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INTERNATIONAL CONFERENCE ON HARMONISATION OF TECHNICALREQUIREMENTS FOR REGISTRATION OF PHARMACEUTICALS FOR HUMANUSE DRAFT CONSENSUS GUIDELINE
THE COMMON TECHNICAL DOCUMENT FOR THE
REGISTRATION OF PHARMACEUTICALS FOR HUMAN USE
EFFICACY
At Step 2 of the ICH Process, a consensus draft text or guideline, agreed by the appropriate ICH Expert Working Group, is transmitted by the ICH Steering Committee to the regulatory authorities of the three ICH regions (the European Union, Japan and the USA) for internal and external consultation, according to This draft guidance, when finalized, will represent the Food and Drug Administration=s current thinking on this topic. It does not create or confer any rights for or on any personand does not operate to bind FDA or the public. An alternative approach may be used if suchapproach satisfies the requirements of the applicable statutes, regulations, or both.
THE COMMON TECHNICAL DOCUMENT
EFFICACY
Draft ICH Consensus Guideline
Released for Consultation, 20 July 2000, at Step 2 of the ICH Process CLINICAL OVERALL SUMMARY
The Clinical Overall Summary (COS) is intended to provide a critical analysis ofthe clinical data in the Common Technical Document. The COS will necessarilyrefer to application data provided in the comprehensive Written Summary ofClinical Studies and Experience, the individual clinical study reports (ICH E3),and other relevant technical reports. But it will primarily present the conclusionsand implications of those data, and will not recapitulate them.
This document is primarily intended for use by regulatory agencies in the review ofthe clinical section of a marketing application. It should also be a useful referenceto the overall clinical findings for regulatory agency staff involved in the review ofother sections of the marketing application. It is intended to be a concise analysisof information pertinent to the clinical use of the pharmaceutical, includingreference to relevant information from the quality and safety sections of theapplication. This document should present the strengths and limitations of thedevelopment program and study results, analyse the benefits and risks of thepharmaceutical in its intended use, and describe how the study results supportcritical parts of the prescribing information. In order to achieve these objectivesthe Clinical Overall Summary (COS) should:• describe and explain the overall approach to the clinical development of a pharmaceutical, including critical decisions (e.g., study endpoints, subjectselection criteria, choice of controls) • provide a brief overview of the clinical findings, including important limitations (e.g. absence of information on some patient populations), pertinent endpointsor combination use, • provide an evaluation of benefits and risks based upon the conclusions of the relevant clinical studies and an evaluation of how prescribing information andother approaches will optimise benefits and minimise risks, • address particular efficacy or safety problems encountered in development, and how they have been evaluated and resolved, • explore unresolved issues, explain why the sponsor believes they should not be considered as barriers to regulatory approval, and describe plans to resolvethem.
• explain the basis for important or unusual aspects of the prescribing information (package insert, Summary of Product Characteristics).
The Common Technical Document – Efficacy (Overall Summary)
The COS will generally be a relatively short document (about 30 pages). The 30page recommendation is a target but is not mandatory. The size will depend on thecomplexity of the application. The use of graphs and concise tables in the body ofthe text is encouraged, in order to facilitate brevity and understanding. The COSshould include discussion of the following topics:• Product Development Rationale• Overview Analysis of Biopharmaceutics• Overview Analysis of Clinical Pharmacology• Overview Analysis of Efficacy• Overview Analysis of Safety• Benefits and Risks• References 1. PRODUCT DEVELOPMENT RATIONALE
The discussion of the rationale for the development of the pharmaceutical should:
• identify the pharmacological class of the pharmaceutical.
• describe the particular clinical/pathophysiological aspect of the disease process
that the pharmaceutical is intended to treat (the targeted indication).
• briefly summarize the scientific background that supported the investigation of the medicine for the indication(s) that was (were) studied.
• briefly describe the clinical development programme of the pharmaceutical• note and explain concordance or lack of concordance with current standard research approaches regarding the design, conduct and analysis of the studies(e.g., use of a different efficacy scale, use of a novel study design, absence offormal dose finding studies). Pertinent regulatory guidance or advice should beidentified.
2. OVERVIEW ANALYSIS OF BIOPHARMACEUTICS
The purpose of this section is to describe and analyse important issues related to
drug formulations that might affect efficacy and/or safety of the to-be-marketed
formulations (e.g. polymorphism of drug substance, dosage form/strength
proportionality, differences between the to-be-marketed formulation and the
formulation(s) used in clinical trials, and influence of food on exposure [Cmax and
AUC], lot-to-lot variability).
3. OVERVIEW ANALYSIS OF CLINICAL PHARMACOLOGY
The purpose of this section is to present a critical analysis of the pharmacokinetic,
pharmacodynamic and in vitro metabolism data in the CTD. It should emphasize
unusual results and known or potential problems, or note the lack thereof. This
section should provide evidence for specific prescribing information addressing:
-
Pharmacokinetics, e.g., comparative pharmacokinetics in healthy subjects,patients, and special populations; pharmacokinetics related to intrinsic factors The Common Technical Document – Efficacy (Overall Summary)
(e.g., age, sex, race, renal and hepatic failure) and to extrinsic factors (e.g.,smoking, concomitant drugs, diet); rate and extent of absorption; distribution,including binding with plasma proteins; specific metabolic pathways, includingpossible genetic polymorphism and the formation of active and inactivemetabolites; stereochemistry issues; clinically relevant pharmacokineticinteractions with other pharmaceuticals or other substances.
Pharmacodynamics, e.g., information on mechanism of action, such as receptorbinding; onset and/or offset of action; relationship of favorable and unfavorablepharmacodynamic effects to dose or plasma concentration (i.e. PK/PDrelationships); PD support for the proposed dose and dosing interval; clinicallyrelevant pharmacodynamic interactions with other pharmaceuticals orsubstances.
Special product features, e.g., immunogenicity; clinical microbiology 4. OVERVIEW ANALYSIS OF EFFICACY
The purpose of this section is to present a critical analysis of the clinical data
pertinent to the efficacy of the pharmaceutical product in the intended population.
The analysis should consider all relevant data, whether positive or negative, and
should explain why and how the data support the proposed indication and
prescribing information. Those studies deemed relevant for evaluation of efficacy
should be identified, and reasons that any apparently adequate and well-controlled
studies are not considered relevant should be provided. Prematurely terminated
studies should be noted and their impact considered.
The following issues should generally be discussed:
• relevant features of the patient populations, including demographic features,
disease stage, any other potentially important covariates, any importantpatient populations excluded from critical studies, and participation of childrenand elderly. Any differences between the studied population(s) and thepopulation that would be expected to receive the pharmaceutical aftermarketing should be discussed.
• appropriateness of the study design(s), including selection of patients, duration of studies and choice of endpoints and control group(s). Any reliance onendpoints that have not previously been used as a basis for approval should bediscussed.
• statistical methods and any issues that could affect the interpretation of the study results (e.g., support for any unplanned analyses; interpolation of data fordiscontinuations and corrections for multiple endpoints).
• similarities and differences in results among studies, or in different patient sub-groups within studies, and their effect upon the interpretation of theefficacy data. Identify sub-groups for which data are insufficient to reachconclusions.
• observed relationships between efficacy and dosage regimen for each indication in the total population and in the different patient subgroups.
• support for the applicability to the new region of data generated in another The Common Technical Document – Efficacy (Overall Summary)
• for products intended for long-term use, efficacy findings pertinent to the maintenance of long-term efficacy and the establishment of long-term dosage.
Support for the chosen duration of the trials should be provided. Developmentof tolerance should be considered.
• data suggesting that treatment results can be improved through plasma concentration monitoring, if any, and documentation for an optimal plasmarange.
• the clinical relevance of the magnitude of the observed effects. .
• for non-inferiority trials used to establish efficacy, the evidence supporting a determination that the trial had assay sensitivity and the basis of the choice ofnon-inferiority margin (ICH E10).
• efficacy in special populations. If efficacy is claimed without clinical data in the population, support should be provided for extrapolating efficacy from effects inthe general population.
5. OVERVIEW ANALYSIS OF SAFETY
The purpose of this section is to provide a concise critical review of the safety data,
noting how results support and justify proposed prescribing information. A critical
assessment of relative safety should consider:
• experience of the pharmacological class, particularly any unusual toxicities.
Approaches taken to monitor for similar effects should be described.
• special approaches to monitor particular toxicities (e.g. ophthalmic, QT • relevant animal toxicology and product quality information. Any findings that impact or could potentially impact the evaluation of safety in clinical use shouldbe described. Any clinical data specifically collected to address potential risksshould be discussed.
• patient population in the safety analyses. The total patient population included in the safety evaluation should be described (number, duration, dose, exposurein special populations, exposure in patients with risk factors).
• common and non-serious adverse events with reference to the tabular presentations in the Written Summary. The discussion should be brief, focusingon events of relatively high frequency and on those with an incidence higherthan placebo or active controls. Any important considerations for theprevention, mitigation or management of these adverse events should be noted.
• serious adverse events (relevant tabulations should be cross-referenced from the Written Summary). This section should discuss the absolute number andfrequency of serious adverse events, including all deaths, and other significantadverse events (e.g., events leading to discontinuation or dose modification).
Any conclusions regarding causal relationship (or lack of this) to the product ordose-response relationships should be provided. In addition, the discussionshould consider the following:- any differences in serious adverse events in population subgroups.
