ClinicalTrials.govWhy Does it Affect Me?Should I Be Concerned?

http://catalyst.harvard.edu

Adapted from the work of the Clinical and Translational Science Awards (CTSA) program’s Clinical Trials Registration Workgroup of the Regulatory Knowledge Key Function Committee

2013

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• Any PowerPoint presentation can only be an introduction to a topic.

• This subject is complex – this will point you to many other resources and our office is happy to assist you further.

• The points outlined in this presentation are neither the law nor the regulations that apply.

Be aware that…

• Explain what ClinicalTrials.gov is and what it can do

• Explain why you should register your studyo FDAAAo ICMJEo Voluntary (Recruitment etc.)

• Identify who is responsible for registration • Provide practice examples • Explain how registration works at YOUR

INSTITUTION• Help Resources (institutional & national)

Learning Objectives

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What is ClinicalTrials.gov?

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Why should I be concerned?

http://www.ClinicalTrials.gov

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• ClinicalTrials.gov is the national registry of federally and privately supported research studies conducted in the United States and around the world.

• The U.S. National Institutes of Health (NIH), through its National Library of Medicine (NLM), has developed this site in collaboration with the Food and Drug Administration (FDA), as a result of the FDA Modernization Act, which was passed into law in November 1997.

• The basic rationale for ClinicalTrials.gov is that it can be a tool to improve transparency and reduce duplication of effort.

• Over 133,000 studies are registered in all 50 states and in 179 countries. (See current data at http://www.clinicaltrials.gov/ct2/home).

• While each study is updated in real time, there is also an archive feature that allows the public to see the history of changes to the record (Note: click on “History of Changes” link towards the bottom of any record).

ClinicalTrials.gov

Help for Registering Studies on ClinicalTrials.gov

• Login here: https://register.clinicaltrials.gov/

• Information on how to submit studies here: http://clinicaltrials.gov/ct2/manage-recs

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ClinicalTrials.gov can be searched in real time to find enrolling and completed studies including:• Conditions• Interventions• Outcome measures• Sponsors/collaborators• Locations• Phases• Dates (Primary completion date, study start date etc.)• Results• Gender-based searches (such as “heart attack and women.”) 8

RationaleIncrease research transparency* and public access

• For the public:• To know how their money is being spent• To provide quicker and wider access than some publications provide• So that trial results may inform their medical decisions• To help people find trials

• For researchers and the research enterprise• To avoid suppression of research results, which impedes the scientific process • To avoid unacknowledged changes being made to the trial protocol (affects

interpretation of findings)• Because publications do not always include all pre-specified outcome measures• To provide a place where researchers can see what is going on elsewhere – even

before results exist, to avoid duplication of effort

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To learn more, visit: http://clinicaltrials.gov/ct2/manage-recs/background.

* See detailed explanations of the value of transparency in Dr. Deb Zarin’s presentation Overview of ClinicalTrials.gov located at http://prsinfo.clinicaltrials.gov/)

Evolution of Clinical Trial Disclosure Requirements: There is a trend – locally and globally – in the direction of more data sharing

• 1997: FDAMA establishes ClinicalTrials.govLaw established a registry of clinical trials for both federally and privately funded trials “of experimental treatments for serious or life-threatening diseases or conditions”

• 2000: ClinicalTrials.gov Database launched

• 2005: ICMJE requires registration of trials (including at ClinicalTrials.gov)The International Committee of Medical Journal Editors states that it believes that it is important to foster a comprehensive, publicly available database of clinical trials, broadly defined!

• 2007: FDAAA expands requirements: (e.g., certain medical device trials); additional trial registration information (e.g., primary outcome measure); and the reporting of summary results, including adverse events, for certain trials. The law also established penalties for non-compliance.

• 2008: ClinicalTrials.gov adds basic results modules, including adverse events

Source: http://clinicaltrials.gov/ct2/about-site/history 10

Updated from D. Zarin, ClinicalTrials.gov, Overview of ClinicalTrials.gov presentation, December 2008, http://prsinfo.clinicaltrials.gov/webinars/module1/resources/Overview_Handouts.pdf. 11

Why should I register a trial in ClinicalTrials.gov?

