (such
as work or school performance).

B. The person finds it difficult to control the worry.

C. The anxiety and worry have been associated with three (or more) of the following six
symptoms (some symptoms being present for more days than not for the past six
months).
Note: Only one item is required in children.

(1) restlessness or feeling keyed up or on edge

(2) being easily fatigued

(3) difficulty concentrating or mind goes blank

(4) irritability

(5) muscle tension

(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder,
e.g. the anxiety or worry is not about having a Panic Attack (as in Panic Disorder),
being embarrassed in public (as in Social Phobia), being contaminated (as in
Obsessive Compulsive Disorder), being away from home or close relatives (as in
Separation Anxiety Disorder) , gaining weight (as in Anorexia Nervosa), having
multiple physical complaints (as in Somatization Disorder), or having a serious illness
(as in Hypochondriasis); and the anxiety and worry do not occur exclusively during
Post-Traumatic Stress Disorder.

E. The anxiety, worry or physical symptoms cause clinically significant distress or

impairment in social, occupational or other important areas of functioning.

F. The disturbance is not due to the direct physiological effects of a substance (e.g. a drug
of abuse, a medication) or a general medical condition (e.g. hyperthyroidism) and
does not occur exclusively during a Mood Disorder, a Psychotic Disorder or a
Pervasive Developmental Disorder.

148
 HAMILTON ANXIETY RATING SCALE (HAMA)

The phrases below describe certain feelings that people have. Rate the patient according
to the extent to which he/she has these conditions. Select one of the five possible
responses for each of the fourteen phrases.
Possible responses:
0 Not present
1 Mild
2 Moderate
3 Severe
4 Very severe

1. Anxious mood
Worries, anticipation of the worst, fearful anticipation, irritability.

2. Tension
Feelings of tension, fatigability, startle response, moved to tears easily, trembling,
feelings of restlessness, inability to relax.

3. Fears
Of the dark, of strangers, of being left alone, of animals, of traffic, of crowds.

4. Insomnia
Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking,
dreams, nightmares, night terrors.

5. Intellectual
Difficulty in concentration, poor memory.

6. Depressed mood
Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing.

7. Somatic (muscular)
Pains and aches, twitchings, stiffness, myoclonic jerks, grinding of teeth, unsteady
voice, increased muscular tone.

8. Somatic (sensory)
Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, pricking
sensation.

9. Cardiovascular symptoms

149
 Tachycardia, palpitations, chest pain, throbbing of vessels, fainting feelings, missing
beat.
10. Respiratory symptoms
Pressure or constriction in the chest, choking feelings, sighing, dyspnea.

11. Gastrointestinal symptoms

Difficulty in swallowing, wind, abdominal pain, burning sensations, abdominal
fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight,
constipation.

12. Genitourinary symptoms

Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia,
development of frigidity, premature ejaculation, loss of libido, impotence.

13. Autonomic symptoms

Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising
of hair.

14. Behavior at interview

Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face,
sighing or rapid breathing, facial pallor, swallowing, etc.

RASKIN DEPRESSION SCALE AND COVI ANXIETY SCALE

For the Raskin and Covi scales, select one of the five possible responses for each phrase
which best describes the patient's state.

Possible responses:
1 Not apparent
2 Mild
3 Moderate
4 Severe
5 Very severe

RASKIN SCALE

1. Discourse

150
 Sadness, hopelessness, loss of interest, thoughts about death, cries easily.

2. Behavior
Seems demoralized, cries, speaks in a low voice, sad, sluggish, loss of energy.

3. Symptoms
Insomnia or hypersomnia, dry mouth, recent suicide attempt, loss of appetite,
difficulty in concentrating, loss of memory.

151
COVI SCALE

1. Discourse
Nervous, not feeling right, restless, frightened without any reason, timorous, keyed-
up, uptight, avoids certain forms of behavior and certain places, difficulty in
concentrating.

2. Behavior
Seems frightened, uneasy, restless, anguished.

3. Somatic complaints
Sweating, shaking, sense of cardiac stricture, tachycardia, respiratory oppression, hot
or cold flushes, restless sleep, knotted stomach, lump in the throat.

Note: To be included, the patient should have a higher score on the Covi than the Raskin
scale.

HAD SCALE

Physicians know that emotions play an important role in most diseases. If your
physician is aware of your emotions, he will be able to help you better.
This questionnaire is designed to allow your physician to understand your
emotions. Read each series of questions and underline the response which best expresses
what you felt during the past week.
Do not hesitate in replying. Your immediate response to each question will
probably provide a better indication of your true feelings than after deep reflection.

I feel tense or nervous:

most of the time
often
from time to time
never

I still enjoy the same things as in the past:

yes, just as much
not as much
only a little

152
 hardly at all

I have a feeling of fear, as if something terrible were going to happen to me:

yes, very definitely
yes, but not too seriously
truly less than in the past
not at all

I laugh easily and see the good side of things:

as much as in the past
even more than in the past
truly less than in the past
no longer

I worry:
very often
rather often
occasionally
very occasionally
I am in a good mood:
never
rarely
rather often
most of the time

I can remain peacefully seated without doing anything and feel relaxed:
yes, regardless of what happens
yes, generally
rarely
never

I have the impression of operating in slow motion:

nearly always
very often
sometimes
never
I have a sense of fear and a knotted stomach:
never
sometimes
rather often
very often

153
I am no longer interested in my appearance:
not at all
I don't pay as much attention to it as I should
I may no longer pay as much attention to it
I pay as much attention to it as in the past

I'm fidgety and can't stay still:

yes, that's exactly right
a little
not that much
not at all

I am delighted at the prospect of doing certain things:

as much as in the past
a little less than in the past
much less than in the past
almost never

I have sudden feelings of panic:

really very often
rather often
not very often
never

I like to read a good book or enjoy a good radio or television program:

often
sometimes
rarely
very rarely

Now check to be sure that you have replied to all the questions.

154
WEANING SCALE OF LADER AND BOURIN

INSTRUCTIONS

Determine the intensity of the following symptoms in the patient. Select the most
suitable code for each of the symptoms.

155
Physical fatigue
0 = None
1 = Tired but without needing to lie down
2 = Need to lie down from time to time
3 = Lying down all day long

156
Sleep disturbances
0 = Normal sleep without a hypnotic
1 = Normal sleep with a hypnotic
2 = 3 to 6 hours of sleep with a hypnotic
3 = Less than 3 hours of sleep with a hypnotic

157
Headaches
0 = None
1 = Occasionally, without any need for analgesics
2 = Continual but moderate, or occasional but severe; salicylates effective
3 = Continual and severe; salicylates not effective

158
Dizziness
0 = None
1 = Occasional slight dizzy spells
2 = Continual but slight dizzy spells or occasional severe dizzy spells
3 = Continual severe dizzy spells; a need to lie down

159
Orthostatic symptoms
0 = None
1 = A fainting sensation upon standing up suddenly
2 = Need to stand up slowly to avoid fainting
3 = Fainting

160
Palpitations
0 = None
1 = Slight palpitations
2 = Occasional disturbing palpitations
3 = Continual disturbing palpitations

161
Shaking
0 = None
1 = Slight shaking but movements not affected
2 = Evident shaking, with slight disturbances of gestures
3 = Severe shaking

162
 Sweating
0 = Normal
1 = Slightly increased
2 = Increased quite apparently
3 = Profuse

Dry mouth
0 = None
1 = Slight, but not subjectively disturbed
2 = Obvious, but not severe or painful
3 = Severe, making speech difficult

Constipation
0 = None
1 = Slight constipation without the need for laxatives
2 = Obvious constipation with a need for laxatives
3 = No peristaltis despite the use of laxatives

Micturition problems

0 = None
1 = Slight micturition problems
2 = Difficulties in bladder emptying; a need for treatment
3 = Retention of urine

163
CASSANO'S WEANING SCALE

INSTRUCTIONS

For each item, choose the score that according to your experience corresponds to
the intensity of the patient's experience. All the items should be scored.

0 = not evident 1 = mild 2 = moderate 3 = severe

1. Anxiety, tension

2. Impatience, restlessness

3. Irritability

4. Lack of energy

5. Difficulty in memorizing and concentrating

6. Depressive mood

7. Depersonalization

8. Derealization

9. Sleep disorders

10. Loss of appetite

11. Headaches

12. Persistent muscle pain and/or aches

13. Nausea, desire to vomit

14. Shaking and/or equilibrium problems

15. Sweating

164
16. Taste of metal

17. Hyperosmia

18. Paresthesias

19. Inflammation of the eyes

20. Photophobia

21. Motor incoordination

22. Dizzy feeling

23. Hyperacusis

24. Pseudoflu syndrome

25. Hypersensitivity and/or pain from pressure on the skin

26. Sensitivity

27. Visual hallucinations

165
 GOOD CLINICAL PRACTICE FOR TRIALS ON MEDICINAL
PRODUCTS IN THE EUROPEAN COMMUNITY.

FOREWORD.

This document should be read and interpreted in the light of Directives

65/65/EEC[1] and 75/318/EEC1 and THE RECOMMENDED BASIS FOR THE
CONDUCT OF CLINICAL TRIALS OF MEDICINAL PRODUCTS IN THE
EUROPEAN COMMUNITY1 (Annex 1).