The Common Technical Document – Efficacy (Overall Summary)
analyses, conclusions, and recommendations regarding the identification ofrisk factors for serious adverse events.
methods to prevent or ameliorate the severity of events.
laboratory findings reflecting actual or possible serious medical effects.
• reactions due to overdose, the potential for dependence and rebound • world-wide marketing experience. The following should be briefly discussed: any new or different safety issues identified any regulatory actions related to safety.
6. BENEFITS AND RISKS
The purpose of this section is to integrate all of the conclusions reached in the
previous sections about the biopharmaceutics, clinical pharmacology, efficacy and
safety of the pharmaceutical and to provide an overall appraisal of the benefits and
risks of its use in clinical practice. This assessment should provide a clear basis for
the proposed Prescribing Information. This section should also consider the risks
and benefits of the pharmaceutical as they compare to available alternative
treatments or to no treatment in illnesses where no treatment may be a medically
acceptable option. The analyses provided in previous sections should not be
reiterated here and this section often can be quite abbreviated when no special
concerns have arisen and the drug is a member of a familiar pharmacological class.
This section should provide an integrated discussion of the benefits and risks of
the pharmaceutical.
The format and content of this discussion of the benefits and risks of the
pharmaceutical will depend greatly on the characteristics of the illness being
treated, the observed therapeutic effects, the anticipated risks of the
pharmaceutical, and differences between the pharmaceutical and other currently
available treatments. However, this analysis of benefits and risks should generally
consider the following points:
• the efficacy of the pharmaceutical, as determined in well-defined study
populations for each proposed indication.
• significant safety findings, including common adverse events and serious adverse events associated with use of the pharmaceutical, and any measuresthat may enhance safety.
• dose-response and dose-toxicity relationships; optimal dose ranges and dosage • efficacy and safety in sub-populations, e.g., those defined by age, sex, ethnicity • any risks to the patient of known and potential clinically significant interactions, including food-drug and drug-drug interactions, and appropriaterecommendations for product use.
• any risks associated with polymorphic metabolism The Common Technical Document – Efficacy (Overall Summary)
• any potential effect of the pharmaceutical on the patient’s activity that could place him at risk, e.g., risk of driving or operating heavy machinery due todrowsiness.
• the anticipated risks and benefits of the product in clinical use, with consideration of variations in clinical practice patterns and availablealternative treatments.
• any plans for post-marketing studies (optional).
9. REFERENCES
A list of references used, in addition to those contained in the dossier, should be
given and stated in accordance with 1979 “Vancouver Declaration” on “Uniform
Requirements for Manuscripts Submitted to Biomedical Journals”, or the system
used in “Chemical Abstracts.”
WRITTEN SUMMARY OF CLINICAL STUDIES AND EXPERIENCE
TABLE OF CONTENTS
Summary of Biopharmaceutic Studies and Associated
Analytical Methods

Comparison and Analyses of Results Across Studies Summary of Clinical Pharmacology Studies
Comparison and Analyses of Results Across Studies Summary of Clinical Efficacy
Background / Overview of Clinical Efficacy Summary of Individual Clinical Efficacy Studies Comparisons and Analyses of Results Across Studies Analysis of Clinical Information Relevant to Dosing Recommendations 9 Summary of Clinical Safety
Vital Signs, Physical Findings, and Other ObservationsRelated to Safety Safety in Special Patient Groups and Situations Synopses of Individual Studies
The Common Technical Document – Efficacy (Clinical Written Summary)
1. SUMMARY OF BIOPHARMACEUTIC STUDIES AND ASSOCIATED
ANALYTICAL METHODS
1.1 Background and Overview
This section provides the reviewer with an overall view of the formulation
development process, the in vitro and in vivo dosage form performance, and the
general approach and rationale used in developing the bioavailability (BA),
bioequivalence (BE), and in vitro dissolution profile database. Reference should be
made to any guidelines or literature used in planning and conducting the studies.
This section should provide the reviewer with an overview of the analytical methods
used, with emphasis on the performance characteristics of assay validation (e.g.,
linearity range, sensitivity, specificity) and quality control (e.g., accuracy and
precision)
1.2 Summary of Results of Individual Studies
A brief, narrative description of each of the individual studies that provide
important in vitro or in vivo data and information relevant to BA and BE should be
presented. The narrative descriptions should provide enough detail about the study
objectives, study design and conduct, data analysis, and important results to allow
the reviewer to understand what the study questions were, what was done to
address them, what data were collected and analyzed, and what the major outcomes
were. These narratives should be consistent with and may be abstracted from the
ICH E3 synopsis. References or electronic links to the full report of each study
should be included in the narratives.
1.3 Comparison and Analyses of Results Across Studies
This section provides a factual summary of the in vitro dissolution, BA, and BE
properties of the drug and drug product in all studies that were carried out, with
particular attention to differences in results across studies. This overview should
consider the following:
• evidence of the effects of formulation and manufacturing changes on in vitro
dissolution and BA and BE. When manufacturing or formulation changes aremade for complex drug products (e.g. a protein product,), pharmacokinetic (PK)studies comparing the product before and after the changes may be performed toensure that the PK characteristics have not changed as a result of productchanges. Although such studies are sometimes referred to as BE studies, theygenerally do not focus on assessing release of drug substance from drug product.
Nonetheless, such studies should be reported as BE studies in this section.
• evidence of the extent of food effects on BA and BE with respect to meal type or timing of the meal (where appropriate).
• evidence of correlations between in vitro dissolution and BA and BE.
• proportionality of BA and BE of different dosage form strengths.
• comparison between single and repeated-dose BE.
The Common Technical Document – Efficacy (Clinical Written Summary)
• BE of the clinical study formulations (for clinical studies providing substantial evidence of efficacy) and the formulations to be marketed.
• the source and magnitude of observed inter- and intrasubject variability in BA and BE measurements, e.g., area under the concentration-time curve (AUC) andpeak concentration (Cmax).
Section 1 Appendix
Tables 1.1 and 1.2 are provided as examples of tabular formats for reporting
information and results related to in vitro dissolution and bioavailability studies
respectively. Tables prepared for reporting the results of bioequivalence studies
would also include the mean ratios (test/reference) for Cmax and AUC and their
90% confidence interval.
These tables are not intended to be templates, but only to illustrate the type of
information that should be considered by a sponsor in designing their own tables for
biopharmaceutic studies. Sponsors should also decide whether information and
results from these studies are best presented in tables, text or figures in order to
aid clarity.
2. SUMMARY OF CLINICAL PHARMACOLOGY STUDIES
2.1 Background and Overview
This section provides the reviewer with an overall view of the clinical pharmacology
studies. These studies include those performed to evaluate human
pharmacokinetics (PK), and pharmacodynamics (PD), and the in vitro studies
performed with human biomaterials pertinent to PK processes. For vaccine
products, this section should provide the reviewer with immune response data that
support the selection of dose, dosage schedule, and formulation of the final product.
Where appropriate, relevant data that are summarized in sections 1, 3 and 4 may
also be referenced to provide a comprehensive view of the approach and rationale
for the development of the pharmacokinetic, pharmacodynamic, PK/PD and human
biomaterial database.
This section should begin with a brief overview of the human biomaterial studies
that were conducted and that were intended to help in the interpretation of PK or
PD data. Studies of permeability (e.g., intestinal absorption, blood brain barrier
passage), protein binding, hepatic metabolism, and metabolic-based drug-drug
interactions are particularly relevant. This should be followed by a brief overview of
the clinical studies that were carried out to characterise PK and PD of the
pharmaceutical, including studies of PK/PD relationships in healthy subjects and
patients, and relevant effects of intrinsic and extrinsic factors on PK and PK/PD
relationships1. Critical aspects of study design and data analysis should be noted,
1 In the ICH E5 guideline on Ethnic Factors in the Acceptance of Foreign Data, factors that may result indifferent responses to a drug in different populations are categorized as intrinsic ethnic factors or extrinsicethnic factors. In this document, these categories are referred to as intrinsic factors and extrinsic factors, The Common Technical Document – Efficacy (Clinical Written Summary)
e.g., the choice of the single or multiple doses used, the study population, choice ofthe intrinsic or extrinsic factors that were studied, the choice of PD endpoints, andwhether a traditional approach or a population approach was used to collect andanalyze data to assess PK or PD.
2.2 Summary of Results of Individual Studies
A brief, narrative description of each of the critical individual studies that provide
in vitro or in vivo data and information relevant to PK, PD and PK/PD relationships
should be presented. The ICH E3 synopses of the individual studies should be
included collectively in section 5 of this written summary document.
The narrative descriptions should provide enough detail about the study objectives,
study design and conduct, data analysis, and important results to allow the reviewer
to understand what the study questions were, what was done to address them, what
data were collected and analyzed, and the major outcomes
References or electronic links to the full report of each study should be included in
the narratives.
Note that summaries of human dose-response pharmacokinetic and PK/PD studies
intended to establish dose range for the targeted indication are to be included in
this section. These studies will be of relatively short duration. In some cases, when
well-controlled dose-response PD or PK/PD studies provide important evidence of
efficacy, they should be placed in the Summary of Clinical Efficacy section and
referenced, but not summarized here.
2.3 Comparison and Analyses of Results Across Studies
This section uses the results of all in vitro human biomaterial studies and PK, PD
and PK/PD studies to characterise the PK, PD and PK/PD relationships of the drug.
Results related to the inter- and intra-individual variability in these data and the
intrinsic and extrinsic factors affecting these pharmacokinetic relationships should
be discussed.
