Clinical and Translational Science

The rapid adoption of digital health technologies (DHT) in clinical trials promises to enhance trial representativeness by eliminating geographical barriers and reducing participant burden. However, their actual impact on participant representation remains poorly understood. Our analysis of 68,206 US-based trials from ClinicalTrials.gov uncovers gaps in participant representation in trials utilizing DHT for data collection (DHTcd). While DHTcd trials achieved overrepresentation of female participants (+1.7% versus US Census data and +5.5% vs. non-DHT trials) and reduced underrepresentation of Black participants by 4.2% (vs. non-DHT trials), they showed underrepresentation of adults aged 65 years and older (-8.8% vs. non-DHT trials). These effects vary by therapeutic area. We furthermore find that DHTcd trials report group-specific sample compositions less frequently than non-DHT trials, suggesting that growing DHTcd adoption has not been systematically used to improve trial representativeness. We conclude that evidence-based and indication-specific implementation strategies are needed to enhance standards for DHT-based data collection in clinical trials and to prevent a widening digital divide in trial participation.

Nicotinamide riboside (NR), an endogenous precursor to the essential coenzyme nicotinamide adenine dinucleotide (NAD+), is characterized as safe and effective at longitudinally elevating NAD+ in blood and tissues, when administered orally. Preclinical research on NR as an augmenter of NAD+ has demonstrated great promise in support of healthy aging, metabolic health, and several diseases, though clinical translation of thesefindings has been limited. Interest in alternative routes of administration of NR has increased in recent years and led to the development of pharmaceutical-grade NR for intravenous and injectable administration. Two separate Phase 1 pilot clinical trials were conducted evaluating NR via bolus injections. While the designs of the two studies are different, the similarities warrant combined presentation to note the similarities, particularly with regards to safety-related outcomes. Trial 1 involved 45 participants that were randomized to a 3x3 design, accounting for three interventions, placebo, NR, and NAD+ and three routes of administration, intramuscular (IM), intravenous (IV), and subcutaneous (SC), resulting in a 9-arm study (placebo IM, n=5; placebo IV, n=5; placebo SC, n=5; NR IM, n=6; NR IV, n=5; NR SC, n=4; NAD+ IM, n=4; NAD+ IV, n=5; and NAD+ SC, n=6). Participants were administered NR once daily for three days, followed by a 7-day washout period. In Trial 2 (n=39), the 2x2 study design incorporated 4-arms for phase 1, where the participants were randomized to 50 or 100 mg of NR, administered either IM or SC in-clinic for 3 consecutive days, followed by a 7-day washout (50 mg IM, n=7; IM, 100 mg IM, n=11; 50 mg SC, n=11; and 100 mg SC, n=10). Phase 2 of Trial 2 involved participants self-administering either 50 or 100 mg of NR subcutaneously. Safety assessments for both trials included vitals, blood biomarkers, participant reported outcomes regarding the experience, and adverse event monitoring. Participant retention for both studies was 100%, and the injections did not result in any attributable unexpected adverse events or experiences. The experiences described by the participants regarding the actual injection varied. In Trial 2, pain more than two minutes after the injection and muscle soreness and tightness were reported by 45.9 and 43.2% of the participants, respectively, regardless of the route of administration or dose. Vitals remained generally consistent throughout both trials, and reductions in systolic blood pressure observed in both trials should be evaluated in larger, properly powered studies. Blood chemistry biomarkers for both trials did not elicit treatment-related patterns. Both trials presented within-group reductions in hsCRP in the NR SC arms, however, given baseline imbalance and small samples size, this finding should be considered hypothesis-generating, only. Overall, in both trials, the interventions, regardless of route of administration were associated with some discomfort but were well tolerated and did not produce any concerning safety signals. It is recommended that comprehensive metabolic and inflammatory panels should continue to be employed in future studies and clinical settings to assess whether consistent patterns emerge in larger populations.