The objective of this guideline is to establish the principles for the standard of Good
Clinical Practice for trials on medicinal products in human beings within the EEC. It is
directed primarily towards the pharmaceutical industry, but also to all who are involved
in the generation of clinical data for inclusion in regulatory submissions for medicinal
products. These principles are pertinent to all four phases of clinical investigation of
medicinal products, including bioavailability and bioequivalance studies and can be
applied more widely by those who undertake experimental investigation in human
subjects.

All parties involved in the evaluation of medicinal products share the responsibility of
accepting and working according to such standards in mutual trust and confidence. Pre-
established, systematic written procedures for the organization, conduct, data collection,
documentation and verification of clinical trials are necessary to ensure that the rights
and integrity of the trial subjects are thoroughly protected and to establish the credibility
of data and to improve the ethical, scientific and technical quality of trials. These
procedures also include good statistical design as an essentiel prerequisite for credibility
of data and moreover, it is unethical to enlist the co-operation of human subjects in trials
which are not adequately designed. By these means all data, information and documents
may be confirmed as being properly generated, recorded and reported.

CONTENTS

Foreword

166
Glossary

Chapter 1 : PROTECTION OF TRIAL SUBJECTS AND CONSULTAT70N OF

EThICS COMMITTEES
Protection of Trial Subjects
Ethics Committees
Informed Consent
Chapter 2: RESPONSABILITIES
Sponsor
Monitor
Investigator

Chapter 3: DATA HANDLING

Investigator
Sponsor/Monitor
Archiving of Data
Language
Chapter 4: STATISTICS
Experimental Design
Randomization and Blinding
Statistical Analys
Chapter 5: QUALITY ASSURANCE

Annex

GLOSSARY

Explanations of terms used in this document

Adverse Event /Adverse Experience (AE) : any undesirable experience occurring to a

subject, during a clinical trial, whether or not considered related to the investigational
product(s). Serious AE means an adverse experience that is fatal, life-threatening,
disabling or which results in in-patient hospitalization or prolongation of hospitalisation.
In addition, congenital anomaly and occurence of malignancy are alway considered
serious AE. An unexpected AE is an experience not previously reported (in nature,
severity or incidence) in the current investigator's Brochure, when an AE has been
assessed and causal relation to investigational product(s) established, it must be
considered as an ADR (see below).

Adverse Drug Reaction (ADR) : a reaction which is noxious and unintended and which

167
occurs doses normally used in man for prophylaxis, diagnosis or therapy of disease or
for the modification of physiological function. In the case of clinical trials injuries by
overdosing, abuse dependence and interactions with other medicinal products should be
considered as ADR.

Audit (of a trial) : a comparison of Raw Data and associated records with the interim or
Final Report in order to determine whether testing was carried out in accordance with
the Protocol and Standard Operating Procedures (SOP), to obtain additional information
not provided in the Final Report, and establish wheteher practices were employed in the
development of data that would impair their validity.
Audit must be conducted either through an intemal facility at the sponsor but
independent of the units responsible for clinical research, or through an extremal
contractor.
An audit certificate is a declaration of confirmation that appropriate audit has taken
place.

Case Report Form (CRF) : a record of data and other information on each subject in a
trial as defined by the protocol. The data may be recorded on any medium, including
magnetic and optical carriers, provided that there is assurance of accurate input and
presentation, and allows verification.

Clinical Trial : any systemic study on medicinal products in human subjects whether in
patients or non-patient volunteers in order to discover or verify the effects of and/or
identity any adverse reaction to investigational products, and/or to study their
absorption, distribution, metabolism and excretion in order to ascertain the efficacy and
safety of the products.

Confidentiality (regarding trial subjects) : maintenance of the privacy of trial subjects

including their personal identity and all personal medical information. If data
verification procedures demand inspection such details, this may only be done by a
properly authorized person. Identifiable personal details must always be kept in
confidence. The trial subject's consent to the use of records for data verification
purposes should be obtained prior to the trials and assurance should be given that
confidentiality will be maintained.
When reporting AEs or any other information to the sponsor and/or the relevant
authorities, the investigator should assure that the subject's privacy is not violated. The
name of the investigator reporting the AE should be stated.

Confidentiality (regarding materiel from sponsor) : maintenance of secrecy of

confidential information from the sponsor in connection with the planning, execution,
reviewing, auditing, or evaluation of a clinical trial.

168
Contract Research Organization (CRO) : a scientific body (commercial, academic or
others) to which a sponsor may transfer some of his tasks and obligations. Any such
transfer should be defined in writing.

Documentation : all records in any form (including documents, magnetic and optical
records) describing methods and conduct of the trial, factors affecting the trial and the
action taken. These include protocol, copies of submissions and approvals from the
authorities and the Ethics Committee investigator(s), curriculum vitae, consent forms,
monitor reports, audit certificates relevant letters, reference ranges, raw data, completed
CRF and the Final Report.

Ethics Committee : an independent body, constituted by medical professionals and non-

medical members, whose responsibility is to verify that the safety, integrity and human
rights of the subjects participating in a particular trial are protected, thereby providing
public reassurance.

Ethics Committee should be constituted and operated so that the suitability of the
investigators, facilities, protocols, the eligibility of trial subjects groups, and the
adequacy of confidentiality safeguards may be objectively and irnpartially reviewed
independently of the investigator, sponsor, and relevant authorities.

The legal status, constitution, and regulatory requirements pertaining to Ethics

Committee, Review Boards, or similar institutions may differ among countries.

A list of the members, and their positions, of the Ethics Committee and a description of
its working procedures including response times should be publicly available.

Final Report : a complete and comprehensive description of the trial after its completion
including a description of expérimental (including, statistical) methods and materials, a
presentation and evaluation of the results, statistical analyses and a critical statistical and
clinical appraisal.

Good Clinical Practice (GCP) : a standard by which clinical trials are designed,
implemented and reported so that there is public assurance that the data are credible, and
that the rights, integrity and confidentiality of subjects are protected.

Good Manufacturing Practice (GMP) : the part of the pharmaceutical quality assurance
which ensures that products are consistently produced and controlled to the quality
standards appropriate for their intended use and as required by the product specification.

Any reference to GMP should be understood as a reference to the current EEC GMP
(cf. Vol. IV of the Rules Governing Medicinal Products in the European Community).

169
Informed Consent : the voluntary confirmation of a subject's willingness to participate in
a particular trial, and the documentation thereof. This confirmation should only be
sought after information has been cgiven about the trial including an explanation of its
objectives, potentiel benefits and risks and inconveniences, and of the subject's rights
and responsibilities in accordance with the current revision of the Declaration of
Helsinki.

Inspection : officially conducted by relevant authorities at the site of investigation and/or

at the sponsor in order to verify adherence to Good Clinical Practice as explained in this
document.

Investigator's Brochure : a collection of data consisting of all the relevant information

known prior to the onset of clinical trial including chemical and pharmaceutical data,
toxicological, pharmacokinetic and pharmacodynamic data in animals and the results of
earlier clinical trials. There should be adequate data to justify the nature, scale and
duration of the proposed trial. The information must be updated during the course of the
trial, if new data arise.

Investigational Product : a pharmaceutical form of an active ingredient or placebo being

tested or used as a reference in a clinical trial.

Investigator (s) : one or more persons responsible for the pratical performance of a trial
and for the integrity, health and welfare of the subjects during the trial.

The investigator is :
- an appropriately qualified person legally allowed to practice medicine/dentistry.
- training and experienced in research, particularly in the clinical area of the proposed
trial,
- familiar with the background to and the requirements of the study,
- known to have high ethical standards and professional integrity.

The legal status of persons authorized to act as investigators may differ between
Member States.

For multicentre trials a coordinating (principal) investigator, responsable for the

coordination of the investigators at the different centres, may be appointed.

Medicinal Product : the meanings of the terms "medicinal product" and "substance",
respectively, are given in Article 1 of Council Directive 65/65/EEC, as amended.

Monitor : a person appointed by the sponsor or Contract Research Organisation (CRO)

170
to be responsible for the sponsor or CRO for the monitoring and reporting on the
progress of the trial and for verification of data. The monitor must have qualifications
and experience to enable a knowledgeable supervision of the particular trial. Trained
technical assistants may help the monitor in collection of documentation and subsequent
processing.

Multicentre Trial : a clinical trial conducted according to one single protocol in which
the trial is identified as taking, place at different investigational sites, therefore carried
out by more than one investigator, but following he same practical details (cf.
Investigator(s)).

Patient File: a file containing democraphic and medical information about a patient or a
subject (e.g. hospital file, a consultation record or a special subject file). Such files are
necessary for a verification of the authenticity of the information presented in the CRF
and, where needed, the possibility of completing or correcting it, provided that the
conditions regulating the use and consultation of such documents are respected (cf.
Confidentiality).

Protocol : a document which states the rationale, objectives and statistical design and
methodology of the trial, with the conditions under which it is to be performed and
managed. A list of items to be included in the protocol is given in the recommended
basis for the conduct of clinical trials of medicinal products in the european community
(Annex).