This section should provide a factual presentation and discussion of all data across
studies that address the following:
1) Results of in vitro drug metabolism and in vitro drug-drug interaction studies
2) All data from human PK studies, including the best estimates of standard parameters and sources of variability. The focus should be on evidencesupporting dose and dose individualization in the target patient population andin special populations, e.g., pediatric or geriatric patients, or patients with renalor hepatic impairment.
3) Results of any population PK analyses, such as results based on sparse sampling across studies that address inter-individual pharmacokinetic variations in the The Common Technical Document – Efficacy (Clinical Written Summary)
PK or PD of the active drug substances that may be due to extrinsic or intrinsicfactors.
4) Dose-response or concentration-response relationships. This discussion should highlight evidence to support the selection of dosages and dose intervals studiedin the pivotal clinical trials. In addition, information that supports the dosageinstructions in the final labelling should be discussed in Section 3.3.4.
5) Any major inconsistencies in the human biomaterial, PK, or PD database and any 6) Any bridging studies that use pharmacological endpoints and that were performed to determine whether foreign clinical data could be extrapolated tothe new region (see ICH E5). The result of the study and analysis of thesimilarity of pharmacological data between regions or races should besummarized in this section. An independent subsection can be created tosummarize these kinds of data.
2.4 Special Studies
This section is for studies that provide special types of data relevant to specific
types of pharmaceuticals. For immunogenicity studies and other studies in which
data may correlate with PK, PD, safety, and/or efficacy data, explanations of such
correlations should be summarised here. Any observed or potential effects on PK,
PD, safety and/or efficacy should be considered in the appropriate section of the
Written Summary as well, with cross-referencing to this section.
Example 1:
Immunogenicity
For protein products and other products to which specific immunological reactionshave been measured, data regarding immunogenicity should be summarized in thissection. For vaccines or other products intended to induce specific immunereactions, immunogenicity data may be described in the efficacy section. Assaysused should be briefly described and information about their performance (e.g.,sensitivity, specificity, reliability, validity) should be summarized; the location inthe application of detailed information should be cross-referenced.
Data regarding the incidence, titre, timing of onset and duration of antibodyresponses should be summarized for each type of antibody assay used (e.g., IgG byELISA, neutralization). Relationships of antibody formation to underlying disease,concomitant medication, dose, duration, regimen, and formulation should beexplored and summarized. For drugs intended to be given as chronic, continuoustherapy, any data on the impact of interruptions of therapy on antigenicity shouldbe analyzed and summarized.
It is particularly important to summarize analyses of potential clinically relevantcorrelates of immunogenicity, e.g., to determine the extent to which the presence ofantibodies of a particular type or titer appears to correlate with alterations of PK,changes in PD, loss of efficacy, loss of adverse event profile, or development ofadverse events. Particular attention should be paid to events that might be The Common Technical Document – Efficacy (Clinical Written Summary)
immunologically mediated (e.g., serum sickness) and events that might result frombinding of cross-reactive endogenous substances by antibodies to the administereddrug.
The Common Technical Document – Efficacy (Clinical Written Summary)
Example 2:
Clinical microbiology
For antimicrobial or antiviral pharmaceuticals, in vitro studies to characterise thespectrum of activity are an important part of the programme of studies relevant toclinical efficacy. Clinical efficacy studies that include characterisation of thesusceptibilty of the clinical isolates as a part of the efficacy determination would beincluded in Section 3, Summary of Clinical Efficacy. However, studies that evaluatesuch findings as the pattern of in vitro susceptibility of strains of bacteria fromdifferent parts of the world (not in the context of clinical efficacy study) would beincluded here.
Section 2 Appendix
Table 2.1 is provided as an example of a tabular format for reporting information
and results related to pharmacokinetic studies. This table is not intended to be a
template, but only to illustrate the type of information that should be considered by
a sponsor in designing their own tables. Sponsors should also decide whether
information and results from clinical pharmacology studies are best presented in
tables, text or figures in order to aid clarity.
In designing tables, if any, for various types of other clinical pharmacology studies
such as those listed below, sponsors should consider including the following types of
information. These examples are for illustrative purposes only and the sponsor
should decide which information needs to be presented.
• Metabolism studies of pharmaceutical using human biomaterials: biomaterials
used (e.g., microsomes, hepatocytes), probe drugs, enzymatic pathways and %contribution and relevant kinetic parameters (e.g., Vmax, Km).
• Drug-drug interactions of pharmaceuticals using human biomaterials: for studies of other drugs inhibiting the new pharmaceutical, include metaboliteinhibited, enzymatic pathways affected, range of inhibitor concentrations used,IC50 and KI values and proposed mechanism of inhibition. For studies of the newpharmaceutical inhibiting other drugs, include the drugs and metabolitesinhibited along with the information mentioned above.
• Population PK studies: co-variates studied, number and type of subjects or patients studied, summary statistical parameters and final estimates of mean (+sd) PK parameters.
3. SUMMARY OF CLINICAL EFFICACY
A separate Section 3 should be provided for each indication, although closely related
indications may be considered together. When more than one Section 3 is
submitted, the sections should be labeled 3A, 3B, 3C, etc.
3.1 Background / Overview of Clinical Efficacy
This section describes the program of controlled studies and other pertinent studies
in the application that evaluated efficacy. Controlled studies include studies with
historical or other external control groups, as well as studies with placebo, no-
The Common Technical Document – Efficacy (Clinical Written Summary)
treatment, dose-response, and active control groups. Any of these results that arepertinent to evaluation of safety should be discussed in Section 4, Summary ofClinical Safety.
The section should begin with a brief overview of the design of the controlledstudies that were conducted to evaluate efficacy. These studies include dose-response, comparative efficacy, long-term efficacy, and efficacy studies in populationsubsets. Critical features of study design should be discussed, e.g., randomization,blinding, choices of control treatment, choice of patient population, study endpoints,study duration, unusual design features such as crossover or randomizedwithdrawal designs, use of run-in periods, and other methods of “enrichment”.
Although this section is intended to focus on clinical investigations, preclinical dataand clinical pharmacological data may also be referenced as appropriate to providea comprehensive summary of human experience related to efficacy.
3.2 Summary of Individual Clinical Efficacy Studies
A brief narrative description for important studies should be presented. The
narrative descriptions should provide enough detail about the study objectives,
study design and conduct, data analysis, and critical results to allow the reviewer to
understand what the study questions were, what was done to address them, what
data were collected and analyzed, and what the major outcomes were. These
narratives should be consistent with and may be abstracted from the synopses of the
clinical study reportsys (ICH E3). References or electronic links to the full report of
each study should be included in the narratives.
3.3 Comparisons and Analyses of Results Across Studies
This section presents all available data that characterize the efficacy of the drug.
This section should cross-reference data from all studies designed to evaluate the
efficacy of the drug. This summary will include analyses of all data, irrespective of
their support for the overall conclusion and should, therefore, discuss the extent to
which the results of the relevant studies do or do not reinforce each other. Any
major inconsistencies in the data regarding efficacy should be addressed and any
areas needing further exploration should be identified.
The section will generally utilize two kinds of analyses: comparison of results of
individual studies, and/or analysis of data combined from various studies. Details of
analyses that are too extensive to be reported in a summary document should be
presented in a separate report, to be placed in Module V, Section 5.3.
This section should also cross-reference important evidence from section 2, such as
data that support the dosage and administration section of the labeling. These data
include dosage and dose interval recommended, evidence pertinent to
individualization of dosage and need for modifications of dosage for specific
subgroups (e.g., pediatric or geriatric subjects, or subjects with renal impairment),
and data relevant to dose-response or concentration response (PK/PD)
relationships.
The Common Technical Document – Efficacy (Clinical Written Summary)
3.3.1
Study Populations
The demographic and other baseline characteristics of patients across all studiesshould be described. The following should be included :• the characteristics of the disease (severity, prior treatment, duration) in the patients studied and any limitations on conclusions imposed by theinclusion/exclusion criteria.
• the adequacy of follow-up and the number of patients who dropped out. The reasons why the patients did not complete the study and the times (afterinitiation of therapy) when the patients were withdrawn or lost to follow upshould be summarized.
• differences in baseline characteristics of the study populations in different studies or groups of studies. Any impact of such differences on the resultsshould be discussed.
• any differences between populations included in critical efficacy analyses and the overall patient population that would be expected to receive the drug whenit is marketed should be noted.
Tabular presentations that combine and compare study populations across studiesmay be useful.
3.3.2
Comparison of Results of all Clinical Efficacy Studies
The results from all studies designed to evaluate the drug’s efficacy should besummarized and compared, including studies with inconclusive or negative results.
Important differences in study design such as endpoints, statistical methods,patient population, and dose should be identified. In general, studies with differentcontrols (placebo, active) should be discussed separately.
If many variables or time points were analyzed, it may be useful to selectrepresentative data for display in comparisons. If results over time are critical,results of many studies over time can be displayed in a single figure, e.g. displayingdifference from control with confidence intervals for the difference, using a separateline for each study. Confidence intervals for the treatment effects should always begiven to aid in the interpretation of point estimates. If differences are shownbetween placebo and test drugs in the change from baseline, the baseline values andthe magnitude of effect in all treatment groups, including placebo, should generallybe presented in the table or in text accompanying a figure. If the objective of anactive control trial was to show equivalence or non inferiority, the difference or theratio of outcomes between treatments should be given with the confidence interval.