BackgroundHealth care inequity includes the lack of adequate representation of various populations in clinical trials. Government, academic and industry organizations have highlighted these issues and committed to actions to improve. In order to assess the current status and future success of these initiatives a quantitative objective measure to assess the state of clinical trial diversity is needed. MethodsFDA review documents for all novel drug approvals from January 2022 through February 16, 2023 were assessed using a scorecard that considers diversity across different demographic subgroups including age (>65 yo), sex (female), race (Black and Asian) and ethnicity (Hispanic/Latino). The scorecard assigns each drug a letter grade, between A and F, for each subgroup (and overall) based on 1) the percent of each sub-population included in the trials and grades relative to the percent of the US population, 2) the number of participants from each subpopulation that received the novel new drug in the trials, 3) the incidence or prevalence of the disease/condition in each of the sub-populations. ResultsThe FDA approved 43 novel new drugs for 44 indications (one drug was simultaneously approved for two indications). The three drugs with A Grades reflecting the best diversity in their registration trials were tapinarof (Vtama from Dermavant), daprodustat (Jesduvroq from GlaxoSmithKline) and eflapegrastim (Rolvedon from Spectrum Pharmaceuticals.) There was good representation of elderly and females with only two drugs receiving a D grade in either of these sub-populations. In contrast, Black and Hispanic representation was often inadequate with 4 drugs receiving F grades. There were 9 drugs (20%) where there were no Black participants receiving the novel new drug and an additional 14 approvals where there were <10 Black participants receiving the novel drug. The median number of Black participants receiving the investigational drug was 9. In the Hispanic/Latino population there were 2 approvals with no Hispanic participants receiving the novel drug and 14 approvals where there were < 10 Hispanic participants receiving the drug. The median number of Hispanic participants receiving the novel drug was 12.5. ConclusionsThis newly developed scorecard provides an objective quantitative approach to assess the current state of diversity in clinical trials supporting new drug approvals. Substantial improvement in racial and ethnic representation is needed. Meaningful change will require actions and cooperation amongst all stakeholders to address this multifaceted issue and will take commitment, perseverance, and appropriate incentives.

ObjectiveYouth with type 2 diabetes have higher metformin treatment failure rates when compared with adults. Our objectives were to develop a population pharmacokinetic (PK) model for metformin in youth to examine current dosing strategies and to quantify the relationship between metformin PK and obesity in youth with type 2 diabetes. Research Design and MethodsWe performed semi-intensive PK sampling in 50 youth less than 18 years with T2D on metformin. We measured metformin levels at pre-dose and at 1-2 and 3-6-hours after a supervised 1000 mg dose of immediate-release metformin. We used non-linear mixed effects modeling to develop a population PK model. Simulations were performed to estimate area under the 24-hour metformin concentration-time curve (AUC) values. ResultsMean age was 15.0 (standard deviation (SD) 1.6) years, 66% were male, mean body mass index (BMI), 35.9 (SD 6.8) kg/m2, and mean estimated glomerular filtration rate (eGFR), 114.7 (SD 22.6) mL/min/1.73m2. Estimated clearance increased by 3% (21.4% relative standard error (RSE)) for every 1 kg/m2 increase in body mass index (BMI), and by 6% (53.8% RSE) for every 10 mL/min/1.73m2 increase in eGFR. When comparing AUC estimates from our model with data from 236 adults on metformin, median AUC for youth was lower than for adults on 2,000 mg of metformin (18.47 mg*h/L vs. 27.49 mg*h/L). Simulations showed that in youth, higher doses of at least 2,550 mg and up to 3,000 mg daily were needed to achieve exposures similar to adults. ConclusionsObesity is associated with increased metformin clearance and reduced AUC in youth and higher doses are needed to achieve comparable drug exposure to adults.