Quality Assurance : systems and processes established to ensure that the trial is
performed and the data are generated in compliance with Good Clinical Practice
including procedures for ethical conduct, SOPs, reporting, personal qualifications etc.
This is validated through inprocess quality control and in – and postprocess auditing,
both being applied to the clinical trial process as well as to the data.

Personnel involved in Quality Assurance audit activities must be independent of those

involved in or managing a particular trial.

Quality Control : the operational techniques and activities undertaken within the system
of Quality Assurance to verify that the requirements for quality of the trial have been
fulfilled.
Quality Control activities concern all members of the investigational team, including the
staff of the sponsor or CRO involved with planning, conducting, monotoring evaluating
and reporting a trial including data processing, with the objective of avoiding trial
subjects being exposed to unnecessary risk, or false conclusions being drawn from
unreliable data.

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Raw Data : records or certified copies of the original clinical and laboratory findings
from the trial.
Serious Adverse Event : (see Adverse Event / Adverse Experience).

Source Data : patient files, oricinal recordings from automated instruments, tracings
(ECG, EEG), x-ray films, laboratory notes etc.

Sponsor : an individual or an organization which takes responsability for the initiation,

management and/or financing of a clinical trial. When an investigator independently
initiates and takes full responsability for a trial which may subsequently become a part
of an application for a marketing authorization, the investigator then assumes the role of
the sponsor as well.

Standard Operating Procedures (SOP) : sponsor's standard, detailed, written instruction

for the management of clinical trials. They provide a general framework enabling, the
efficient implementation and performance of all the functions and activities for a
particular trial as described in this document.

Study Coordinator (local) : an appropriately experienced person nominated by the

investigator to assist administering the trial at the investigational site.

Subject : a human being (either a patient or a non-patient volunteer) participating in a

clinical trial.

Trial Audit: (see Audit).

Trial Master File : a hard copy of all the documentation relating to a clinical trial (cf.
Documentation).

Unexpected Adverse Event : (see Adverse Event / Adverse Experience).

Verification/Validation of Data : the procedures carried out to ensure that the data
contained in the final clinical trial report (Final Report) match original observations.
These procedures may apply to raw data, hard copy, or electronic CRFs, computer print-
outs and statistical analyses and tables (cf. Audit, Inspection, Quality Control).

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 CHAPTER 1
PROTECTION OF TRIAL SUBJECTS AND CONSULTATION OF
ETHICS COMMITTEES

Protection of Trial Subjects.

1.1. The current revision of the Declaration of Helsinki is the accepted basis for clinical
trial ethics, which must be fully known and followed by all engaged in research on
human being.

1.2. The personal integrity and welfare of the trial subjects is the ultimate responsibility
of the investigator in relation to the trial; but independent assurance that subjects are
protected by an Ethics Committee and freely obtained informed consent.

Ethics Committees.

1.3 The sponsor and/or investigator must request the opinion of relevant Ethics
Committee(s) regarding suitability of clinical trial protocole (including annexes) and of
the methods and material to be used in obtaining and documenting informed consent of
the subjects.

1.4 The Ethics Committee must be informed of all subsequent protocol amendments and
of serious or unexpected AEs occurring during the trial, likely to affect the safety of the
subjects or the conduct of the trial and should be asked for its opinion if a re-evaluation
of the ethical aspects of the trial appears to be called for.

1.5 Subjects must not be entered into the trial until the relevant Ethics Committee(s) has
issued its favourable opinion on the procedures and documentation.
Sponsor/investigator should consider recommendations made by the Ethics Committee.

1.6 In submitting clinical trial proposals to an Ethics Committee, they should be asked to
consider the following

a) the suitability of the investigator for the proposed trial in relation to his/her
qualifications, expérience, supporting staff, and available facilities, on basis of the
information available to the Committee.

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b) the suitability of the protocol in relation to the objectives of the study, its scientific
efficiency i.e. the potential for reaching sound conclusions with the smallest possible
exposure of subjects, and the justification of predictable risks and inconveniences
weighed against the anticipated benefits for the subjects and/or others.

c) adequacy and completeness of the written information to be given to the subjects.

their relatives, guardians and, if necessary, legal representatives.

d) the means by which initial recruitment is to be conducted and by which full

information is to be given, and by which consent is to be obtained. All written
information for the subject and/or legal representative must be submitted in its final
form.

e) provision for compensation/treatment in the case of injury or death of a subject if

attributable to a clinical trial, and any insurance or indemnity to cover the liability of the
investigator and sponsor.

f) the extent to which investigators and subjects may be rewarded/compensated for

participation.

1.7 The Ethics Committee should give its opinion and advice in writing within a
reasonable time limit, clearly identifying the trial, the documents studied and date of
review.
Informed Consent.

1.8 The principles of informed consent in the current revision of the Helsinki
Declaration should be implemented in each clinical trial.

1.9 Information should be given in both oral and written form whenever possible. No
subjects should be obliged to participate in the trial. Subjects, their relatives, guardians
or, if necessary, legal representatives must be given ample opportunity to enquire about
details of the trial. The information must make clear that refusal to participate or
withdrawal from the trial at any stage is without any disadvantages for the subject's
subsequent care. Subjects must be allowed sufficient time to decide whether or not they
wish to participate.

1.10 The subject must be made aware and consent that personal information may be
scrutinized during audit by competent authorities and properly authorized persons, but
that personal information will be treated as stricly confidential and not be publicly
available.

1.11 The subject must have access to information about the procedures for compensation

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and treatment should he/she be injured/disabled by participating in the trial.

1.12 If a subject consents to partipate after a full and comprehensive explanation of the
study (including its aims, expected benefits for the subjects and/or others, reference
treatments/placebo, risks and inconveniences - e.g. invasive procedures - and, where
appropriate, an explanation of alternative, recognised standard medical therapy), this
consent should be appropriately recorded. Consent must de documented either by the
subject's dated signature or by signature of an independent witness who records the
subject's assent. In either case the signature confirms that the consent is based on
information which has been understood, and that the subjects has freely chosen to
participate without prejudice to legal and ethical rights while allowing the possibility of
withdrawal from the study without having to give any reason unless AEs have occurred.

1.13 If the subject is incapable of giving personal consent (e.c,. unconsciousness or

severe mental illness or disability), the inclusion of such patients may be acceptable if
the Ethics Committee is, in principle, in agreement and if the investigator is of the
opinion that participation will promote the welfare and interest of the subject. The
agreement of a legally valid represensative that participation will promote the welfare
and interest of the subject should also be recorded by a dated signature. If neither signed
informed consent nor witnessed signed verbal consent are possible, this fact must be
documented with reasons by the investigator.

1.14 Consent must always be given by the signature of the subject in a non-therapeutic
study, i.e. when there is no direct clinical benefit to the subject.

1.15 Any information becoming available during the trial which may be of relevance for
the trial subjects must be made known to them by the investigator.

CHAPTER 2
RESPONSIBILITIES.

Note : Responsibilities related to data handling, archiving, statistics and assurance of

quality are included in subsequent chapters.

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Sponsor.

2.1 The sponsor must establish detailed Standard Operating Procedures (SOP) to comply
with Good Clinical Practice, and is responsible for conducting an internal audit of the
trial. The sponsor should agree with the investigator on the distibution of
responsibilities (cf. 2.3. k).

2.2 Both the sponsor and investigator must agree on and sign the protocol as an
agreement of the details of the clinical trial and the means of data recording (e.g. CRF).
Any amendments to the protocol must have agreement of both sponsor and investigator
before the amendment is implemented; any such agreement must be documented.

2.3 Particular responsibilities of the sponsor:

a) to select the investigator taking into account the appropriateness and availability of
the trial site and facilities, and be assured of investigator's qualifications and availability
for the entire duration of the study; to assure the investigator's agreement to undertake
the study as laid down in the protocol, according to these guidelines of Good Clinical
Practice, including the acceptance of verification procedures, audit and inspection.

b) to inform the investigator of the cheminal/pharmaceutical, toxicological,

pharmacological and clinical information (including previous and on-going trials),
which should be adequate to justify the nature, scale and duration of the trial, as a
prerequisite to planning the trial and to inform the investigator of any relevant new
information arising during the trial. All relevant information must be included in the
Investigator's Brochure which must be supplemented and/or updated by the sponsor
whenever new pertinent information is available.

c) to submit notification/application to the relevant authorities (when appropriate) and to

ensure submission of any necessary documents to the Ethics Committe, and to ensure
communication of any modification, amendment or violation of protocol if the change
may impact on the subject's safety, and to inforrn the investigator and relevant
authorities about discontinuation of the trial and the reasons for discontinuation.

d) to provide the fully characterized investigational medicinal product(s) prepared in

accordance with Good Manufacturing Practice (GMP), suitably packaged and labelled in
such way that any blinding procedure is ensured.
Sufficient samples of each batch and a record of its analyses and characteristics must be
kept for reference, so that there is the possibility for an independent laboratory to re-
check the investigational products, e.g. for bioequivalence.
Records of the quantities of investigational medicinal products supplied must be
maintained with batch/serial numbers. The sponsor must ensure that the investigator

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within his/her institution establishes a system for the safe handling, storace and use of
the delivered investigational products (cf. 2.5. j).

e) to appoint, and ensure the on-going training of, suitable and appropriately trained
monitors and their clinical research support personnel.

f) to appoint appropriate individuals and/or committees for the purpose of steering,

supervision, data handling, statistical processing, and trial report writing,

g) to consider promptly, jointly with investigator, all serious AEs and take appropriate
mesures necessary to safeguard trial subjects, and to report to appropriate authorities
according to their requirements.

h) to inform promptly the investigator of any immediately relevant information that

becomes available during a trial and ensure that the Ethics Committee is notified by the
investigator (s) where required.

i) to ensure the preparation of a comprehensive Final Report of the trial suitable for
regulatory purposes wheter or not the trial has been completed. Safety up-dates may be
required. For longterm trials an annual report may be required by the authorities.

j) to provide adequate compensation/treatment for subjects in the event of trial related

injury or death, and provide indemmity (legal and financial cover) for the investigator,
except for claims resulting from malpractice and/or negligence.

k) to agree with the investigator(s) on the allocations of responsabilities for data

processing, statistical handling, reporting of the results, and publication policy.