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FDA Amendments Act of 2007 (FDAAA)*

Most prospective clinical trials involving regulated drugs, biological products, and devices must be registered on ClinicalTrials.gov. (The law also requires reporting of results and adverse events for a subset of these studies.) *The Food and Drug Administration Amendments Act of 2007 (FDAAA or US Public Law 110-85) was passed on September 27, 2007. The law requires mandatory registration and results reporting for certain clinical trials of drugs, biologics, and devices. To learn more about FDAAA 801 Requirements, visit: http://clinicaltrials.gov/ct2/manage-recs/fdaaa

# 1 It’s the law!

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FDAAA – Registration*Required for “Applicable Clinical Trials”:

• Interventional studies (drugs, biologics, devices) • Phase 2 – 4 (not phase 1 drug; not small feasibility device)**• US FDA jurisdiction (e.g., IND/IDE or US site)• Studies initiated after September 27, 2007, or initiated on or

before that date and were still ongoing as of December 26, 2007

When:• Within 21 days of enrollment of 1st subject• Update at least every 12 months (30 days for Recruitment

Status and Primary Completion Date)

** The following are also not applicable clinical trials: observational studies; single patient expanded access (treatment IND)

* REMEMBER: this is simplification of the law. See http://clinicaltrials.gov/ct2/manage-recs/fdaaa 14

FDAAA – Results SubmissionRequired for:

• Applicable Clinical Trials • In which the study product is approved (for any use) by FDA

When:• Within 12 months of Primary Completion Date (final data

collection for primary endpoint)• If product not approved by Primary Completion Date but is

approved later, then results due 30 days after approval

Note: The Primary Completion Date may be well before you think the study is over. There may be additional follow-up that continues for years, but ClinicalTrials.gov wants results data submitted within a year of the final data collection for the primary endpoint. That means getting to work on analysis and reporting quickly.

http://clinicaltrials.gov/ct2/manage-recs/fdaaa

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FDAAA – Results Submission cont’dDelays are possible, primarily for manufacturer or under limited special circumstances:

– Acceptable delays MAY (but will not automatically) be granted:

• If you are the manufacturer seeking initial approval

• If you are the manufacturer seeking approval for a new use

• If you request an extensions for “good cause”

– Pending publication is NOT considered good cause for delay

http://clinicaltrials.gov/ct2/manage-recs/fdaaa

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International Committee of Medical Journal Editors (ICMJE) • Requires registration in a publicly available, searchable system.

ICMJE doesn’t require registration in ClinicalTrials.gov, but in any of several international registries, WHO, or European Studies registry. ClinicalTrials.gov is just the most obvious, easy and logical for our researchers, since they may have to post there for government reasons anyway.

• Scope is broader than FDAAA

• Includes 1000+ journals that have adopted the ICMJE policy, such as BMJ, JAMA, and NEJM

Source: http://www.icmje.org/journals.htmlThe list of journals following ICMJE’s Uniform Requirements for Manuscripts Submitted to Biomedical Journals (URM) is available on the ICMJE website. The URM includes the obligation to register clinical trials. There may be some journals that follow the ICMJE recommendations, but have never requested a listing on the ICMJE webpage. There may be some listed journals that do not follow all of the many recommendations and policies in the document. Authors and others with questions about the processes or policies of a specific journal should consult that journal directly.

#2 You Want to Publish!

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ICMJE – Registration: Which studies?Required for prospective studies that:

• Assign subjects to one or more health related interventions to evaluate the effects on health outcomes.

ICMJE scope is much broader than the scope of FDAAA:• Interventions include any intervention used to modify a

biomedical or health related outcome (e.g. drugs, devices, surgical procedures, behavioral treatments, dietary interventions).

• Health outcomes include any biomedical or health-related measure obtained in participants including pharmacokinetic measures and adverse events.

18Source: http://www.icmje.org/publishing_10register.html

ICMJE - Registration

• When to register:oPrior to enrollment of 1st subject

• ICMJE doesn’t require results submission• ICMJE will not consider results data posted in

the tabular format required by ClinicalTrials.gov to be prior publication

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Source: http://www.icmje.org/publishing_10register.htmlThere are several databases that one can use to comply with ICMJE. Other acceptable databases are listed at the ICMJE FAQs: http://www.icmje.org/faq_clinical.html.