Background. Compounded tirzepatide is prescribed at scale as a cheaper substitute for branded Mounjaro and Zepbound, yet the cost case is almost always built by setting one compounded price against one branded list price. That framing ignores the question that actually decides the answer: cheaper than which branded price the patient can reach. Branded tirzepatide is now sold at sharply different tiers, namely insurance copay (often $25-$150/month), LillyDirect Self Pay ($299-$449/month), and retail cash price ($1,000-$1,200/month). Whether compounded saves money turns entirely on which of these a given patient faces. A second open question is whether the two formulations even produce comparable effectiveness, since observed differences may reflect selection on insurance, baseline characteristics, and adherence rather than the drug. Methods. We conducted a retrospective cohort study of tirzepatide users in the Mochi Health telehealth program, classified by formulation from their refills as branded-only (Mounjaro/Zepbound; 6,238), compounded-only (71,683), or switchers (4,996); switchers were excluded from the formulation contrast. Among single-formulation patients with a documented six-month weight observation, the analytic cohort was 7,271 (869 branded, 6,402 compounded). The primary outcome was six-month percent body weight loss; the secondary outcome was >=10% response. We used 1:1 nearest-neighbor propensity-score matching (0.25 SD caliper) on baseline covariates only - age, sex, baseline BMI, baseline weight, comorbid diabetes, hypertension, dyslipidemia, prior bariatric surgery, and self-reported insurance coverage - deliberately excluding post-treatment variables such as adherence and time in program, which are mediators of the formulation effect. We pre-specified an equivalence margin of +/-2 percentage points on mean loss and tested equivalence with two one-sided tests (TOST). A directed acyclic graph (DAG) makes the identifying assumptions explicit; metformin use could not be reliably ascertained and is treated as an unmeasured confounder. The cost comparison reports the savings or premium of compounded versus branded under five branded price scenarios: retail list, LillyDirect Self Pay (two dose tiers), and insurance copay (typical and low end). It is a cost comparison (cost-minimization under demonstrated similar effectiveness), not a formal cost-effectiveness analysis: we computed no ICER, QALY, or discounting. Results. Branded and compounded patients had similar outcomes even before adjustment (mean loss 11.7% vs 11.5%; >=10% response 60.9% vs 58.8%). The largest baseline difference between the groups was insurance coverage (branded patients far more likely insured; standardized mean difference 0.67), which matching balanced to 0.01. After 1:1 matching (718 pairs, all |SMD| < 0.04), mean loss was 11.4% vs 11.4% (difference +0.08 pp, 95% CI -0.70 to +0.80) and >=10% response 59.3% vs 57.2% (difference +2.1 pp, 95% CI -3.1 to +7.1). The two formulations were statistically equivalent within the pre-specified +/-2 pp margin (TOST p < 0.001). Cost depends on the branded scenario: compounded saves $6,000 over six months versus retail list price, $1,494 versus LillyDirect maintenance-dose (5-15 mg) Self Pay, and $594 over a low-dose (2.5 mg) LillyDirect prescription, while it costs $300 more than branded under a typical insurance copay ($150/month) and is more expensive still at lower copays (savings turn negative below $200/month). Conclusions. Branded and compounded tirzepatide were statistically equivalent in six-month effectiveness within a pre-specified +/-2 pp margin, so the choice between them is essentially a cost decision - and that cost advantage is real but conditional on the branded price the patient can access. It is large against retail list price and shrinks to zero or reverses against LillyDirect Self Pay or a low insurance copay. Whether compounded is the lower-cost choice for an individual patient is, therefore, a question about which price tier that patient faces.

Chronic wounds, such as diabetic and ischemic ulcers, involve impaired perfusion and delayed healing. TOP-N53 is a novel bifunctional molecule combining nitric oxide (NO) release with phosphodiesterase-5 (PDE5) inhibition to enhance local NO-cGMP signalling, resulting in vasodilation and angiogenesis. This first-in-human, randomized, double-blind, vehicle-controlled Phase I trial assessed the safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) of single subcutaneous TOP-N53 doses in 29 healthy male volunteers. Each participant received injections of TOP-N53 and vehicle in the same forearm, but either at the proximal or at the distal site in an intra-individually blinded manner. Safety assessments included local and systemic parameters. PK and PD responses were evaluated by analysis of TOP-N53 and its bioactivation metabolite TOP-52 in plasma, and by Laser Speckle Contrast Imaging (LSCI), a non-invasive method to measure skin perfusion, respectively. TOP-N53 was safe and well tolerated, with no serious adverse events or local or systemic adverse reactions. Plasma concentrations remained below the quantification limit and LSCI showed sustained dose-dependent increases in local skin perfusion at doses of 4.84 {micro}g and 9.075 {micro}g TOP-N53 SC for up to 24 h post injection when compared to vehicle. These findings support the favourable safety and tolerability profile of TOP-N53 associated with locally improved skin perfusion, encouraging its further clinical development as a topical treatment for chronic wounds with microvascular dysfunction.