Monitor.

2.4 The monitor is the principal communication link between the sponsor and the
investigator.

Responsibilities of the monitor:

a) to work according to a predetermined SOP, visit the investigator before, during and
after the trial to control adherence to the protocol and assure that all data are correctly
and completely recorded and reported, and that informed consent is being obtained and
recorded from all subjects prior to their participation in the trial.

b) to ensure that the trial site has adequate space, facilities (including laboratories),

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equipment, staff, and that an adequate number of trial subjects is likely to be available
for the duration of the trial.

c) to ensure that all staff assisting the investigator in the trial have been adequately
informed about and comply with the details of the trial.

d) to enable/ensure communication between the investigator and sponsor promptly at all

times.

e) to check the CRF entries with the source documents and to inform the investigator of
any errors/omissions.

f) to check that the storage, dispensing, return and documentation of the supply of
investigational medicinal product(s) are safe and appropriate and in accordance with
local regulations (cf. 2.5. j).

g) to assist the investigator in any necessary notification/application procedure.

h) to assist the investigator in reporting the trial data and results to the sponsor.

i) to submit a written report to the sponsor and the steering committee (if any) after each
visit (monitor report) and after all relevant telephone calls, letters and other contacts with
the investigator (audit paper trail concept).

Investigator.

2.5 Responsibilities of the investigator.

a) to be thoroughly familiar with the properties of the investigational medicinal

product(s) as described in the investigator's Brochure.

b) to ensure that he/she has sufficient time to conduct and complete the trial, and has
adequate staff and appropriate facilities (including laboratoiries) which are available for
the duration of the trial, and to ensure that other trials do not divert essential subjects or
facilities away from the trial in hand.

c) to provide retrospective data on numbers of patients who would have satisfied the
proposed entrance criteria during preceding time periods in order to assure end edequate
recruitment rate for the trial.

d) to submit an up-to-date curriculum vitae and other credentials to the sponsor and -

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where required - to relevant authorities.

e) to agree and sign the protocol with the sponsor and confirm in writting that he/she has
read, understands and will work according to the protocol and Good Clinical Practice,
accepting the oversight of the monitor and control procedures, and agree with the
sponsor on a publication policy.

f) to nominate (if appropriate) a local study coordinator to assist administration of the

trial.

g) to submit notification/application to relevant bodies including local hospital

management, and to the Ethics Committee, jointly with sponsor where appropriate.

h) to provide information to all staff members invoived with the trial or with other
elements of the patients' management.

i) to obtain informed consent from trial subjects prior to inclusion in the trial in
accordance with principles described in sections 1.8. to 1. 1 5.

j) to establish a system regarding investigational medicinal products to ensure that

deliveries from the sponsor of such products are correctly received by a responsible
person (e.g. a pharmacist), that such deliveries are recorded; that investigational products
are handled and stored safety, and properly; that investigational products are only
dispensed to trial subjects in accordance with the protocol; that any unused products are
retumed to the sponsor. At the end of the trial, it must be possible to reconcile delivery
records with those of usage and returned stocks. Account must be given of any
discrepancies. Certificates of delivery and returns must be signed.

k) to manage code procedures and documentation with meticulous care, and ensure that
the treatment code is only broken in accordance with the protocol and that the monitor is
consulted/informed when this is done.

l) to collect record and report data properly,.

m) to notify (with documentation) the sponsor and when applicable the Ethics
Committee (and relevant authorities when required) immediately in the case of serious
AEs and to take appropriate measures to safeguard subjects.

n) to make all data available to the sponsor/monitor and/or relevant authority (where
required) for verification/audit/inspection purposes.

o) to sign and forward the data (CRFs), results and interpretations (analyses and reports)

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of the trial from his/her centre to the sponsor (and relevant authorities when required).
Collaborative investigators and those responsible for the analyses (including, statistical
analyses) and the interpretation of the results should also sign.

p) to agree with and sign the Final Report of the trial. For multicentre trials the signature
of the coordinating investigator may suffice if agreed in the protocol.

q) to ensure that the confidentiality of all information about subjects is respected by all
persons involved as well as the information supplied by the sponsor.

r) to observe the following points pariicularly related to patient care :

- if appropriate, fully functional resuscitation equipment should be immediately available

in case of emergency.

- the investigator is medically responsible for those subjects who are under his/her care
for the duration of the trial and must ensure that appropriate medical care maintained
after the trial.

- clinically significant abnormal laboratory values or clinical observations must be

followed up to the subject's benefit after completing of the trial.

- subjects enrolled in a trial should be provided with a card bearing information

identifying that he/she is in a trial if appropriate. Contact addresses/telephone numbers
should be given in case of actions needed at another place.

- in the medicinal records is should be clearly marked that the subjects is participating in
a clinical trial.

- the family doctor should normally, with the subject's consent, be informed.

CHAPTER 3
DATA HANDLING

Investigator.

3.1 The investigator undertakes to ensure that the observations and findings are recorded

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correctly and completely in the CRFs and signed.

3.2 Entry to computerized system is acceptable when controlled as recommended in the

EEC guide to GMP.

3.3 If trial data are entered directly into a computer there must always be adequate
safeguard to ensure validation including a signed and dated print-out and back-up
records. Computerized systems should be validated and a detailed description for their
use be produced and kept up-to-date.

3.4 All corrections on a CRF and elsewhere in the hard copy raw data must be made in a
way which does not obscure the original entry. The correct data must be inserted with
the reason for the correction, dated and initialled by the investigator. For electronic data
processing only authorized persons should be able to enter or modify data in the
computer and there should be a record of changes and deletions

3.5 If data are altered during processing, the alteration must be documented and the
system validated.

3.6 Laboratory values with normal reference ranges should always be recorded on CRF
or attached to it. Values outside a clinically accepted reference range or values that differ
importantly from previous values must be evaluated and commented upon by the
investigator.

3.7 Data other than those requested by the protocol may appear on the CRF clearly
mark-ed as additional findings, and their significance should be described by the
investigator.

3.8 Units of measurement must always be stated, and transformation of units must
always be indicated and documented.

3.9 The investigator should always make a confidential record to allow the unambiguous
identification of each patient.
Sponsor/Monitor.

3.10 The sponsor must use validated, error-free data processing, programmes with
adequate user documentation.

3.11 Appropriate measures should be taken by the monitor to avoid overlooking missing
data or including, logical inconsistencies. If a computer assigns missing values
automatically, this should be made clear.

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3.12 When electronic data handling systems or remote electronic data entry are
employed, SOPs for such systems must be available. Such systems should be designed
to allow correction after loading, and the correction must appear in an audit file (cf. 3.4.
and 3.16.).

3.13 The sponsor must ensure the greatest possible accuracy when transforming data. It
should always be possible to compare the data print-out with the original observations
and findings.

3.14 The sponsor must be able to identify all data entered pertaining to each subject by
means of an unambiguous code (cf. 3.9.).

3.15 If data are transformed during processing, the transformation must be documented
and the method validated.

3.16 The sponsor must maintain a list of persons authorized to make corrections and
protect access to the data by appropriate security systems.

Archiving of Data.

3.17 The investigator must arrange for the retention of the patient identification codes
for at least 15 years after the completion or discontinuation of the trial. Patient and
other source data must be kept for the maximum period of time permitted by the
hospital, institution or private practice, but not less than 15 years. The sponsor, or
subsequent owner, must retain all other documentation pertaining to the trial for the
lifetime of the product. Archived data may be held on microfiche or electronic record,
provided that a back -up exists and that hard copy can be obtained from it if required.

3.18 The protocol documentation, approvals an all other documents related to the trial,
including certificates that satisfactory audit and inspection procedures have been carried
out, must be retained by the sponsor in the Trial Master File.

3.19 Data on AEs must always be included in the Trial Master File.

3.20 The Final Report must be retained by the sponsor, or subsequent owner, for five
years beyord the lifetime of his product. Any change of ownership of the data should be
documented.

3.2 All data and documents should be made available if requested by relevant
authorities.

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Language.

3.22 All written information and other material to be used by patients and paraclinical
staff must use language which is clearly understood.

