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      Putting participants and study partners FIRST when clinical trials end early

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          Abstract

          Between 2018 and 2019, multiple clinical trials ended earlier than planned, resulting in calls to improve communication with and support for participants and their study partners (“dyads”). The multidisciplinary Participant Follow‐Up Improvement in Research Studies and Trials (Participant FIRST) Work Group met throughout 2021. Its goals were to identify best practices for communicating with and supporting dyads affected by early trial stoppage. The Participant FIRST Work Group identified 17 key recommendations spanning the pre‐trial, mid‐trial, and post‐trial periods. These focus on prospectively allocating sufficient resources for orderly closeout; developing dyad‐centered communication plans; helping dyads build and maintain support networks; and, if a trial stops, informing dyads rapidly. Participants and study partners invest time, effort, and hope in their research participation. The research community should take intentional steps toward better communicating with and supporting participants when clinical trials end early. The Participant FIRST recommendations are a practical guide for embarking on that journey.

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          What makes clinical research ethical?

          Many believe that informed consent makes clinical research ethical. However, informed consent is neither necessary nor sufficient for ethical clinical research. Drawing on the basic philosophies underlying major codes, declarations, and other documents relevant to research with human subjects, we propose 7 requirements that systematically elucidate a coherent framework for evaluating the ethics of clinical research studies: (1) value-enhancements of health or knowledge must be derived from the research; (2) scientific validity-the research must be methodologically rigorous; (3) fair subject selection-scientific objectives, not vulnerability or privilege, and the potential for and distribution of risks and benefits, should determine communities selected as study sites and the inclusion criteria for individual subjects; (4) favorable risk-benefit ratio-within the context of standard clinical practice and the research protocol, risks must be minimized, potential benefits enhanced, and the potential benefits to individuals and knowledge gained for society must outweigh the risks; (5) independent review-unaffiliated individuals must review the research and approve, amend, or terminate it; (6) informed consent-individuals should be informed about the research and provide their voluntary consent; and (7) respect for enrolled subjects-subjects should have their privacy protected, the opportunity to withdraw, and their well-being monitored. Fulfilling all 7 requirements is necessary and sufficient to make clinical research ethical. These requirements are universal, although they must be adapted to the health, economic, cultural, and technological conditions in which clinical research is conducted. JAMA. 2000;283:2701-2711.
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            Clinical trials of new drugs for Alzheimer disease

            Alzheimer disease (AD) accounts for 60–70% of dementia cases. Given the seriousness of the disease and continual increase in patient numbers, developing effective therapies to treat AD has become urgent. Presently, the drugs available for AD treatment, including cholinesterase inhibitors and an antagonist of the N-methyl-D-aspartate receptor, can only inhibit dementia symptoms for a limited period of time but cannot stop or reverse disease progression. On the basis of the amyloid hypothesis, many global drug companies have conducted many clinical trials on amyloid clearing therapy but without success. Thus, the amyloid hypothesis may not be completely feasible. The number of anti-amyloid trials decreased in 2019, which might be a turning point. An in-depth and comprehensive understanding of the contribution of amyloid beta and other factors of AD is crucial for developing novel pharmacotherapies. In ongoing clinical trials, researchers have developed and are testing several possible interventions aimed at various targets, including anti-amyloid and anti-tau interventions, neurotransmitter modification, anti-neuroinflammation and neuroprotection interventions, and cognitive enhancement, and interventions to relieve behavioral psychological symptoms. In this article, we present the current state of clinical trials for AD at clinicaltrials.gov. We reviewed the underlying mechanisms of these trials, tried to understand the reason why prior clinical trials failed, and analyzed the future trend of AD clinical trials.
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              Why has therapy development for dementia failed in the last two decades?

              The success rate of the pharmaceutical research and development (R&D) for dementia drugs has been abysmally low, in the last two decades. Also low has been the number of pipeline drugs in development, compared to other therapy areas. However, the rationale of early terminations has not been reported in the majority of trials. These are key findings of the recently published pharmaceutical pipeline analysis by the UK-based Office of Health Economics (OHE). Our understanding of main challenges include (1) the significant gaps of knowledge in the nosology and complexity of the underpinning biological mechanisms of the commonest, not familial, forms of late onset dementias; (2) low signal-to-noise ratio, notwithstanding the lack of validated biomarkers as entry and/or end-point criteria; (3) recruitment and retention, particularly in the asymptomatic and early disease stages. A number of current and future strategies aimed at ameliorating drug development are outlined and discussed.
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                Author and article information

                Contributors
                elargent@pennmedicine.upenn.edu
                Journal
                Alzheimers Dement
                Alzheimers Dement
                10.1002/(ISSN)1552-5279
                ALZ
                Alzheimer's & Dementia
                John Wiley and Sons Inc. (Hoboken )
                1552-5260
                1552-5279
                02 August 2022
                December 2022
                : 18
                : 12 ( doiID: 10.1002/alz.v18.12 )
                : 2736-2746
                Affiliations
                [ 1 ] Department of Medical Ethics and Health Policy University of Pennsylvania Perelman School of Medicine Philadelphia PA USA
                [ 2 ] Alzheimer's Therapeutic Research Institute University of Southern California San Diego CA USA
                [ 3 ] Care Partner Philadelphia PA USA
                [ 4 ] The Association for Frontotemporal Degeneration King of Prussia PA USA
                [ 5 ] AbbVie Neuroscience Clinical Development North Chicago IL USA
                [ 6 ] Department of Neurology Harvard Medical School Massachusetts General Hospital Boston MA USA
                [ 7 ] Department of Neurology Washington University School of Medicine in St. Louis St. Louis MO USA
                [ 8 ] National Institutes of Health National Heart, Lung, and Blood Institute Bethesda MD USA
                [ 9 ] Signant Health Blue Bell PA USA
                [ 10 ] Alzheimer's Association Chicago IL USA
                [ 11 ] Department of Psychiatry and Behavioral Sciences VA Advanced Imaging Research Center San Francisco Veterans Administration Medical Center University of California San Francisco San Fancisco CA USA
                [ 12 ] Division of Geriatrics Department of Medicine Howard University and Hospital Washington DC USA
                [ 13 ] Institute for Health & Aging Philip Lee Institute for Health Policy Studies University of California San Francisco San Francisco CA USA
                [ 14 ] The Michael J. Fox Foundation for Parkinson's Research New York NY USA
                [ 15 ] National Institutes of Health National Institute on Aging Bethesda MD USA
                [ 16 ] National Center for Bioethics in Research and Health Care Tuskegee University Tuskegee AL USA
                [ 17 ] Department of Psychiatry Duke University School of Medicine Durham NC USA
                Author notes
                [*] [* ] Correspondence

                Emily A. Largent, Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, 423 Guardian Drive, Room 1403, Philadelphia, PA 19104, USA.

                E‐mail: elargent@ 123456pennmedicine.upenn.edu

                Article
                ALZ12732
                10.1002/alz.12732
                9926498
                35917209
                ee2c0271-9a04-4679-a957-79cb6cd251ea
                © 2022 The Authors. Alzheimer's & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer's Association.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                : 19 May 2022
                : 08 March 2022
                : 10 June 2022
                Page count
                Figures: 0, Tables: 5, Pages: 11, Words: 8336
                Categories
                Policy Forum
                Policy Forum
                Custom metadata
                2.0
                December 2022
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.2.7 mode:remove_FC converted:11.04.2023

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