This work takes place at two interacting levels. One is a reflection on how to define therapeutic efficacy. The other one is a series of comparative simulation experiments confronting two definitions of therapeutic efficacy. In real-world settings, treatment efficacy is typically estimated through randomized controlled trials (RCTs), yielding what we define as gross efficacy (GE). However, biases introduced by the enrollment process and imperfect results of randomization can affect GE estimates. In contrast, in a model informed drug development (MIDD) perspective, an in silico clinical trial (ISCT) is unbiased. It is conducted via computational simulations using a quantitative systems pharmacology (QSP) model of disease and treatments and a virtual population. The two (or more) compared treatments are given in turn to the same virtual patient, with the same environment, at the same time, in an as close as possible representation of the whole population of interest, resulting in the prediction of the net efficacy (NE). Because inter-individual and inter-occasion differences are removed, the NE prediction contains no external bias. In order to explore the two paradigms, GE and NE, clinical trials were simulated using a disease model of advanced EGFR-mutated lung adenocarcinoma (aLUAD), a subtype of Non Small Cell Lung Cancer (NSCLC) and two treatment models, one for the investigational treatment, osimertinib in monotherapy, (A), and one for the control treatment, chemotherapy agents cisplatin and pemetrexed (B). The model used in the current simulations was a simplified model of a model that has proven its credibility in prospectively and blindly predicting accurately the results of real world phase 3 clinical trials, after a thorough validation procedure. The simplified model was applied in two different settings to a large virtual population. The first setting was designed to compute the net efficacy of treatment A versus B. The second setting was set-up to mimic 1,000 real-life, parallel group design RCTs, based on standard sampling theory to compare A and B. The number of patients per arm was selected to be equal to or greater than the currently published trials. As opposed to the first approach, the approach mimicking the RCT provides measures of the gross efficacy. A single RCT was randomly drawn to simulate a phase 3 trial which concludes a clinical development program. While the mean hazard ratios of clinical outcomes calculated by the GE approach and the hazard ratio of clinical outcome given by the NE approach are not very different, they could nevertheless lead to quite different assessments of the population benefit of the new treatment compared to a comparator and to different regulatory decisions. Further, some values of GE from the distribution of "observed" GE were rather far from the mean GE and the NE. The convergence of the GE estimate takes more than a couple of RCTs, showing that a single phase 3 trial is not enough. However, the number of trials sufficient for convergence is impracticable. This work also shows that a randomized phase 3 trial of a genuinely effective therapeutic can easily fail to demonstrate a difference between the two groups of treatment due solely to sampling fluctuations, incorrectly leading to the discontinuation of the investigational drug because of lack of chance. These findings suggest that while ISCTs cannot replace real-world RCTs, they provide valuable insights for establishing clinical development strategy, trial design, trial monitoring, and trial results interpretation.

Glucagon receptor-like peptide receptor agonists, GLP-1 RAs, are one of the most commonly used drugs for type-2 diabetes mellitus. The clinical guidelines recommend GLP-1 RAs as adjunct to diabetes therapy in patients with chronic kidney disease, presence or risk of atherosclerotic cardiovascular disease, obesity, and other cardiometabolic conditions. The weight loss seen in clinical trials has been explored further in healthy individuals, putting GLP-1 RAs on track to be the next weight loss treatment. Although the adverse event profile is relatively safe, most GLP-1 RAs come with a labeled black boxed warning of the risk of thyroid cancers, based on animal models and some postmarketing case reports in humans. Considering the increasing popularity of this drug class and its expansion into a new popular indication, a further review of most recent postmarketing safety data is warranted to quantify thyroid hyperplasia and neoplasms instances. In this study we analyzed over eighteen million reports from United States Food and Drug Administration Adverse Event Reporting System and identified 17,653 relevant GLP-1 RA monotherapy reports to provide the evidence of significantly increased propensity for thyroid hyperplasias and neoplasms in patients taking GLP-1 RA as monotherapy when compared to patients taking sodium-glucose cotransporter-2 inhibitor monotherapy.