The results should be evaluated by using the predefined criteria for definingequivalence or non inferiority with the rationale for the criteria provided (see ICHE10). Important differences in outcomes between studies with a similar designshould be delinated and discussed. Cross-study comparisons of factors that mayhave contributed to differences in outcomes should be described.
The Common Technical Document – Efficacy (Clinical Written Summary)
If a meta-analysis of the clinical studies is performed, it should be clear whetherthis analysis is conducted according to predefined protocol criteria or is a post hocexercise, and appropriate statistical adjustments should be discussed. Any source ofbias related to differences between subject populations or differences in efficacymeasurements between trials should be described to allow assessment of therelevance and validity of the results and conclusions (See ICH E9). A detaileddescription of the methodology and results of the meta-analysis should generally besubmitted in a separate report (section 5.3 of Module V).
3.3.3
Analyses of Demographic Subsets and other Covariates
The results of individual studies or overview analyses of efficacy in specificpopulations, e.g., the elderly, or in specific disease stages, e.g., severe depression,should be summarized in this section. These analyses should be derived from bothindividual studies and from cross-study subset analyses.
Given the limited sample sizes in individual studies, analyses across multiplestudies may be used to examine results in a subset of patients. These subsetanalyses should be carried out for major demographic (age, sex, race) and otherintrinsic and extrinsic factors (e.g., disease severity, prior treatment, concomitantillness, concomitant drugs, ethanol, tobacco, body weight). The limitations of suchanalyses, however, must be recognized (ICH E9).
The results of any bridging studies using clinical endpoint - for example to evaluatethe ability to extrapolate certain types of foreign clinical data to the new region (seeICH E5)- should be summarised in this section. An analysis of the similarity ofefficacy in subjects between regions should be summarized here. An independentsubsection can be created to summarize these kinds of data.
3.4 Analysis of Clinical Information Relevant to Dosing
Recommendations
This section should provide an integrated summary and analysis of all data frompre-clinical studies, pharmacokinetic studies, other clinical pharmacology studies,and controlled and uncontrolled clinical studies that pertain to the dose-response orblood level-response relationship of effectiveness, the dose-blood level relationship,the method of dose selection, and choice of dose interval. For pharmacokinetic andpharmacodynamic studies from which data have been summarized in Section 2.3, itmay be appropriate to draw upon those data in this summary while cross-referencing the summaries in Section 2.3, without repeating the summaries.
Results and analysis of these studies should support the dosing recommendationsproposed in labeling, including the recommended starting and maximal doses, themethod of dose titration, and any other instructions regarding individualization ofdosage. Any identified deviations from relatively simple dose-response or blood-level response relationships due to non-linearity of pharmacokinetics, delayedeffects, tolerance, enzyme induction, etc. should be described.
Any evidence of differences in dose-response relationships that result from apatient’s age, size, sex, disease, or other factors should be described. Any evidence of The Common Technical Document – Efficacy (Clinical Written Summary)
different pharmacokinetic or pharmacodynamic responses should also be discussed,or discussions in Section 2 may be cross-referenced. The ways in which suchdifferences were looked for, even if no differences were found, should be described(e.g., specific studies in subpopulations, analysis of efficacy results by subgroup, orblood level determinations of test drug).
3.4.1
Evidence of Long-Term Efficacy and/or Tolerance Effects
Available information on persistence of efficacy over time should be summarized.
The number of patients for whom long-term efficacy data are available, and thelength of exposure, should be provided. Any evidence of tolerance (loss oftherapeutic effects over time) should be noted. Examination of any apparentrelationships between dose changes over time and long-term efficacy may be useful.
Controlled studies specifically designed to collect long-term efficacy data should beclearly differentiated from other, less rigorous, studies such as open extensionstudies. This distinction also applies to specific studies designed for evaluation oftolerance and withdrawal effects.
The effect of switching to other therapies upon assessment of long-term efficacyduring the clinical trials should be discussed. Predefined switching criteria and thecharacteristics of the subjects who switched should be described for each treatmentarm. Sufficient information should be given to allow assessment of the impact ofthese factors on the ultimate conclusions of the clinical trial. Similar considerationsapply to any kind of rescue therapy. In the analysis of outcome (survival, majormorbid events), data from subjects who switched to another therapy should beincluded in the data up to the time of the switch. After the subjects switch their datashould be included in the intent-to-treat population in the assessment of the majorclinical outcome. Data concerning withdrawal or rebound effects pertinent toproduct safety should be presented in the safety section (see section 4).
Section 3 Appendix
Tabular presentations should be provided that summarise the most important
results from all studies pertinent to the evaluation of efficacy (including studies that
were terminated or are not yet completed, studies that failed to show effectiveness
for any reason, studies available only as publications, studies reported in full
technical reports (ICH-E3), and studies described in abbreviated reports). When
more than one section 3 is provided for an application with more than one
indication, usually each section should have its own appendix with tables.
Example tables are provided, but thought should be given to the use of these
examples. These examples will not be precisely relevant to every application.
Conversely, applications will generally require many other unique tables and/or
figures that are not represented in these examples.
Applicants should note that it is not mandatory to use the example tabular formats
provided in this guidance. Applicants are encouraged to modify the tabular formats
as needed and provide the best possible presentation of information, in order to
The Common Technical Document – Efficacy (Clinical Written Summary)
facilitate the understanding and evaluation of the results. It is recognised thatalternate formats may be necessary to ease preparation of an electronic document.
The Common Technical Document – Efficacy (Clinical Written Summary)
Description of Clinical Efficacy and Safety Studies 4. SUMMARY OF CLINICAL SAFETY
This section is a summary of data relevant to safety in the intended patient
population, integrating the results of individual clinical study reports, and other
relevant reports, e.g., the integrated analyses of safety that are routinely submitted
in some regions.
The display of safety-related data can be considered at three levels (ICH E3):
− The extent of exposure (dose, duration, number of patients, type of patients)
should be examined as a determinant of the degree to which safety can beassessed from the database.
− The more common adverse events and changes in laboratory tests should be identified and classified in a reasonable fashion, and their analysis should besummarized.
− Serious adverse events (defined in ICH E2A) and other important adverse events (defined in ICH E3) should be identified and their analysis should besummarized.
Analysis of safety in subsets of the population (e.g. healthy subjects and patients,demographic) should be presented where appropriate.
The safety profile of the drug, described on the basis of analysis of all clinical safetydata, should be outlined in a detailed, clear, and objective manner, by appending aselection of descriptive tables and figures.
4.1 Exposure to the Drug
4.1.1
Overall Safety Evaluation Plan
The overall safety evaluation plan should be described briefly, including specialconsiderations/observations concerning the preclinical data, any relevantpharmacological class effects, and how the overall clinical development programmewas designed to evaluate safety.
4.1.2
Overall Extent of Exposure (Table 4.1)
A table (see example) and appropriate text should be generated that present theoverall extent of drug exposure from all phases of the clinical study developmentprogramme. The table should indicate the numbers of subjects/patients exposed atvarious doses, routes, and durations. If a large number of different doses and/ordurations of exposure were used, these may be grouped in a manner appropriate forthe drug under review. Thus, for any dose or range of doses, duration of exposure The Common Technical Document – Efficacy (Clinical Written Summary)
can be summarized by the number of subjects/patients exposed for specific periods oftime, such as 1 day or less, 2 days to 1week, 1 week to 1 month, 1 month to 6 months,6 months to 1 year, more than 1 year (ICH E3). In some applications it may beimportant to identify diagnostic subgroups and/or groups receiving specificconcomitant therapies deemed particularly relevant to safety assessment in theintended use.
The dose levels used for each subject/patient in this presentation could be themaximum dose received by that subject/patient, the dose with longest exposure,and/or the mean daily dose, as appropriate. In some cases, cumulative dose may bepertinent. Dosage may be given as the actual daily dose or on a mg/kg or mg/m2basis, as appropriate. If available, drug concentration data (e.g., concentration at thetime of an adverse event, maximum plasma concentration, area under curve) may behelpful in individual subjects for correlation with adverse events of changes inlaboratory variables.
It is assumed that all subjects who were enrolled and received at least one dose ofthe treatment are included in the safety analysis; if that is not so, an explanationshould be provided.
4.1.3
Demographic and Other Characteristics of Study Population
A summary table should provide the reader with an overview of the demographiccharacteristics (Table 4.2) of the population that was exposed to the therapeuticagent during its development. Choice of age ranges used should take into accountconsiderations discussed in ICH E7 [Studies in Support of Special Populations:Geriatrics] and ICH E11 [Clinical Investigation of Medicinal Products in thePaediatric Population].
In addition, one or more tables should show the relevant characteristics of patients,and the numbers of patients with special characteristics should be considered.
For example: − Stage/severity of disease− Hospitalized patients versus outpatients− Impaired renal or hepatic function− Patients taking particular medications− Major geographical locations where studies were conducted− Presence of concomitant illnesses (e.g., coronary artery disease, diabetes The text accompanying the table(s) should mention any imbalance(s) between thedrug and placebo and/or comparator regarding any of the above demographiccharacteristics, particularly if they could lead to differences in safety outcomes.
It should be noted that certain patients were excluded from studies (concomitantillness, severity of illness, concomitant medications).
The Common Technical Document – Efficacy (Clinical Written Summary)
Separate demographic tables should be provided for every indication, althoughclosely related indication may be considered together. This is particularlyimportant when the various indications involve patient populations with verydifferent demographic characteristics, e.g., luteinising hormone releasing hormoneanalogues for prostatic cancer, endometriosis, and precocious puberty.