3.23 Competent authorities have agreed to accept CRFs completed in English.

CHAPTER 4

Statistics

4.1 Access to biostatistical expertise is necessary before and throughout the entire trial
procedure, commencing with designing of the protocol and ending with completion of
the Final Report.

4.2 Where and by whom the statistical work shall be carried out should be agreed upon
by both the sponsor and the investigator.

Experimental Design

4.3 The scientific integrity of clinical trial and the credibility of the data produced
depend first on the design of the trial. In case of comparative trials the protocol should,
therefore, describe :

a) an "a priori" rationale for the target difference between treatments which the trial is
being designed to detect, and the power to detect that difference, taking into account
clinical and scientific information and professional judgement on the clinical
significance of statistical differences.

b) measures taken to avoid bias, particularly methods of randomisation when relevant.

Randomisation and Blinding.

4.4 In case of randomisation of subjects the procedure must be documented. Where a

sealed code for each individual treatment has been supplied in a blinded, randomised

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study, it should be kept at the site of the investigation and with the sponsor.

4.5 In case of a blinded trial the protocol must state the conditions for which the code
may/must be broken. A system is required enabling access to the treatment of individual
subjects in case of an emergency.
The system must only permit access to treatment key of one subject at a time. If the
code is broken it must be justified in the CRF.

Statistical Analysis.

4.6 The type(s) of statistical analyses to be used must be specified in the protocol, and
any other subsequent deviations from this plan should be described and justified in the
Final Report of the trial. The planning of the analysis and its subsequent execution must
be carried out or confirmed by an identified, appropriately qualified and experienced
statisticien. The possibility and circumstances of interim analyses must also be specified
in the protocol.

4.7 The investigator and monitor must ensure that the data are of high quality at the
point of collection and the satistician must ensure the integrity of the data during their
processing.

4.8 The results of analyses should be presented in a manner likely to facilitate the
interpretation of their clinical importance, e.g. by estimates of the magnitude of the
treatment effect/difference and confidence intervals, rather than sole reliance on
significance testing.

4.9 An account must be made of missing and unused and spurious data during statistical
analyses. All omissions of this type must be documented to enable review to be
performed.

CHAPTER 5
QUALITY ASSURANCE

5.1 A system of Quality Assurance, including all the elements described in this chapter
and the relevant parts of the Glossary, must be employed and implemented by the
sponsor.

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5.2 All observations and findings should be verifiable. This is particularly important for
the credibility of data and to assure that the conclusions presented are correctly derived
from the raw data. Verification processes must, therefore, be specified and justified.
Statistically controlled sampling may be an acceptable method of data vérifications in
each trial.

5.3 Quality control must be applied to each stage of data hanling to ensure that all data
are reliable and have been processed correctly.

5.4 Sponsor audit must be conducted by persons/facilities independent of those

responsible for the trial.

5.5 Any or all of the recommandations, requests or documents addressed in this

Guideline may be subject to, and must be available for, an audit through the sponsor or a
nominated independent organization and/or competent authorities (inspection).

5.6 Investigational sites, facilities and laboratories, and all data (including source data)
and documentation must be available for inspection by competent authorities.

ANNEX

1. INTRODUCTION.

This Annex is intented to provide guidance on some of the practical aspects of clinical
trials. It includes much of the guidance contained in the "Recommended Basis for the
conduct of Clinical Trials" (The Rules Governing Medicinal Products in the European
Community, Vol. III, 1989, p. 115-132, Catalogue No. CB-55-89-843-EN--C, ISBN 92-
825-9612-2). As parts of the guideline "Recommended Basis for the Conduct of
Clinical Trials" are now included in this Annex, the guideline will be revised
accordingly.

2. GENERAL BACKGROUND.

It is important for anyone preparing a trial of a medicinal product in human that the
specific problems of a particular clinical trial be thoroughly considered and that the
chosen solutions be scientifically sound and ethically justified. It should be emphasized
that this responsability lies on the sponsor of trial as well as on the actual
investigator(s). Furthermore, considering the strategy of clinical evaluation of new

185
active ingredients, it is highly advisable to plan and design the individual trial as a part
of a logically constructed chain investigations.

3. DEFINITION OF CLINICAL TRIALS.

In this context, a clinical trial of medicinal product(s) means any systematics study in
human subjects whether in patients or non-patient volunteers in order to discover or
verify the effects of and/or identify any adverse reaction to the investigational products,
and/or to study their absorption, distribution, metabolism and excretion in ordre to
ascertain the efficacy and safety of the products.

Clinical trials are generally classified into phases 1 to IV. It is not possible to draw
distinct lines between the phases, and diverging opinions about details and methodology
do exist. Definitions (in brief) of the individual phases, based on their purposes related
to clinical developpment of medicinal products, are given below :

a) Phase 1:
First trials of a new active ingredient in man, often healthy volunteers. The purpose is to
establish a preliminary evaluation of safety and a first outline of the
pharnacokinetic/dynamic profile of the active ingredient in humans.

b) Phase II :
Therapeutic pilot studies. The purpose is to demonstrate activity and to assess short-
term safety of the active ingredient in patients suffering from a disease or condition for
which the active ingredient is intented. The trials are performed in a limited number of
subjects and often, at a later stage, in a comparative (e.g. placebo-controlled) design.
This phase also aims at the determination of appropriate dose ranges/regimens and (if
possible) clarification of dose/response relationships, in order to provide an optimal
background for the design of wider therapeutic trials.

c) Phase III :
Trials in larger (and possibly varied) patient groups with the purpose of determining the
short- and long-term safety/efficacy balance of formulations of the active ingredient, as
well as to assess its overrall and relative therapeutic value. The pattern and profile of
more frequent adverse reactions must be investigated and special features of the product
must be explored (e.g. clinically relevant drug interactions, factors leading to differences
such as age etc). The design of trials should preferably be randomized double blind, but
other designs may be acceptable for e.g. longterm safety studies. Generally the
circumstances of the trials should be as close as possible to normal conditions of use.
d) Phase IV:
Studies performed after marketing of the final medicinal product(s), although definition

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of this phase is not completely agreed upon. Trials in phase IV are carried out on the
basis of information in the summary of product characteristics of the marketing
authorization, e.g. post-marketing surveillance, assessment of therapeutic value or
strategies. According to the circumstances, phase IV studies require trial conditions
(including at least a protocol) such as described above for premarketing studies. After a
product has been placed on the market, clinical trials exploring e.g. new indications, new
methods of administration or new combinations, are considered as trials for new
medicinal products.

4. MEASURES TO ENSURE OPTIMAL TRIAL CONDITIONS.

A trial protocol (see item 6) must be worked out and adhered to, and proper instruction
must be given to all involved.
The conditions of the physical framework in which the trial is carried out must be well
arranged and carefully prepared. They must be of a sufficient quality e.g. regarding,
supervision of patients/healthy volunteers, staffing, laboratory facilities (where
necessary), emergency instructions, etc.
Finally, the distribution of responsibilities between the sponsor, the monitor and the
investigator(s), and all colaborators must be clearly defined before the start of the
clinical trial.

5. PRE-TRIAL DATA.

Chemical, pharmaceutical, animal pharmacological and toxicological data on the

substance and/or the pharmaceutical form in question must be available and
professionally evaluated before a new product is subjected to clinical trials. The
sponsor's responsibility for providing, exhaustive, complete and relevant material, e.g.
by means of an Investigator's Brochure, is emphasized.
If an active ingredient is to be studied in phase Il, III and IV, all existing research data in
humans must be considered. Before phase II studies are initiated, results from previous
human pharmacology investigations are mandatory. Apart from effects on target
functions, possible effects on other important organ systems should have been studied at
relevant dosage levels, although it may not be possible in all studies. Results from
kinetic studies of the active ingredient, its distribution and/or elimination, perhaps with
several routes of administration, and results from other investigations on which the
choice of dosage is based, e.g. studies of dose/response and/or concentration/effect
relations and safety studies, must be considered. Before starting phase III investigations,
results from earlier clinical trials must be studied. The possibility of interactions with
medicinal products containing other active ingredients should be given consideration.

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6. TRIAL PROTOCOL.

A well designed trial relies predominantly on a thoroughly considered, well structured

and complete protocol.
The protocol must, where relevant, contain the information given in the following, list of
items, or this list should at least be checked, whenever a trial contemplated.

6.1 General information.

a) title of the project;

b) the name of the clinically responsible investigator(s) of the trial and the name of other
possible partipants and their professional background (e.g. "medical doctor",
"biochemist", "nurse", statistician", etc);
c) the name of the sponsor, if any;
d) the clinic/department/group of physicians where the trial will take place (affiliations,
addresses).

6.2 Justification and objectives

a) the aim of the trial;

b) the reason for its execution;
c) the essentials of the problem itself and its background, referring to relevant literature.

6.3 Ethics

a) general ethical consideration relating to the trial;

b) description of how patients/healthy volunteers will be informed and consent will be
obtained;
c) possible reasons for not seeking informed consent.

6.4 General time schedule.

a) description of the time schedules (including dates) of the trial, i.e. its start,
investigation period and termination;
b) justification of the time schedules, e.g. in the light of how far the safety of the active
ingredients/medicinal products has been tested, the time course of the disease in question
and expected duration of treatment.