IntroductionInfants with hypoxic-ischemic encephalopathy (HIE) are at high risk for neurodevelopmental impairment, despite current standards of care. Adjunctive treatments to promote brain repair are needed. The antidiabetic drug metformin has recently been recognized as a neurorestorative agent, but, to date, has not been used in infants. Herein, we describe a clinical trial with the aim of demonstrating the safety and feasibility of metformin use to improve neurodevelopmental outcomes in infants with HIE. Methods and AnalysisIn collaboration with patient and family stakeholders, we designed a pragmatic clinical trial to assess the safety and feasibility of metformin administration in infants. To determine appropriate dosing of metformin, we performed Physiologically Based Pharmaco-Kinetic (PBPK) modeling after scaling a published adult PBPK model of metformin to an infant population of full-term newborns to 3-month-olds. Based on this PBPK modeling and target drug exposure, we determined an optimal target dose of 25 mg/kg/day. Trial participants will complete baseline bloodwork and then receive 6 weeks of daily metformin at 50% of the target dose (12.5mg/kg). At a mid-study visit, repeat laboratory testing will be done, followed by an additional 6 weeks of metformin at target dosing of 25mg/kg. The final study visit will include repeat labs following therapy at target dosing. Pharmacokinetics of metformin will be evaluated with bloodwork collected at study visits, as well as an optional at-home monitoring sub-study. The incidence of safety events and feasibility measures will be reported using descriptive statistics. Our infant PBPK model will be validated with study samples and the dose for future trials adjusted based on new knowledge about metformin PK in infants. Ethics and DisseminationApproval of the Boston Childrens Hospital Research Ethics Committee will be obtained prior to study initiation. Trial oversight will be under the direction of a Data Safety Monitoring Board (DSMB) composed of individuals with the appropriate expertise, including external neonatologists and pharmacologists. RegistrationThis study has been registered at www.clinicaltrials.gov under NCT06429007. WHAT IS ALREADY KNOWN ON THIS TOPICO_LIHypoxic-ischemic encephalopathy (HIE) is a major cause of newborn death and neurodevelopmental morbidity. C_LIO_LITherapeutic hypothermia reduces the risk of death or disability in infants with HIE, but nonetheless, a large proportion of infants experience long term sequelae. C_LIO_LIMetformin is an anti-diabetic drug that has shown promise to promote recovery after brain injury, but it has not been widely used in infants or young children. C_LI WHAT THIS STUDY HOPES TO ADDO_LITo investigate whether the administration of metformin in infants with a history of HIE is safe and feasible. C_LIO_LITo investigate the pharmacokinetics of metformin in infants. C_LI HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICYO_LIThe results of this trial will serve as the foundation for future clinical trials to study the efficacy of metformin in improving neurodevelopmental outcomes in children with HIE. C_LI

Glucagon/glucagon-like peptide-1 (GLP-1) receptor co-agonists may provide greater weight loss than agonists targeting the GLP-1 receptor alone. We report results from three phase 1 trials investigating the glucagon/GLP-1 receptor co-agonist NNC9204-1177 (NN1177) for once-weekly subcutaneous use in adults with overweight or obesity. Our focus was a 12-week multiple ascending dose (MAD), placebo-controlled, double-blind trial in which adults (N=99) received NN1177 (dose-escalated to treatment doses of 200, 600, 1,300, 1,900, 2,800, 4,200, and 6,000 g) or placebo. Two other trials also contribute to the findings in this report: a first human dose (FHD) / single ascending dose (SAD), placebo-controlled, double-blind trial in which adults (N=49) received NN1177 (treatment doses of 10, 40, 120, 350, 700 and 1,100 g) or placebo, and a drug-drug interaction (DDI), open-label, single-sequence trial in which adults (N=45) received a 4,200 g dose of NN1177. Pharmacokinetic, safety and tolerability, and pharmacodynamic endpoints were assessed. For the MAD and FHD/SAD trials, baseline characteristics were generally balanced across groups. The half-life of NN1177 was estimated at between 77.3 and 111 hours. NN1177 appeared tolerable across trials; however, a number of safety concerns were observed, including an increase in heart rate (range 5-22 beats per minute) and decrease in reticulocyte count, which were both dose dependent, and increased markers of inflammation (fibrinogen and C-reactive protein), hepatic disturbances (increased aspartate aminotransferase and alanine aminotransferase), impaired glucose tolerance (dose groups 2,800-6,000 ug) and reduced blood levels of some amino acids. Clinically relevant weight loss was achieved (up to 12.6% at week 12; 4,200 ug in the MAD trial), but this was not accompanied by cardiometabolic improvements. In conclusion, although treatment with NN1177 was associated with dose-dependent and clinically relevant weight loss, unacceptable safety concerns precluded further clinical development.