4.1.4
Description of Safety Studies Not Presented Elsewhere
Studies pertinent to the evaluation of efficacy will be listed in tables and havenarrative summaries (including safety data) in Section 3. Any important safetystudies not adequately described in tables or Section 3 should be briefly describedhere. For example, narrative descriptions of controlled studies to evaluateparticular adverse events (sedation, sexual function, effects on driving, absence of aclass adverse effect) or to assess safety in particular demographic subsets andnarrative descriptions of uncontrolled safety trials would often not be included inSection 3 and should be presented here.
4.2 Adverse Events
4.2.1
Frequency of Adverse Events
Data on the frequency of adverse events should be described in text and tables. Textshould appear in this section and the tables in the section 4 Appendix.
All new adverse events occuring after treatment has begun (including those not seenat baseline or that worsened during treatment) should be summarized in tableslisting each event, the number of subjects/patients in whom the event occurred andthe frequency of occurrence in subjects/patients treated with the drug underinvestigation, with comparator drugs, and with placebo. In most cases, it will also beuseful to identify in such tables "treatment emergent signs and symptoms" (TESS,those not seen at baseline and those that worsened even if present at baseline). Suchtables could also present results of other doses and could be modified to show, e.g.,adverse event rates by severity, by time from onset of therapy, or by assessment ofcausality. When most of the relevant safety data are derived from a small number of studies,presentation of data by study will often suffice. Conversely, when the relevantexposure data is not concentrated in a small number of studies, it may be moreappropriate to group the studies and pool the results to present an overallsummary. Any study with an unusual adverse event pattern should be presentedseparately.
Adverse events should be described as shown in the individual study report (ICHE3). In combining data from many studies, it is important to use standardized termsto describe events and collect synonymous terms under a single preferred term.
This can be done with a standard dictionary, and the MedDRA terminology (ICH M1guideline) should be used. Until MedDRA can be fully implemented, otherdictionaries can be used, but must be specified. Frequencies should be presented forpreferred terms and for appropriately defined groupings. Examination of whichadverse events led to change in therapy (discontinuation of drug use, change in The Common Technical Document – Efficacy (Clinical Written Summary)
dose, need for added therapy) can help assess the clinical importance of adversedrug reactions (ADR). These rates can be added to the adverse event rate tables, orcan be presented in separate tables. Overall discontinuation rates by study may beuseful but it is also important to specify the particular adverse events leading todiscontinuation in a separate table. The preferred terms should be grouped by bodysystem and arranged by decreasing frequency.
If substantial differences are seen between clinical trials in the rates of adverseevents, these differences should be noted and possible reasons should be discussed(e.g., relevant differences in study populations, in dose administration).
4.2.2
Analyses of Adverse Events
Pooling Across Studies to Obtain Subject Sub-groups for Estimatingand Comparing Incidence Examination of less common adverse events that may not even occur in somestudies is important in safety analysis. Pooling data from different studies isa method to improve the precision of incidence estimates, i.e., to narrow theconfidence intervals and to decrease the influence of local factors. The largersample available in a pooled analysis may also permit explorations forinteractions in subgroups of the population, such as age, sex, race,concomitant illness, or concomitant drug use. Finally, a more general goal ofpooling is to facilitate the generation of hypotheses about risk, some of whichmay become the focus of future studies that are more definitive.
Although pooling may be useful and appropriate, it should be approachedwith caution because interpretation can be difficult; it is more informative toacknowledge and display the variability and explain it.
The following issues should be considered in planning pooled analyses: • It is most appropriate to combine data from studies that are of similar design, e.g., similar in dose, duration, methods of determining adverseevents, and population.
• If the incidence for a particular adverse event differs substantially across the individual studies in a pool, the pooled estimate is lessinformative.
• The extent of analysis needed depends on the severity of the adverse event and the strength of evidence of drug causation. Differences inrates of drug-related, serious events deserve more investigation,whereas rates of other adverse events do not merit elaborate analysis.
• Examination of which patients experience extreme laboratory value abnormalities may be useful in identifying subgroups of patients who areat particular risk for certain adverse events.
The Common Technical Document – Efficacy (Clinical Written Summary)
If a decision is made to pool data from several studies, the rationale forselecting the method used for pooling should be described. It is most commonto combine the numerator events and the denominators for the selectedstudies. Other more formal weighting methods are available, e.g., weightingstudies on the basis of study size or inversely to their variance. If the goal ofpooling is to increase the power to detect a difference between two treatmentgroups, e.g., drug vs. placebo, a test of heterogeneity, might be useful (ICHE9). Alternatively, a more informal evaluation can be used.
Groups of studies that could be used in pooled safety analyses include: • All controlled studies or subsets of controlled studies, such as all placebo-controlled studies, studies with any positive control, studieswith a particular positive control, or studies of particular indications(and thus carried out in different populations).
These groupings are the best source of information about the morecommon adverse events and can distinguish drug-related events fromspontaneous events. Rates in control and treatment groups should becompared.
• All studies, excluding short-term studies in healthy subjects.
This grouping is most useful for evaluating rarer events.
• All studies using a particular dose route or regimen, or a particular • Studies in which adverse event reports are elicited by checklist or direct questioning or studies in which events are volunteered.
• Pools of studies by region.
It is almost always useful to carry out the first two groupings; the otherschosen will vary from drug to drug and will be influenced by inspection ofindividual study results. Whatever methods are used, it should berecognized that, as for results of single studies, any numerical rate is arough approximation.
4.2.2.2 Tabular displays of adverse event rates in section 4 Appendix should beused to compare rates in treatment and control groups. For this analysis itmay be helpful to combine the event severity categories and the causalitycategories, if they are used, leading to a simpler side-by-side comparison oftreatment groups. Additionally, comparisons of rates of adverse eventsbetween treatment and control groups in individual trials should besummarized here.
It is usually useful to examine more closely the more common adverseevents that seem to be drug related (e.g., those that show that a doseresponse and/or a clear difference between drug and placebo rates) forrelationship to the following: The Common Technical Document – Efficacy (Clinical Written Summary)
− demographic characteristics such as age, sex, race − other baseline features such as renal status; − drug concentration.
It may also be useful to summarize the results of examination of time ofonset and duration for these drug-related events.
It is not intended that every adverse event be subjected to rigorousstatistical evaluation of possible relationship to each of the above factors. Itmay be apparent from initial display and inspection of the data that asignificant relation to demographic or other baseline features is not present.
In that case, no further analysis of these particular factors is needed.
Further, it is not intended that all such analyses performed be presented orsummarized in this report. While the full integrated analysis of safety thatis submitted in some regions will contain details about all such analyses,this summary of human safety experience should summarize those analysesthat yielded potentially important (positive or negative) informationregarding the safety of the drug.
Under certain circumstances, life table or similar analyses may be moreinformative than reporting of crude adverse event rates.
4.2.2.3 In general, all deaths occurring during the clinical programme, includingthe posttreatment follow-up period and deaths that may have resulted froma process that began during studies should be listed in a table in the section4 Appendix (excepting only deaths that are clearly disease-related, instudies of conditios with high mortality such as advanced cancer, or studieswhere mortality from disease is a primary study endpoint). Deaths shouldbe examined individually and analyzed on the basis of rates in individualtrials and appropriate pools of trials, considering both total mortality andcause-specific deaths. Although cause-specific mortality can be difficult todetermine, some deaths are relatively easy to interpret. Thus deaths due tocauses expected in the patient population (heart attacks and sudden deathin an angina population) are individually not informative but even a fewcases of death due to QT prolongation-associated arrhythmias, aplasticanemia, or liver injury may be informative. Special caution is needed beforean unusual death is attributed to concomitant illness.
The Common Technical Document – Efficacy (Clinical Written Summary)
Summaries of all serious adverse events (other than death but including theserious adverse events temporally associated with or proceeding thedeaths) should be displayed. The display should include major laboratoryabnormalities, abnormal vital signs, and abnormal physical observationsthat are considered serious adverse events by using the ICH E2Adefinitions. Results of analyses or assessments of serious adverse eventsacross studies should be presented.
4.2.2.5 Marked hematologic and other laboratory abnormalities (other than thosemeeting the definition of serious) and any events that led to a substantialintervention (withdrawal of test drug/investigational product treatment,dose reduction, or substantial additional concomitant therapy), other thanthose reported as serious adverse events, should be displayed.
Events that led to premature discontinuation of drug treatment representan important safety concern and deserve particular attention in the analysisof drug safety for two reasons. First, even for expected events (based onpharmacologic activity), the need to discontinue (or otherwise alter)treatment reflects the severity and perceived importance of the event topatient and physician. Second, discontinuation may represent a drug-related event not yet recognized as drug related. Adverse events leading towithdrawals should be considered possibly drug-related even if this was notrecognized initially and even if the event was thought to representintercurrent illness. Rates of discontinuations should be compared acrossstudies and compared with those for placebo and/or active control treatmentIn addition, the study data should be examined for any evidence thatspecific patient features might increase the risk of these events (e.g.,demographic characteristics, concomitant illnesses, dose of the drug, orparticular concomitant treatments). Serious adverse events that occurredafter the drug use was discontinued should be included in Section 4.2.2.4.
4.2.2.6 The locations in the application of individual narratives of patient deaths,other serious adverse events, and other significant adverse events deemedto be of special interest because of clinical importance (as provided inindividual study reports) should be referenced here for the convenience ofthe reviewer. The narratives themselves should be a part of the individualstudy reports, and should not usually be included here, unless anabbreviated narrative of particular events is critical to the assessment ofthe drug.