6.5 General design

a) specification of the type of trial, e.g. controlled study, pilot study, and preferably,

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which phase it fits into;
b) description of the randomisation method, including, procedure and practical
arrangement;
c) description of the trial design (e.g. parallel groups, cross-over design) and the blind
technique selected (e.g. double blind, single blind);
d) specification of other bias reducing factors to be implented.

6.6 Subject selection.

a) specification of the material (patients/healthy volunteers) including age, ethnic croups,

pronostic factors, etc, where relevant;
b) clear statement of diagnostic admission criteria;
c) exhaustive criteria for inclusion, pre-admission exclusions and post-admission
withdrawals of patients from the trial.

6.7 Treatment.

a) clear account of the product(s) to be used (marketing formulations, not "laboratory

drugs") and justification of the doses to be used;
b) description of treatment applied to control group(s) or control period(s) (placebo,
other products, etc);
c) route of administration, dose, dosing schedules, treatment period(s) for the test
product containing the active ingredient and the comparative product(s);
d) rules for use of concomitant treatment;
e) measures to be implemented to ensure the safe handling of the products;
f) measures to promote and control close adherence to the prescribed instructions
(compliance monitoring).

6.8 Assessment of efficacy

a) specification of the effect parameters to be used;

b) description of how effects are measured and recorded;
c) times and periods of effect recording;
d) description of special analyses and/or tests to be carried out (pharmacokinetic, clinical
laboratory, radiological, etc).

6.9 Adverse events.

a) methods of recording adverse events;

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b) provisions for dealing with complications;
c) information on where the trial code will be kept and how it can be broken in the event
of an emergency;
d) details for the reporting of adverse events, including by whom and to whom it shall be
done, and how fast the reports must be submitted.
6.10 Practicalities

a) a meticulous and specified plan for the various steps and procedures in order to
control and monitor the trial most effectively;
b) specifications and instructions for anticipated deviations from the protocol;
c) allocation of duties and responsibilities within the research team and their
coordination;
d) instructions to staff, including trial description;
e) addresses, telephone numbers, etc. enabling any staff member to contact the research
team at any hour;
f) considerations of confidentially problems, it any.

6.11 Handling of records

a) procedures for handling and processing records of effects and adverse events to the
product(s) under study;
b) procedures for the keeping of special patient lists and patient records for each
individual taking part in the trial. Records should permit easy identification of the
individual patient/healthy volunteer. A copy of the Case Report Form (CRF) should be
included.

6.12 Evaluation

a) a specified account for how the response is to be evaluated;

b) methods of computation and calculation of effects;
c) description of how to deal with and report subjects withdrawn from/dropped out of the
trial;
d) quality control of methods and evaluation procedures.

6.13 Statistics.

a) a thorough description of the statistical methods to be employed;

b) the number of patients planned to be included. Reason for choice of sample size,
including reflections on (or calculations of) the power of the trial and clinical
justification;
c) description of the statistical unit;

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d) the level of significance to be used;
e) rules for the termination of the trial.

6.14 Financing, reporting, approvals, insurance, etc.

In relation to the protocol it would often be advisable to state the attitude towards a
series of problems, which directly or indirectly may influence performance and results of
trial.
The essentials are presented later in items 8-10 and include financing the trial, insurance
and liability problems and labelling.

6.15 Summary, Supplements.

The protocol should comprise a comprehensive summary and relevant supplements (e.g.
information to the patients, instruction to staff description of special procedures).

6.16 References.

A list of relevant literature, referred to in the protocol, must be included.

7. CASE REPORT FORMS.

In order to adequately present the results of a clinical trial, it is essential that a fully
comprehensive collection of information on the subject, the administration of the
investigational medicinal product and the outcome of the protocol procedures is
available. This is done usine, a Case Report Form (CRF) which should be established to
facilitate observation of the subject, which also takes into account the protocol for the
trial. In establishing a CRF, the following items should be considered. This list is not
comprehensive and the CRF must take account of the nature of the investigational
product. Omission of one or more of these items should be explained:
a) date, place and identification of the trial;
b) identification of the subject;
c) age, sex, height, weight and ethnic group of the subject;
d) particular characteristics of the subject (e.g. smoking, special diet, pregnancy,
previous treatment);
e) diagnosis; indication for which the medicinal product is administered in accordance
with the protocol;
f) adherence to the inclusion/exclusion criteria;
g) duration of the disease; time to last break out (if applicable);
h) dose, dosage schedule and administration of the medicinal product; notes on
compliance;

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i) duration of treatment;
j) duration of the observational period;
k) concomitant use of medicinal products and non-medicinal interventions/therapy;
1) dietary regimens;
m) recording of the effect parameters (inc.date, time, recorder's signature);
n) recorded adverse events. Type, duration, intensity, etc : consequences and measures
taken;
o) reason for withdrawal (if applicable) and/or breaking of the code.

8. FINANCING THE TRIAL.

All financial problems involved in conducting and reporting a trial should be clearly
arranged and a budget made out. Information should be available about the sources of
economical support (e.g. foundations, private or public funds, sponsor/manufacturer).
Likewise it should be clearly apparent how the expenditures are distributed, e.g.
payment of volunteers, refunding expenses of the patients, payment for special tests,
technical assistance, purchase of apparatus, possible fees to or reimbursement of the
members of the research team, payment of the University/Clinic, etc.

Competent authorities may require detailed knowledge about the connection (economic,
etc) between the individual researcher and the manufacturer of the product(s) involved,
in cases where such information is not obvious.

9. INSURANCE AND LIABILITY.

Patients/healthy volunteers taking part in a clinical trial should be satisfactorily insured

against any injury caused by the trial. The liability of the involved parties (investigators,
sponsor/manufacturer, hospital/clinics, etc) must be clearly understood before the start of
a trial of a medicinal product containing an active ingredient.

10. LABELLING.

The provisions of Council Directive 65/65/EEC as amended on labelling should be

applied by anology to the labelling of medicinal products or placebo used in clinical
trials. In addition, the labelling should include the words "For Clinical trial" and the
name of physician responsible for the trial (the investigator).

11. SYSTEMS OF NOTIFICATION/APPROVAL OF CLINICAL TRIALS.

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In Member States where regulation of medicinal products requires a notification or an
application for approval before a trial is commenced the national rules must be consulted
and complied with. In some countries a special form must be used. The
notification/application must be signed by the investigator, the sponsor and the head of
the institution or department, where the trial is to take place. The person(s) signing will
be held responsible for the performance of the trial. including all deviations from the
protocol, in accordance with the national regulations. The notification/application
usually should comprise the information specified in the form, a trial protocol with a
brief summary and the information and documentation specified in the present
document, but the requirements may vary among the Member States. For a product
already authorized as a medicinal product, a reference to information previously
submitted will usually be sufficient.

In general, notifications/applications should be filed with the competent authority in the

following situations

a) non authorized products : all clinical trials;

b) authorized medicinal products, if the trial is

- planned to explore new indications;
- carried out in patient groups not previously studied adequately,
- done with considerably higher dosages than previously approved.

Furthermore, phase IV studies e.g. studies designed to deterrnine the frequency of

adverse reactions, or involving a very large number of patients to be treated (in
accordance with the marketing authorization) for a very long period, or assessment of
therapeutic strategies, may require to be notified.

A multi-centre trial (confined to one country) is in general to be regarded as one trial for
which one complete notification/application with a master protocol and documentation
should be submitted. In addition, each centre must submit a form conforming its
participation in the trial.

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 CLINICAL TESTING OF ANXIOLYTIC DRUGS

This chapter defines the methodological problems associated with testing anxiolytic
drugs in man. The original indication of anxiety in all its forms is no longer acceptable
because anxiety disorders have been dissected into a number of distinct entities no
matter which classification has been used (DSM IV or ICD 10). Tricyclic antidepressants
or inhibitors of the uptake of serotonin (SSRIs) are still largely used to treat panic
attacks, social phobia, obsessive compulsive disorder or even post-traumatic stress
disorder (1). Nevertheless, the development of anxiolytic drugs almost inevitably passes
by the treatment of generalised anxiety disorder (GAD) or ajustment disorder with
anxious mood (ADAM).
The life-time prevalence of GAD is between 4 and 6 % (2) , slightly less prevalent than
phobia. However the lack of pathognomonic symptoms and the heterogeneity of the
symptoms associated with a frequent comorbidity with the diseases of axis 1 of DSM IV
lead to major diagnostic problems which can compromise the clinical studies for new
drugs (3,4).

Thus, GAD can be diagnosed by exclusion after elimination of all the forms of anxiety.
However, DSM III R and DSM IV have improved diagnostic reliability by focusing on
the presence of worry (or fear), but the duration of symptoms must be for at least 6
months.
Patients suffering from transient or subsyndromic levels of anxiety are classified as
ADAM. According to the DSM IV the essential feature of this disorder is a maladaptive
reaction to an identifiable psychosocial stressor. It is one of the most frequent psychiatric
diagnoses made in serious physically ill 5) and in older patients (6). A final classification
issue concerns the value of entering only patients who meet the 3-month duration
criteria. In both cases of GAD and ADAM an illness duration of 3 months may represent
a fair compromise for some drug trials.
The problem of comorbidity in anxiety represents a serious methodological difficulty.
Patients presenting "pure" symptoms of anxiety without an associated pathology are rare
and probably not very representative of the general population. Several authors have
insisted on the frequency of associated depression and particularly of associated
dysthymia (7,8,9).
The cumulation of these difficulties in defining recruitable patients leads to major
problems in the development of new drugs for the treatment of anxiety. Furthermore,
benzodiazepines (BZD) are the gold standard in the treatment and the clinical tools
available such as the Hamilton anxiety scale (HAM-A) (10) were developed subsequent
to (and dependent on) the demonstration of the use of BZD. Thus use of these scales
may not always be appropriate for new types of anxiolytic drugs.