In some countries, melatonin is sold without a physician prescription and dosage is unregulated. Transdermal products have become popular including those marketed for children. We measured consumer assumptions about these products among adult residents of the United States, analyzed lot-to-lot variability, and compared the pharmacokinetics of melatonin administered in oral, lotion, and bath product forms. Survey respondents (n=199) believed oral melatonin was more effective than transdermal products and that all melatonin products were relatively safe. Melatonin lotion products analyzed by HPLC displayed lot-to-lot variability as well as changes in formulation and product claims. To determine pharmacokinetics, three different treatments (oral tablets, lotion, and bath immersion) were administered to twelve undergraduate participants in a randomized, crossover design. Five additional participants completed bath product treatment only. Participants collected saliva samples up to 48 hours after administration, which were analyzed for melatonin by enzyme-linked immunosorbent assay. Oral (n=11) and lotion formulations (n=12) caused maximum salivary melatonin levels within 30 minutes after administration, but bath immersion did not cause increases in saliva melatonin (n=17). The half-life of oral melatonin was 1.17 [0.69 -- 1.65] hours versus 5.72 [3.75 -- 7.68] hours for lotion treatment (p = 0.011, effect size r = 0.770). Melatonin lotion may pose a risk to consumers who assume it is safe and less effective than oral tablets, when in fact it may be very potent and remain at high physiological levels into the following day. This study is registered on clinicaltrials.gov (NCT06382610) and was funded by the Sleep Research Society.

PurposeUp to 80% of patients undergoing taxanes or platinum-based chemotherapy (CT) develop a disturbing peripheral polyneuropathy referred to as CIPN, that affects their treatment compliance to CT and long-term quality of life (QoL). Cumulative evidence shows that taxanes and platinum agents sensitize epidermal nociceptive terminals by potentiating the activity of nociceptor thermosensitive channels. Our aim was to evaluate the efficacy and safety of a non-pharmacological nociceutical formulation acting on epidermal nociceptive endings preventing, delaying and/or lessening CIPN sensory symptoms during CT. MethodsWe designed a proof-of-concept, double-blind, randomized, two-arms multicenter clinical study (NCT06733545). Participants started a daily topical application of the assigned formulation in hands (moisturizing or nociceutical). Upon appearance of neuropathic symptoms in hands and/or feet, they applied the creams twice daily in hands and feet. Diagnosis and follow up of CIPN grade and adverse effects were conducted by study investigators, as well as a QoL questionnaire. ResultsA cohort of 142 patients treated with taxanes and/or platinum agents were randomly assigned to the two groups. Withdrawals were similar in both arms (9 and 14), leading to a balanced number of patients per group (61 moisturizing vs 58 nociceutical). Overall, a similar number of participants developed a peripheral neuropathy in both arms (73% moisturizing vs 67% nociceutical, p=0.1). A lower CIPN incidence in hands was observed in the nociceutical arm (32% vs 13%, p=0.03). Furthermore, the nociceutical formulation delayed the appearance of neuropathic symptoms as compared to the moisturizing cream (6 vs 8 cycle, p=0.009). The Leonard scale questionnaire revealed that the nociceutical formulation attenuated the severity of patients neuropathic symptoms from extremely to hardly any (58% vs. 35%, p<0.0017), increasing patient QoL. ConclusionThis pilot study suggests that topical protection of nociceptive epidermal terminals with a topical nociceutical formulation reduced the incidence of CIPN in hands, delayed its onset and increased the QoL of patients. These findings provide solid evidence for a larger, confirmatory clinical study.