4.2.3
Integrated Analysis of Serious and Significant Events
Although deaths, other serious events, and other significant events are presentedseparately both in study reports and here, assessment of the causality and the The Common Technical Document – Efficacy (Clinical Written Summary)
cofactors for these events is often complicated by the fact that they are uncommon.
As a result, consideration of the more important events as a group, and togetherwith less important events of potentially related pathophysiology, may be of criticalvalue in understanding the safety profile. For example, the relationship totreatment of an isolated sudden death may become much clearer when considered inthe context of cases of syncope, palpitations, and asymptomatic arrhythmias.
Serious events should be examined for frequency over time, particularly for drugsthat may be used chronically. Similarly, serious events should be examined forevidence of relationship to dose, and/or specific treatment regimens.
4.3 Clinical Laboratory Evaluations
This section describes changes in patterns of laboratory tests with drug use. Marked
laboratory abnormalities and those that led to a substantial intervention are
reported in section 4.2.2. If these data are also presented in this section, this
duplicate reporting should be made clear for the reviewer. The needed evaluations
of laboratory values will in part be determined by the results seen, but, in general,
the analyses described below should be provided. For each analysis, comparison of
the treatment and control groups should be carried out, as appropriate and as
compatible with study sizes. In addition, normal laboratory ranges should be given
for each analysis (ICH E3).
A brief overview of the major changes in laboratory values across the clinical studies
should be provided. Laboratory data comprise haematology, biochemistry, urinalysis
and other data as appropriate. Each parameter at each time over the course of the
study (e.g., at each visit) should be described at the following three levels:
• the central tendency, i.e., the group mean and median values,
• the range of values, and the number of subjects or patients with abnormal values
or with abnormal values of a certain size (e.g. twice the upper limit of normal, 5times the upper limit; choices should be explained). When data are pooled fromcentres with differences in normal laboratory ranges, the methodology used inpooling should be described. The analysis of individual patient changes bytreatment group can be shown with a variety of approaches, including (ICH E3): − "Shift tables" - These tables show the number of subjects/patients who are low, normal, or high at baseline and then at selected time intervals.
− Tables showing the number or fraction of patients who had a change in a value of a predetermined size at selected time intervals.
− A scatter graph comparing the initial value and the on-treatment values of a laboratory measurement for each patient. These displays identify outliersreadily (it is useful to include patient identifiers for the outliers).
• Individual clinically important abnormalities, including those leading to discontinuations.The significance of the laboratory changes and the likelyrelation to the treatment should be assessed (e.g., by analysis of such features asrelationship to dose, relation to drug concentration, disappearance on continued The Common Technical Document – Efficacy (Clinical Written Summary)
therapy, positive dechallenge, positive rechallenge, and the nature ofconcomitant therapy).
4.4 Vital Signs, Physical Findings, and Other Observations Related to
Safety
The manner of presenting cross-study observations and comparisons of vital signs
(e.g., pulse, blood pressure, temperature, respiratory rate), weight and other data
(e.g., electrocardiograms and X-rays) related to safety should be similar to that for
laboratory variables. If there is evidence of a drug effect, any dose-response or drug
concentration-response relationship or relationship to patient variables (e.g.,
disease, demographics, concomitant therapy) should be identified and the clinical
relevance of the observation described. Particular attention should be given to
changes not evaluated as efficacy variables and to those considered to be adverse
events.
Any data pertinent to specific safety concerns that are collected (e.g., Holter
monitoring QT interval prolongation, PK/PD studies, pharmacologic studies) should
be presented separately. The events themselves (Torsade de pointes arrhythmias,
syncopal events) would be presented as adverse events.
4.5 Safety in Special Patient Groups and Situations
4.5.1
Intrinsic Factors
This section should summarize safety data pertinent to individualising therapy orpatient management on the basis of demographic and other intrinsic factors.
Intrinsic factors (ICH E5) include age, sex, height, weight, lean body mass, genetics,body composition, other illness and organ dysfunction. Analysis of the impact ofsuch factors on safety outcomes will have been shown in other sections but should besummaried here, together with pertinent PK or other information, e.g., in patientswith renal or hepatic disease. If a sufficiently large number of patients with a givenco-morbid condition such as hypertension, heart disease, or diabetes, was enrolled,analyses should be carried out to assess whether the co-morbid condition affectedthe safety of the drug under study. Cross reference should be made to the tables ordescription of adverse events when analyses of such sub-groups has been carriedout.
4.5.2
Extrinsic Factors
This section should summarize safety data pertinent to individualizing therapy orpatient management on the basis of extrinsic factors. Extrinsic factors (ICH E5) arefactors associated with the patient environment. Examples are the medicalenvironment, use of other drugs (see 5.3, Drug Interactions), use of tobacco, use ofalcohol, and food habits.
For example, if a potential interaction with alcohol is suggested by the metabolicprofile, by the results of studies, by post-marketing experience, or by information onsimilar drugs, information should be provided here.
The Common Technical Document – Efficacy (Clinical Written Summary)
4.5.3 Drug- Interactions
Studies on potential drug-drug or drug-diet interactions are presented in the
Clinical Pharmacology section of the dossier. Interactions with potential impact on
safety should be summarized here, based on PK, PD, or clinical observations.
Any observed changes in the adverse event profile, changes in blood levels thought
to be associated with risk, or changes in drug effects associated with other therapy
should be presented here.
The Common Technical Document – Efficacy (Clinical Written Summary)
4.5.4
Use in Pregnancy and Lactation
Any information on safety during pregnancy or breast-feeding that becomesavailable during clinical development or from other sources should be summarisedhere.
4.5.5
Overdose
All available information on overdose, including signs/symptoms, laboratoryfindings, and therapeutic measures/treatments and antidotes (if available) should besummarized and discussed. Information on the efficacy of specific antidotes anddialysis should be provided if available.
4.5.6
Drug Abuse
Any relevant studies/information regarding the investigation of the dependencepotential of a new therapeutic agent in animals and in humans should be discussedand clearly cross-referenced to the preclinical summary. Particularly susceptiblepatient populations should be identified and recommendations justified.
If studies on abuse potential have not been performed for a drug that belongs to aclass of drugs known to have abuse potential, , the reasons why studies areconsidered unnecessary should be discussed.
4.5.7 Withdrawal/Rebound
Any information or study results pertinent to rebound effects should be summarized
and discussed. Events that occur, or increase in severity, after discontinuation of
double-blind or active study medication should be examined to see if they are the
result of withdrawal of the study medication. Specific studies concerning
withdrawal and/or rebound should be presented separately.
Data concerning tolerance should be presented under section 3, Summary of Clinical
Efficacy.
4.5.8 Effects on Ability to Drive or Operate Machinery or Impairment of
Mental Ability
Safety data related to any impairment in the senses, coordination, or other factor
that would result in diminished ability to drive a vehicle or operate machinery or
that would impair mental ability should be summarized. When specific studies
concerning effects on ability to drive or operate machinery or impairment of mental
ability are performed, the results should be presented separately.
4.6 Post-marketing data
If the drug has already been marketed, details of the number of subjects estimated
to have been exposed should be provided and categorised, as appropriate, by
indication, dosage, route, treatment duration, and geographic location. The
methodology used to estimate the number of subject exposed should be described. If
estimates of the demographic details are available from any source, these should be
provided.
The Common Technical Document – Efficacy (Clinical Written Summary)
A tabulation of serious events reported after the drug is marketed should beprovided, including any potentially serious drug interactions.
Any post-marketing findings in subgroups should be described.
Section 4 Appendix
Tabular presentations should be provided that summarise the key results from all
studies pertinent to the evaluation of safety.
Example tables are provided, but thought should be given to the use of these
examples. These examples will not be precisely relevant to every application.
Conversely, applications will generally require many other unique tables and/or
firgures that are not represented in these examples.
Applicants should note that it is not mandatory to use the example tabular formats
provided in this guidance. Applicants are encouraged to modify the tabular formats
as needed and provide the best possible presentation of information, in order to
facilitate the understanding and evaluation of the results. It is recognised that
alternate formats may be necessary to ease preparation of an electronic document.
See sections 4.2.1, 4.2.2.3, and 4.3 of this guidance for additional discussion
regarding the content of section 4 tables.
Table 4.1
Patient Drug Exposure by Mean Daily Dose and Duration of Treatment Demographic Profile for Patient Studies with Test Product Treatment Emergent Adverse Event Incidence in the Largest Trials Patient Discontinuations by Study: Controlled Trials 5. SYNOPSES OF INDIVIDUAL STUDIES
The ICH E3 guideline (Structure and Content of Clinical Study Reports) suggests
inclusion of a study synopsis with each clinical study report, and provides one
example of a format for such synopses.
This section should include the table entitled Listing of Clinical Studies, described
in guidance for Module V, followed by all individual study synopses organized in the
same sequence as the study reports in Module V.
It is expected that one synopsis will be prepared per study for use in all regions, and
the same synopsis will be used in this section and as part of the clinical study report
in module V. The length of a synopsis will usually be up to 3 pages, but a synopsis
The Common Technical Document – Efficacy (Clinical Written Summary)
for a more complex and important study may be longer, e.g. 10 pages. Within theindividual synopsis, tables and figures should be used as appropriate to aid clarity.