194
Finally the modification of the different classifications (DSM or ICD) over time has not
helped the development of psychotropic agents, in particular anxiolytics, because the
criteria of inclusion, and therefore the patient populations, have changed with time. The
concept of "all forms of anxiety" is no longer acceptable either as an operational concept
or a therapeutic entity. The clinical methodology proposed in this chapter takes into
account the different clinical and pharmacological constraints without forgetting that
since the the discovery of the BZDs, no anxiolytic apart from buspirone, has reached the
market. At the present moment, the clinical studies in this area have been forced to
favour antidepressants expanding their therapeutic reach into GAD.

Phase I studies
The goal of phase I studies is to find in human volunteers the maximum tolerated dose
and to study the pharmacokinetic profile of the drug in question. The Food and Drug
Administration (FDA) guideline of 1977 proposes that the first dose administrable to
man is 1/5 to 1/10 of the maximal non-toxic dose in the rat. The first dosing studies are
carried out in an open, single dose fashion. The doses are then progressively increased
while assuring that the previous dose was well tolerated until the first side effects are
observed.
For anxiolytics it is possible to define in healthy volunteers potential sedative effects
allowing the choice of non sedative doses for study in phase II. The different test which
may be used in phase I are listed below.

Test procedures
The following psychomotor tests are used:
Pictures test. This test is used to assess long-term memory. A set of 15 pictures is
presented to each subject who is allowed 10 seconds to name and memorize them. Thirty
minutes later, a free recall of the names of the pictures is performed, and the restitution
score is reported at intervals of 30 seconds over a total time of 2 minutes. A new set of
pictures is presented at each session.

DSST. This test is adapted from the Wechsler Adult Intelligence Scale. On the top of the
sheet is a list of symbols to be substitued for each digit. The subjects were required to
complete as many digit-symbol substitutions as possible in 90 seconds by writing down
the appropriate symbol. The number of correct substitutions was scored. Six parallel
forms are used (11).

Choice Reaction Time (CRT). This test is used to assess sensorimotor performance (12)

195
and performed with an electronic automatized apparatus, the Leeds Psychomotor Tester
(LPT). Subjects are required to extinguish one of six red lights presented in a semicircle
and randomly illuminated by touching the appropriate response plot. From a session of
50 stimuli, the mean score (in milliseconds) of three parameters is automatically tested
by LPT: the latency of the perception to the visual stimuli (recognition reaction time,
RRT); the time taken to extinguish the light (motor reaction time, MRT) and the sum of
the both measurements (total reaction time, TRT).

Critical Flicker Fusion (CFF). This test assesses central integrative capacity (13). The
LPT, which was positioned one meter away from the subject, showed four red diodes
flickering at an increasingly rapid frequency. When a certain frequency is reached, the
signals appear as a continuous light, i.e., they are fused. The frequency (measured in
Hertz at which the lights seem continuous was recorded for each subject. Individual
thresholds were determined by the psychologic method of limits on three ascending and
three descending values.

Side effects questionnaire. Thus self-evaluation checklist of 26 items (e.g., nausea,

blurred vision, modification of appetite, dizziness) is given to subjects to record the
frequency and severity of side effects from the treatment.

Subjective rating scales. At the end of the session, subjects self-rated their feelings by a
mark across a series of three ungrated Visual Analog Scales of 100-mm lines with
opposite statements at each end (e.g., calmness/agitation, tiredness/dynamism, better or
worse capacity of cencentration). Scores are measured in millimeters from the middle of
the lines to the mark. These tests are administered in the same order throughout the
experimental period. Each test session lasts 30 minutes.
Studies in normal volunteers have reported that BZD can produce sedation, psychomotor
impairment and anterograde amnesia (14). However, most of the studies have been
carried out with single, immediate dosages (15,16,17) using the therapeutic doses
prescribed for anxious patients. Few ongoing studies investigating possible tolerance
effect on cognitive performance have been reported (18,19,20,21).
It would appear that the doses of BZD normally used in clinical treatment prolong
reaction time (cf table I) or reduces the threshold for critical flicker fusion (cf table II).

Nitrazepam 5 and 10 mg
Flurazepam 15 and 30 mg
Flunitrazepam 1 and 2 mg
Lorazepam 1 and 2 mg
Diazepam 2.5 and 5 mg

Table 1 : Benzodiazepines increasing CRT (after 11)

196
Diazepam 5 mg
Nedazepam 15 mg
Oxazepam 20 and 40 mg
Lorazepam 0.5 and 1 mg
Temazepam 30 mg
Nitrazepam 5 mg

Table 2 : Benzodiazepines decreasing threshold of CFF (after 11)

The development of substances such as abecarnyl and alpidem, partial agonists at BZD
receptors, did not take into account results obtained in healthy volunteers concerning
sedative effects. It was hoped that tolerance would develop to the sedative effects to a
greater extent than to the anxiolytic effects. However this phenomenon remains to be
demonstrated. It is quite possible that sedative and amnestic effects contribute to the
anxiolytic effects of BZDs in man.
However it has been shown in the test described above lorazepam and alprazolam when
administered in low doses (0.25 mg and 0.125 mg respectively twice daily) can improve
psychometric performance in healthy volunteers (22,23). These findings underline the
problem of the clinical dose where either disinhibition (facilitating performance) or
sedative effects may be seen.
The pharmacokinetic assessment is not especially difficult for anxiolytics although it is
interesting to determine if sedative effects is associated with peak plasma levels after
dose administration.

Phase II studies
The main purpose of phase II studies is to solve an equation with two unknown
parameters, i.e. to find the efficacious dose in a given pathology, in this case in GAD or
ADAM. In fact, it is essential to identify an effective dosage range and obtain
preliminary evidence of efficacy. Less and less often, initial phase II studies are open or
single-blind because it leads to non objective evaluation. In most cases, 5-arm studies
with 3 doses of the product to study, a placebo and a reference drug are proposed with 60
patients in each group.
Nowadays it can be a 2-arm study which compares the drug under study (very often an
antidepressant drug for which the dosage in the treatment of depression is known) and a
placebo. In this case a single dose of the drug is used if we have an idea of its activity in
another pathology. Then, 100 patients per group are recruited. This second option can
lead to failures as the efficacious dose is not necessary the same in pathologies as
different as depression, obsessive compulsive disorder, social phobia, etc.

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So the first of the major phase II designs is a parallel-group design, usually with three
doses in a non-overlapping dose ranges (e.g., low, medium and high) of the study drug
compared to placebo and a reference drug. For the time being, in most cases, the
reference substances are BZDs and especially, alprazolam, bromazepam, diazepam or
lorazepam (24).
In the pattern described above, patients can be included with a final fixed dose, preceded
by a progressive increase in dose, with 1-2 weeks at each dose level. However it is
important to point out that although the use of fexible doses at this early stage of
development has proven to be problematic and reveals serious problems of statistical
analysis as it leads to too many sub-groups at different doses.
In contrast, the disadvantage of fixed doses is the inherent inflexibility and subsequent
drop-outs for patients who do not support a dose which is too high, and a lack of
effectiveness if the dose is too low. Nevertheless current practice favours fixed dose
schedules.
Phase II has the objective of defining dose limits and the most difficult aspect is the
definition of the lowest active dose. For anxiolytics, two methods have been used either
a neurophysiological effect on the electroencephalogram (EEG) or, which is even more
difficult, the lowest therapeutic effect possible. Under these conditions, the minimum
effective dose is often defined as the dose below which one can show a significant
difference against placebo. However, this difference between placebo is problematic
because in GAD or in ADAM the placebo response after a month treatment is close to 50
% which practically means that it would be difficult to show a response of 60 % i.e. only
10 % superior to placebo! The question then is to know how long a clinical trial must be
programmed for (1 month or more) to show a difference in defining the minimal
effective dose.

Phase III studies

After the definition of the effective dose range in phase II, the goal of phase III studies is
to confirm these results on a larger patients population in comparison with a variety of
reference drugs. Actually for GAD or for ADAM the currently accepted reference
products are antidepressants SSRIs, SNRIs, etc., and it would be interesting to compare
the efficacity of the different types of antidepressants available. The main problem is to
find a positive control which is active against placebo given the large nature of the
placebo response. Phase III studies can also be of longer duration than phase II studies,
with a long term evaluation after 8 weeks treatment. GAD is a chronic illness with a high
level of relapse and it is important that this factor be programmed into long-term
treatment trials. Here, at the beginning of the programme, one can plan to divide the
treated patients into two groups at the end of 8 weeks treatment, one of the groups then
being treated with placebo and the other maintained on the active drug. Under these
conditions it is necessary at the start of the study to have approximately 100 to 250
patients per group. The evaluation criteria for relapse or for withdrawal phenomenon are
listed in the paragraphs below.