Policy Requirements – Recap(Relative numbers of trials subject to policy)

FDAAA Results & AE Reporting

ICMJE Registration

FDAAA and FDAMA Registration

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Note: NIH policy encourages registration and reporting, whether required by law or not. Some institutes have their own policy requiring registration; check your institution’s policies.

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Who is responsible for registering the trial? ICMJE:Anyone can register, but the author is responsible for ensuring complete registration

FDAAA:The Responsible Party (RP) is defined as:

– The IND/IDE holder, OR– If no IND/IDE:

• The industry, cooperative group, consortium or other external sponsor that initiated the study, OR

• If initiated by a principal investigator– The grantee institution OR– If no external funding, the PI

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FDAAA: Designation of Responsible Party

RP can be designated by the sponsor to a PI who:

• Is responsible for conducting the study• Has access to and control over the data• Has the right to publish the trial results, AND• Has the ability to meet the requirements

Example of RP designation• PI initiated study at Institution X* funded by NHLBI

o Institution X is the sponsor (grant funding recipient)o Institution X can be the RP or designate the PI as

the RP Note: even if not designated as RP, the PI can still enter

data into ClinicalTrials.gov

* e.g., Harvard Medical School, Massachusetts General Hospital, Boston Children’s Hospital, etc.

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Let’s Practice: Assuming that FDAAA applies… Who is the responsible party in charge of registering the following studies?

1. Department funded/ PI initiated research

2. NIH funded research/ Institution X is the grantee institution

3. Pharmaceutical company initiated research/ multi-center study including site at Institution X

4. Device company funded research/ Institution X PI is the IDE holder

5. Cooperative Group study

See the next slide for answers…

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Who is the responsible party in charge of registering the following studies? (Answers)

1. Department funded/ PI initiated researchThe PI

2. NIH funded research/ Institution X is the grantee institutionInstitution X, BUT the institution may use the right to designate to appropriate PI. Make sure you understand your institution’s policy.

3. Pharmaceutical company initiated research/ multi-center study including site at Institution X

The pharmaceutical company

4. Device company funded research/ Institution X PI is the IDE holderPI as IDE holder

5. Cooperative Group studyStay tuned; This is still unclear. The law and guidance currently available don’t have all possible scenarios spelled out. 25

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What happens if I don’t register?

Consequences of NoncomplianceFDAAA

• Public notices of noncompliance and violations• Withholding of NIH funds• FDA sanctions• Civil monetary penalties (up to $10,000/day)

ICMJE• Cannot publish in journals following ICMJE policy, and other select journals

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What are my responsibilities for the following studies? Hmmm…

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Study #1Effectiveness of Bupropion for Treating Nicotine Dependence in Young People

• Study Design: multi-center, randomized, efficacy study• Interventions: Bupropion, placebo• Primary Outcome: Smoking behavior over 6 months• Study initiated and funded by Company XRegister? For FDAAA? For ICMJE?Results?Responsible Party?

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Study #1 (Answers)Effectiveness of Bupropion for Treating Nicotine Dependence in Young People

Register? For FDAAA? For ICMJE? Register due to both FDAAA and ICMJE.

Results reporting? As this study falls under FDAAA and Bupropion is already an FDA approved drug, results reporting will be needed.

Responsible Party? Company X.

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Study #2Assess the impact on Quality of Life (QoL) of long term caregivers of patients with multiple sclerosis.

• Centers/sample size: Multi-site, 450 subjects• Intervention/method: Caregivers take QoL survey monthly for 2

years• Other fact: NIH funded study and University X is the grant

recipient

Register? For FDAAA? For ICMJE?Results? Responsible Party?

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Study #2 (Answers)Assess the impact on Quality of Life (QoL) of long term caregivers of patients with multiple sclerosis.