The Common Technical Document – Efficacy (Clinical Written Summary)
Table 1.1
Summary of Bioavailability Studies
The Common Technical Document – Efficacy (Clinical Written Summary)
Table 1.2
Summary of In Vitro Dissolution Studies
The Common Technical Document – Efficacy (Clinical Written Summary)
Table 2.1
Summary of PK Studies
Mean Pharmacokinetic Parameters (%CV) Substrate Drug The Common Technical Document – Efficacy (Clinical Written Summary)
The Common Technical Document – Efficacy (Clinical Written Summary)
Table 3.1
Description of Clinical Efficacy and Safety Studies
The Common Technical Document – Efficacy (Clinical Written Summary)
Table 3.2
Results of Efficacy Studies
The Common Technical Document – Efficacy (Clinical Written Summary)
Table 4.1
Patient Drug Exposure by Mean Daily Dose and Duration of Treatment1,2
N= Cutoff Date:
Duration
Mean Daily Dose (mg)
The Common Technical Document – Efficacy (Clinical Written Summary)
1 Similar tables can be calculated for median, for modal, and for maximum dose. The same table can be generated for any pool of studies and any subgroup of interest, e.g., on the basis of age, sex,ethnic factors, comorbid condition, concomitant medications, or any combination of these factors.
2 Dose may also be expressed as mg/kg, mg/m 2, or in terms of plasma concentration if such data are available.
The Common Technical Document – Efficacy (Clinical Written Summary)
Table 4.2
Demographic Profile for Patient Studies with Test Product
Cutoff Date:
Treatment Groups
The Common Technical Document – Efficacy (Clinical Written Summary)
The Common Technical Document – Efficacy (Clinical Written Summary)
Table 4.3
Treatment Emergent Adverse Event Incidence in the largest trials
Reported incidence (%) by Treatment Groups
Body System / Adverse
Study 95-0403
Study 96-0011
Study 97-0007
The Common Technical Document – Efficacy (Clinical Written Summary)
The Common Technical Document – Efficacy (Clinical Written Summary)
Table 4.4
Patient Withdrawals1 by Study: Controlled Trials
Cutoff Date:
Total Withdrawal
Reason for Withdrawal
1 Withdrawals are subjects who were enrolled but did not complete the study (includes subjects who discontinued treatment or changed to a different treatment prematurelyand/or were lost to follow-up) The Common Technical Document – Efficacy (Clinical Written Summary)
Table 4.5
Deaths Listing1,2
Treatment = Test Product
Cutoff Date:
Trial Center Patien
Description
(mg) (Days
A footnote should describe the rule for including deaths in the table, e.g., all deaths that occurred during a period of drug exposure or within a period ofup to 30 days following discontinuation from drug and also those occurring later but resulting from adverse events that had an onset during exposureor during the 30 day follow up period. Other rules may be equally appropriate.
Similar lists should be provided for patients exposed to placebo and active control drugs.
The Common Technical Document – Efficacy (Clinical Written Summary)
This listing should include all deaths meeting the inclusion rule, whether arising from a clinical trial or from any secondary source, e.g., postmarkingexperience. The source should be identified in this column, i.e., 1 0 for deaths arising from primary source clinical trials and 2 0 for those arising fromsecondary sources.
The Common Technical Document – Efficacy (Clinical Study Reports)
MODULE V – CLINICAL STUDY REPORTS
Organisation of Clinical Study Reports and Related Information
Preamble
Through the ICH process, a guideline has been published on the structure and
content of clinical study reports (E3). This document provides guidance on the
organisation of these study reports and other clinical data within a Common
Technical Document (CTD) for registration of a pharmaceutical product for human
use. These elements should facilitate the preparation and review of a marketing
application.
This guideline is not intended to indicate what studies are required for successful
registration. It indicates an appropriate organization for the clinical data reports
that are in the application.
The organization of clinical data within a CTD for the registration of new
pharmaceuticals has been addressed here. With appropriate modifications, this
organisation may also be applied to other types of applications presenting clinical
data.
The Common Technical Document – Efficacy (Clinical Study Reports)
Organization of Clinical Study Reports and Related Information in
Module V (Clinical) of The Common Technical Document (CTD)
July 20, 2000
Table of Contents of Clinical Study Reports and Related Information 1. Reports of Bioavailability (BA) and Bioequivalence (BE) Studies 1.1 BA Study Reports1.2 BE Study Reports1.3 In Vitro-In Vivo Comparison Study Reports1.4 Reports of Bioanalytical and Analytical Methods 2. Reports of Studies Using Human Biomaterials Pertinent to Absorption or Disposition2.1 Plasma Protein Binding Study Reports2.2 Reports of Hepatic Metabolism and Interaction Studies2.3 Reports of Studies Using Other Human Biomaterials 3. Reports of Human Pharmacokinetic (PK) Studies 3.1 Healthy Subject PK and Initial Tolerability Study Reports3.2 Patient PK and Initial Tolerability Study Reports3.3 Intrinsic Factor PK Study Reports3.4 Extrinsic Factor PK Study Reports3.5 Population PK Study Reports 4. Reports of Human Pharmacodynamic (PD) Studies 4.1 Healthy Subject PD and PK/PD Study Reports4.2 Patient PD and PK/PD Study Reports 5. Reports of Efficacy and Safety Studies 5.1 Study Reports of Controlled Clinical Studies Pertinent to the ClaimedIndication5.2 Study Reports of Uncontrolled Clinical Studies5.3 Reports of Analyses of Data From More Than One Study5.4 Other Study Reports 6. Reports of Post-Marketing Experience7. Case Report Forms and Individual Patient Listings The Common Technical Document – Efficacy (Clinical Study Reports)
Guideline on Organisation of Clinical Study Reports and
Related Information in Module V (Clinical) of
The Common Technical Document (CTD)
July 20, 2000
This guideline suggests a specific organization for the placement of clinical studyreports and related information to simplify preparation and review of dossiers andto ensure completeness. The placement of a report should be determined by theprimary objective of the study. Each study report should appear in only onesection. Where there are multiple objectives, the study should be cross-referencedin the various sections. An explanation such as “not applicable” or “no studyconducted” should be provided when no report or information is available for asection or subsection.
A Table of Contents for Study Reports
A Table of Contents for the study reports should be provided.
B. Tabular Listing of All Clinical Studies
A tabular listing of all human studies and related information should be provided.
For each study, this tabular listing should generally include the type of information
identified in Table 1 of this guideline. Other information may be included in this
table if the applicant considers it useful. The sequence in which the studies are
listed should follow the sequence described in Section C below. Use of a different
sequence should be noted and explained in an introduction to the tabular listing.
C. Clinical Study Reports
1. Reports of BA and BE Studies
BA and BE studies evaluate the rate and extent of release of the active substance
from the medicinal product. BA/BE studies may use PK, PD, clinical, or in vitro
dissolution endpoints, and may be either single dose or multiple dose. When the
primary purpose of a study is to assess the PK of a drug, but also includes BA or
BE information, the study report should be submitted in Section 3, and referenced
in Sections 1.1 and/or 1.2.
Section 1.1 BA Study Reports
BA studies in this section include 1) studies comparing the release and
systemic availability of a drug substance from a solid oral dosage form to the
systemic availability of the drug substance given intravenously (absolute BA
study) or as an oral liquid dosage form (relative BA study), 2) dosage form
proportionality studies, and 3) food-effect studies.
Section 1.2 BE Study Reports
BE studies in this section compare the rate and extent of release of the drug
substance from drug products (e.g., tablet to tablet, tablet to capsule). BE
studies may include comparisons between 1) the drug product used in clinical
The Common Technical Document – Efficacy (Clinical Study Reports)
studies supporting effectiveness and the to-be-marketed drug product, 2) thedrug product used in clinical studies supporting effectiveness and the drugproduct used in stability batches, and 3) similar drug products from differentmanufacturers.
Section 1.3 In Vitro – In Vivo Comparison Study Reports
In vitro dissolution studies that provide BA/BE information, including studies
used in seeking to correlate in vitro data with in vivo comparisons, should be
placed in Section 1.3. Reports of in vitro dissolution tests used for batch
quality control and/or batch release should be placed in the Quality section of
the CTD.
Section 1.4 Reports of Bioanalytical and Analytical Methods for Human
Studies
Bioanalytical and/or analytical methods for BA/BE or in vitro dissolution
studies should ordinarily be provided in individual study reports. Where a
method is used in multiple studies, the method and its validation should be
included once in Section 1.4 and referenced in the appropriate individual study
reports.
2. Reports of Studies Using Human Biomaterials Pertinent to
Absorption or Disposition
Human biomaterials is a term that refers to proteins, cells, and tissues derivedfrom human sources that are used in vitro or ex vivo to assess absorption anddisposition properties of drug substances. Examples include cultured humancolonic cells that are used to assess permeability through biological membranes,and human albumin that is used to assess plasma protein binding. Of particularimportance is the use of human biomaterials such as hepatocytes and/or hepaticmicrosomes to study metabolic pathways relative to drug absorption andelimination and to assess bi-directional drug-drug interactions with thesepathways. Studies using biomaterials to address other properties (e.g., sterility orpharmacodynamics) should not be placed in the Clinical Study Reports Section.
Section 2.1 Plasma Protein Binding Study Reports
Ex vivo protein binding study reports should be provided in Section 2.1.
Protein binding data from PK blood and/or plasma studies should be provided
in Section 3.
Section 2.2 Reports of Hepatic Metabolism and Interaction Studies
Reports of metabolic/interaction studies with hepatic tissue should be placed
in Section 2.2.