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Inclusion criteria for phase II or phase III clinical trials
The subjects included in the studies are non-hospitalised patients of either sex (18 to 65
years). Hospitalisation is not needed for two reasons : GAD and ADAM rarely lead to
hospital admittance and the phase I and early phase II studies were given sufficient
safety information about the product. Nevertheless the patient must present the
diagnostic critaria for GAD and ADAM. A difficulty with GAD is the fact that the
disease may evolve over the six months placebo period which leads to real practical
difficulties where the subject may wish for treatment prior to the end of the six months
period.
The score of the HAM-A scale must be greater than 20 and remain stable during the
"run-in" period, which includes the wash-out period and the immediate entry period.
Furthermore, this score should not differ by more than 10 % (2 points) between two
tests during the same run-in period.
The patients must additionally have a score on the Covi scale greater than that of the
Raskin scale to ensure that the patients are anxious rather than depressed. The two scales
are easy and quick to use being made up of 3 items scored between 0 and 4.

Exclusion criteria for phase II and phase III clinical studies

An exhaustive list of the exclusion criteria is difficult to define. It is important to
eliminate any pathology which might interfere with GAD or ADAM.
An episode of major depression with a score superior to 15 on the Montgomery-Asberg
(MADRS) scale (25) is an exclusion criteria as is a major weight problem (boulimia or
anorexia), any developing major organic disease or alcoholism. In addition,
administration of psychotropic drugs in the 2 weeks prior to the trial is an exclusion.
Further causes of exclusion are the presence of other anxious states as defined in DSM
IV which are not GAD, or ADAM.
Any associated treatment must be clearly defined in the protocol. The usual
pharmacokinetic interactions (absorption, distribution, metabolism, elimination) must be
considered as well as pharmacokinetic interactions common to anxiolytics. It is essential
to eliminate coadministration of drugs which may be sedative or have effects on
vigilance. For example, nasal vasoconstrictors may be problematic.

Evaluation criteria for phase II and phase III clinical studies

Among all the evaluation criteria, it is necessary to clearly define the primary criterial in
the protocol.
However, there is no single scale which is ideal for evaluating anxiolytic activity.
Among the different evaluation scales, ranking scales, etc. the principal criteria remains
the HAM-A. Among all the ranking scales, the problem of the threshold for the presence
of anxiety and particularly the percentage of improvement of a given score for an

199
anxiolytic effect remain controversial.
- evaluation scales for anxiety
The oldest scale, the HAM-A, remains the most used and useful. It has 14 items of
which only 3 are related to GAD : anxious mood, attention and behaviour during the test.
The other items, particularly somatic ones, are not specific to anxious states. However,
we previously defined that a score 20 on HAM-A is usually taken as an inclusion
criteria. The global score of HAM-A reflects the total severity of the clinical syndrome
but it is not an appropriate measure of anxiety such as GAD in the presence of other
problems such as phobia or depressions. Again, we are confronted with the problem of
comorbidity.
As we have previously seen, other scales can be associated with HAM-A such as the
Covi scale for which a score of 9 is commonly used as a criterium of inclusion. The Covi
scale is a global evaluation tool which makes use of the overall judgement of the
clinician. It consists of three items intented to evaluate speech, behaviour and the
somatic complaints of the anxious subject (26). Each item is graded from 0 (absent) to 4
(very considerable). The total score for the scale therefore varies from 0 to 12. A score
of 6 indicates the presence of anxiety score of 3 correspond to mild or absent
symptoms: a score of 3 or less is regarded as a success, a score of more than 3 is
regarded as a treatment failure. This test is essentially used in the inclusion criteria to
ensure that the patient is more anxious than depressed (see above).
The Tyrer scale is made up of 10 items of the Comprehensive Psychiatric Rating Scale
(CPRS) which are frequently present in anxious patients: interior tension, hypocondria,
hostilite feelings, worry associated with hostility, general worry, phobia, neurovegetative
disorders (1 and 2), reduction of sleep, pain and muscle tension (27). This scale is often
used for secondary evaluation criteria because it is not specific to GAD.
These difference scales are normally filled in by an assessor and it is necessary to train
the assessors to give uniform response to ensure there are no investigator differences.
The translation of the scales and the questionnaires may also be problematic and require
specific validation studies.

- anxiety self-rating scales

These are advantageous in that they reduce the variability associated with an external
assessor. This is particularly important because of the large degree of subjectivity
associated with anxiety.
The Sheehan incapacitation scale is a visual analogue scale on which the patient grades
the repercussions of his or her anxiety syndrome between "not a all" and "very severely"
the patient evaluates the three areas of his or her personal life: work, family life and
social life. This provides a global reflection of the repercussions of the disorder on the
patient's quality of life (28).

- Global rating scales

CGI (Clinical Global Impression) is often used. A score of 4 on a scale of 7 is taken as

200
inclusion criterion. A difference of 2 points is a criterion of therapeutic success (24). The
CGI is the scale most commonly used in association with HAM-A.

In conclusion, it is essential to ensure homogeneity between the ratings of the clinical

investigators. Group sessions uniting the different investigators are required to ensure a
standard score for a given degree of anxiety. During these sessions, videos are presented
showing patients being assessed using the relevant scale. It is important that the
assessment be stable with time and also that there are not large differences in the scores
between investigators. Thus while the score allows quantification, it is also essential for
inclusion in a clinical study for an anxiolytic because the global score on HAM-A must
be superior to 20.

Discontinuation dependence and withdrawal

Rebound, recurrence, withdrawal and dependence are closely related phenomena but
these terms are not synonymous.
The definition of dependence includes the presence of withdrawal symptoms leading to
an inability to discontinue the drug and by itself is enough to qualify patients for the new
DSM III-R (29) diagnosis of "psychoactive substance dependence" (30). However, a
distinction must be made between BZD addiction and anxious patients who use BZD
(31).
Addiction is a complex concept which refers to a pattern of drug use that is out of
control, with social, medical, legal or economic harm resulting from drug use (30,31).
Anxious patients are by definition dependent on their drug because they experience
withdrawal symptoms on discontinuation, and the term "physiological dependence"
implies that biological adaptation to the effects of the drug occurs (32,33,34). In those
patients, three basic kinds of discontinuation syndromes have been identified on clinical
and theoretical grounds, based on the character, time course and intensity of the
symptomatology following discontinuation of treatment (34,35,36).
Recurrence refers to symptoms similar in character to premorbid sympomatology and
should be no more severe in intensity than the original symptoms. It occurs slowly over a
period of weeks or months after stopping treatment.
Rebound refers to symptoms more intense than those observed before drug treatment; it
usually develops within hour or days of drug discontinuation.
Withdrawal refers to symptoms different from those originally treated by BZD which
occur in a time-limited fashion corresponding to the expected decline in blood level of
the drug.
Theoretically, these symptoms constitute a corrective physiological reaction to the
absence of the drug. Factors that contribute to greater withdrawal severity include a
higher daily dose of BZD, a duration exceeding six months, the use of short half-life
BZD, and abrupt discontinuation of the treatment (30,37,38,39).
For the withdrawal phase of an anxiolytic, we will use the same methodological design

201
 as previously described, stressing the EEG because tonic-clonic seizures during BZD
discontinuation are a rare phenomenon but have been reported for several agents. EEG
has to be performed because there is insufficient epidemiological information on the risk
factors, although withdrawal seizures occur more often in subjects with predisposing
factors such as a history of brain damage, alcohol addiction or abnormal
electroencephalograms (33,40), or in patients who are receiving drugs which lower the
seizure threshold (41). Mellman and Uhde (42) have shown that a subject has a
significant increase in anxiety during BZD withdrawal, together with increase plasma
corticol level, a change indicating the presence of neuroendocrine disturbance and
arousal during this process. Therefore, this is further evidence that endocrinological tests
are relevant.
The emphasis will be on the sleep scales, which are the first to be disturbed during the
withdrawal phase.
In addition to weekly assessments of anxiety, it is necessary to measure the efficacy of
treatment to detect a recurrence or a rebound effect (for example a 50% increase on the
Hamilton anxiety scale is in favour of a rebound effect. We will add to this design a
weekly withdrawal assessment including both patient-rated and physician-rated
measurements.

- Physician-rated measurements
The Tranquilizer Withdrawal Scale (43), translated and validated in French (44). There
are 11 items rated 0-3.
The Benzodiazepine Withdrawal Check-list (45), a binary 16-item check-list.

- Patient-rated measurements
The Benzodiazepine Withdrawal symptom questionnaire (46): a 20-item self-rating scale
rated 0-2 on a severity scale.
The Withdrawal symptom score (47): a 14-item self-rating scale rated on a four-point
severity scale.
Example: Buspirone shows less withdrawal symptoms than BZD and seems to be free of
addiction potential (48).

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[1] The Rules Goveming Medicinal Products in the European Communicy, Vol. 111 p. 1 15 - 132. 1989. Cat.
No. CB-89-843-EN-C.
ISBN 92-825-9612-2.

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