Register? For FDAAA? For ICMJE? This study does not have an intervention of a drug, device or biologic; it would not fall under FDAAA. This study appears to be a purely observational study, so registration being required due to ICMJE is unlikely.* *However, since ICMJE says “when in doubt, register”, some PIs may want to register, to ensure that publication options won’t be curtailed subsequently. Also please remember that one can always voluntarily register their study.

Results Reporting? As this study did not fall under FDAAA and there is no previously FDA approved drug/device/biologic, results reporting is not needed.

Responsible Party? If the PI decided to register due to ICMJE, the responsible party could be anyone. However, it would likely be the PI as he/she would be interested in publishing. There may be an institutional policy that addresses this.

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Study #3Implantable device designed to relieve the symptoms of heart failure through counter-pulsation technology.

• Study Design: Open label• Intervention: Implantable device (IDE obtained)• Primary outcome: to test the feasibility of the device• 8 people enrolled, 6 month study

Register? For FDAAA? For ICMJE?Results? Responsible Party?

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Study #3 (Answers)Implantable device designed to relieve the symptoms of heart failure through counter-pulsation technology.

Register? For FDAAA? For ICMJE? If this study is only looking at feasibility of the device then it would not need to be registered due to FDAAA. This study may need to be registered due to ICMJE if there is a health-related intervention used to evaluate the effects on health outcomes.

Results Reporting? As this study did not fall under FDAAA and there is no previously FDA approved drug/device/biologic, results reporting is not needed.

Responsible Party? If the PI decided to register due to ICMJE, the responsible party could be anyone. However, it would likely be the PI as he/she would be interested in publishing. Also there could be an institutional policy to address this.

Sidenote: IF this fell under FDAAA, the IDE holder would be the RP.

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What is the FDAAA requirement for informed consent language?

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Informed Consent Language• FDA-Mandated Changes in Consent Form Language• The FDA has added a new element of consent that is required for

“applicable clinical trials.” All applicable clinical trials are required to include this new element of consent by March 7, 2012.

• By federal regulation, the required language must be incorporated verbatim and cannot be altered in any way. “A description of this clinical trial will be available on www.ClinicalTrials.gov, as required by US law. This website will not include information that can identify you. At most, the website will include a summary of the results. You can search this website at any time.”

• Subjects who were consented before March 7, 2012 will NOT have to be re-consented or otherwise sign addendum consent with this language. For more information or questions, contact your institution’s IRB office or office of regulatory affairs.

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“As required by law”• Note: you should only include that section if the trial is an “applicable

clinical trial” required by law to post in ClinicalTrials.gov.

• If not, do not use this language.

Guidance for Sponsors, Investigators, and Institutional Review Boards Questions and Answers on Informed Consent Elements,

21 CFR § 50.25(c) (Small Entity Compliance Guide) Feb. 2012

Nonbinding on government!

Guidance: http://www.fda.gov/downloads/RegulatoryInformation/Guidances/UCM291085.pdf

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What if I have more questions?

Additional Resources• General ClinicalTrials.gov information: http://

clinicaltrials.gov/ct2/about-site• FDAAA related information:

http://clinicaltrials.gov/ct2/manage-recs/fdaaa• Food and Drug Administration Amendments Act of 2007 Public Law No.

110-85:http://www.gpo.gov/fdsys/pkg/PLAW-110publ85/pdf/PLAW-110publ85.pdf

• For specific questions or comments: register@clinicaltrials.gov. • Office of Extramural Research (OER):

http://grants.nih.gov/Clinicaltrials_fdaaa/ • Frequently Asked Questions for NIH Grantees:

http://grants.nih.gov/Clinicaltrials_fdaaa/faq.htm • ICMJE’s Obligation to Register Clinical Trials:

http://www.icmje.org/publishing_j.html • Contact your institution’s Clinical Trials Registration Administrator via the

Harvard Catalyst Regulatory Atlas: Atlas:http://connects.catalyst.harvard.edu/regulatoryatlas/?mode=c&id=50

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This slide set was made possible by a collaboration of CTSA organizations (Mayo Clinic, Partners, University of Michigan Medical School, University of Rochester) and the National Library of Medicine.

The Clinical and Translational Science Awards Program (CTSA) is part of the Roadmap Initiative, Re-Engineering the Clinical Research Enterprise and is funded by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH).

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