Section 2.3
Studies Using Other Human Biomaterials
Reports of studies with other biomaterials should be placed in section 2.3.
3. Reports of Human Pharmacokinetic (PK) Studies
Assessment of the PK of a drug in healthy subjects and/or patients is critical to
designing dosing strategies and titration steps, to anticipating the effects of
The Common Technical Document – Efficacy (Clinical Study Reports)
concomitant drug use, and to interpreting observed pharmacodynamic differences.
These assessments provide a description of the body’s handling of a drug over time,focusing on maximum plasma concentrations (peak exposure), area-under-curve(total exposure), clearance, and accumulation of the parent drug and itsmetabolite(s).
The PK studies in Sections 3.1 and 3.2 generally (1) measure plasma drug andmetabolite concentrations over time, (2) measure drug and metaboliteconcentrations in urine or faeces when useful or necessary, and/or (3) measuredrug and metabolite binding to protein or red blood cells. On occasion, PK studiesmay include measurement of drug distribution into other body tissues, bodyorgans, or fluids (e.g., synovial fluid or cerebrospinal fluid), and the results of thesetissue distribution studies should be included in Section 3.1 to 3.2, as appropriate.
These studies characterise the drug’s PK and provide information about theabsorption, distribution, metabolism, and excretion of a drug and any activemetabolites in healthy subjects and/or patients. Studies of mass balance andchanges in PK related to dose (e.g., determination of dose proportionality) or time(e.g., due to enzyme induction or formation of antibodies) are of particular interestand should be included in Sections 3.1 and/or 3.2. Apart from describing mean PKin normal and patient volunteers, PK studies also describe the range of individualvariability. Additional studies can also assess differences in systemic exposure asa result of changes in PK due to intrinsic (e.g., age, gender, racial, weight, height,disease, genetic polymorphism, and organ dysfunction) and extrinsic (e.g., drug-drug interactions, diet, smoking, and alcohol use) factors. In the ICH E5 guidelineon Ethnic Factors in the Acceptance of Foreign Data, factors which may result indifferent responses to a drug in different populations are categorized as intrinsicethnic factors or extrinsic ethnic factors. In this document, these categories arereferred to as intrinsic factors and extrinsic factors, respectively. Reports of PKstudies examining the influence of intrinsic and extrinsic factors on exposureshould be organized in Sections 3.3 and 3.4, respectively.
In addition to standard multiple-sample PK studies, population PK analyses basedon sparse sampling during efficacy and safety studies can also address questionsabout intrinsic and extrinsic factors contributing to the variability in the dose-exposure-response relationship. Because the methods used in population PKstudies are substantially different from those used in standard PK studies, thesestudies should be placed in Section 3.5.
Section 3.1 Healthy Subject PK and Initial Tolerability Study Reports
Study reports of PK and initial tolerability in healthy subjects should be placed
in Section 3.1.
Section 3.2 Patient PK and Initial Tolerability Study Reports
Reports of PK studies and initial tolerability in patients should be placed in
Section 3.2.
Section 3.3 Intrinsic Factor PK Study Reports
PK study reports to assess intrinsic factors, such as age, race and gender,
should be placed in Section 3.3.
The Common Technical Document – Efficacy (Clinical Study Reports)
Section 3.4: Extrinsic Factor PK Study Reports
PK studies to assess extrinsic factors, such as other drugs, food, or smoking,
should be placed in Section 3.4.
The Common Technical Document – Efficacy (Clinical Study Reports)
Section 3.5: Population PK Study Reports
Because the methods used in population PK studies are substantially different
from those used in standard PK studies, these studies should be placed in
Section 3.5.
4. Reports of Human Pharmacodynamic (PD) Studies
Reports of studies with a primary objective of determining the effects of a drug
product in humans, as opposed to those studies whose primary objective is to
establish efficacy or to accumulate safety data (see Section 5), should be placed in
Section 4.
PD studies in Section 4 thus should include 1) studies of pharmacologic properties
known or thought to be related to the desired clinical effects (biomarkers), 2)
short-term studies of the main clinical effect, and 3) studies of other properties not
related to the desired clinical effect, including studies to focus on specific safety
concerns, e.g., QTc prolongation. Because a quantitative relationship of these
pharmacological effects to dose and/or plasma drug and metabolite concentrations
is usually of interest, PD information is frequently collected together with drug
concentration information (concentration-response or PK/PD studies).
Relationships between PK and PD data may generally be evaluated using an
appropriate model that can be used as a basis for interpolation and/or
extrapolation of dose- and/or concentration-response information.
Dose-finding and/or PK-PD studies may be conducted in healthy subjects and/or
patients, and may also be incorporated into the studies that evaluate safety and
efficacy in a clinical indication. Reports of PD, dose-finding, and/or PK/PD studies
conducted in healthy subjects should be placed in Section 4.1, and the reports for
those studies conducted in patients should be placed in Section 4.2.
In some cases, the PD, dose-finding, and/or PK-PD information found in
pharmacodynamic studies conducted in patients will provide data that contribute
to assessment of efficacy, either because they show an effect on an acceptable
surrogate marker (e.g., blood pressure) or on a clinical benefit endpoint (e.g., pain
relief). When these studies are part of the efficacy demonstration, they are
considered clinical efficacy and safety studies that should be included in Section 5,
not in Section 4.
Section 4.1 Healthy Subject PD and PK/PD Study Reports
PD and/or PK/PD studies having non-therapeutic objectives in healthy subjects
should be placed in Section 4.1.
Section 4.2 Patient PD and PK/PD Study Reports
PD and/or PK/PD studies in patients should be submitted in Section 4.2.
5. Reports of Efficacy and Safety Studies
Section 5 should include reports of all clinical studies of efficacy and/or safety
carried out with the drug, conducted by the sponsor or otherwise available,
including both completed and ongoing studies of the drug in proposed and related
indications, and, where appropriate, studies of indications other than those
proposed. The study reports should provide the level of detail appropriate to the
The Common Technical Document – Efficacy (Clinical Study Reports)
study. ICH E3 describes the contents of a full report for a study contributingevidence pertinent to both safety and efficacy. Abbreviated reports can beprovided for some studies (see E3 and individual guidance by region).
Within Section 5, studies should be organized by design (controlled, uncontrolled)and, within controlled studies, by type of control. Within each section, studiesshould be categorized further, ordered by whether the study report is complete orabbreviated (ICH E-3), with completely reported studies presented first.
Published reports with limited or no further data available to the sponsor shouldcome last.
In cases where the application includes multiple therapeutic indications, thereports should be organized in a separate Section 5 for each indication. In suchcases, if a clinical efficacy study is relevant to only one of the indications includedin the application, it is included in the appropriate Section 5; if a clinical efficacystudy is relevant to multiple indications, the study report should be included in themost appropriate Section 5 and referenced as necessary in other Sections 5, e.g.,Section 5A, Section 5B.
5.1 Study Reports of Controlled Clinical Studies Pertinent to the Claimed
Indication
The controlled clinical study reports should be sequenced by type of control:
• Placebo control (could include other control groups, such as an active
• No-treatment control• Dose-response (without placebo)• Active control (without placebo)• External (Historical) control, regardless of the control treatmentWithin each control type, where relevant to assessment of drug effect, studiesshould be organized by treatment duration. Studies of indications other than theone proposed in the application, but that provide support for the proposed use,should be included in Section 5.1.
Where a pharmacodynamic study contributes to evidence of efficacy, it should beincluded in Section 5.1. The sequence in which studies were conducted is notpertinent to their presentation. Thus, placebo-controlled trials, whether early orlate, should be placed in Section 5.1. Controlled safety studies should also bereported in Section 5.1.
5.2 Study Reports of Uncontrolled Clinical Studies
Study reports of uncontrolled clinical studies (e.g., reports of open label safety
studies) should be included in Section 5.2.
5.3 Reports of Analyses of Data from More than One Study
Clinical issues in an application may be addressed by an analysis considering data
from more than one study. The results of such an analysis should generally be
summarized in the clinical summary documents, but a detailed description and
presentation of the results of such analyses are critical to their interpretation.
The Common Technical Document – Efficacy (Clinical Study Reports)
Where the details of the analysis are too extensive to be reported in a summarydocument, they should be presented in a separate report. Such reports should beplaced in Section 5.3. Examples of reports that would be found in this sectioninclude: a report of a formal meta-analysis or extensive exploratory analysis ofefficacy to determine an overall estimate of effect size in all patients and/or inspecific subpopulations, and a report of an integrated analysis of safety thatassesses such factors as the adequacy of the safety database, estimates of eventrates, and safety with respect to variables such as dose, demographics, andconcomitant medications.
5.4 Other Study Reports
This section may include:
-
Reports of interim analyses of studies pertinent to the claimed indications Reports of controlled or uncontrolled studies not related to the claimed Published reports not included in Section 5.1. However, when literature isimportant to the demonstration or substantiation of efficacy, it should beincluded in Section 5.1 6. Reports of Post-Marketing Experience
For products that are currently marketed, reports that summarize marketing
experience (incuding all significant safety observations) should be included in
Section 6.
7. Case Report Forms and Individual Patient Listings
Case report forms and individual patient data listings are described as appendices
16.3 and 16.4 in the ICH clinical study report guideline. When these are
submitted, they should be included in Section 7 and placed in the same order as the
clinical study reports and indexed by study.

Source: http://orgametrie.free.fr/pages/guidelines/e10.pdf

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