Human induced pluripotent stem cells (hiPSCs) show great promise in the development of novel strategies to mitigate reproductive diseases and promote successful reproductive outcomes. Recently, a novel approach for the fast and efficient differentiation of ovarian support cells (OSCs) to generate a versatile platform for basic research and clinical applications was demonstrated. This study details the clinical process development and application of an OSC product, known as Fertilo, to improve the in vitro maturation (IVM) of human oocytes, a method referred to as OSC-IVM. First, transcription factor (TF) mediated OSC differentiation using research-grade raw materials was shown to produce granulosa-like cells that improve the MII maturation rate of human oocytes. To support clinical application, several raw material upgrades were initiated, including substitution of the differentiation matrix with a higher-quality alternative, laminin-521, and the generation of a clinically suitable hiPSC seed bank and master cell bank. Single cell RNA sequencing of OSCs generated using the updated protocol for clinical translation demonstrated the consistency and reproducibility of cellular outcomes. Next, analytical release testing of the clinical product was performed and a murine oocyte maturation assay was developed to establish the potency of OSCs for use in OSC-IVM. Finally, the qualified Fertilo product was applied in a two-phase longitudinal cohort analysis, with the results showing improvement in key outcomes compared to traditional IVM treatment. Our findings demonstrate the first-time clinical development and application of an hiPSC-derived product to improve reproductive outcomes after IVM and advance womens health.

Reports of metformin drug products contaminated with unacceptable levels of the probable human carcinogen N-Nitrosodimethylamine (NDMA) prompted a national sampling of post-market metformin drug products in early 2020. To broadly sample the United States market and minimize supply chain bias, metformin medication samples were crowdsourced directly from individuals across many states. 155 samples were received, and liquid chromatography-high resolution mass spectrometry tests for a panel of nitrosamines and N,N-Dimethylformamide (DMF) revealed significant levels of NDMA and DMF that relate to formulation. 49% of all medication samples contained detectable levels of NDMA and, when scaled to maximum daily tablet dose, 16% of all medication samples contained NDMA levels exceeding the United States Food and Drug Administration acceptable daily intake (ADI) limit. The highest NDMA detection from the tested samples was 748 ng per 500 mg tablet, which, when scaled to a common 2000 mg per day dosage regimen, is 31 times the ADI limit. The presence of N,N-Dimethylformamide (DMF) across 74% of the sampled metformin products is concerning given its same carcinogenicity categorization as NDMA and proposed role in formation of NDMA. Results underscore the need for continued surveillance of product quality, recalls of tainted medications, and investigation of metformin manufacturing practices.

AimSGLT2 inhibitors provide multiple benefits to patients with type 2 diabetes - including improved glycemic control and decreased risks of cardiorenal disease. Because drug responses vary among individuals, we initiated investigations to identify genetic variants associated with the magnitude of drug responses. MethodsCanagliflozin (300 mg) was administered to 30 healthy volunteers. Several endpoints were measured to assess clinically relevant responses - including drug-induced increases in urinary excretion of glucose, sodium, and uric acid. ResultsThis pilot study confirmed that canagliflozin (300 mg) triggered acute changes in mean levels of several biomarkers: fasting plasma glucose (-4.1 mg/dL; p=6x10), serum creatinine (+0.05 mg/dL; p=8x10-4), and serum uric acid (-0.90 mg/dL; p=5x10-10). The effects of sex on glucosuria depended upon how data were normalized. Whereas males responses were [~]60% greater when data were normalized to body surface area, males and females exhibited similar responses when glucosuria was expressed as grams of urinary glucose per gram-creatinine. The magnitude of glucosuria was not significantly correlated with fasting plasma glucose, estimated GFR, or age in these healthy non-diabetic individuals with estimated GFR>60 mL/min/1.73m2. ConclusionsNormalizing data relative to creatinine excretion will facilitate including data from males and females in a single analysis. Furthermore, because our ongoing pharmacogenomic study (NCT02891954) is conducted in healthy individuals, this will facilitate detection of genetic associations with limited confounding by other factors such as age and renal function. RegistrationNCT02462421 (clinicaltrials.gov) FundingResearch grants from the National Institute of Diabetes and Digestive and Kidney Diseases: R21DK105401, R01DK108942, T32DK098107, and P30DK072488.

IntroductionTacrolimus is an immunosuppressant used extensively in solid organ transplantation. Whilst highly effective in preventing organ rejection, it has a narrow range of safe and effective concentrations and wide pharmacokinetic variability, which can lead to and suboptimal outcomes or unacceptable toxicities. Importantly, much is known about the sources of pharmacokinetic variability. There is a clear link between body size, pharmacogenetic variants of cytochrome P450 (CYP) 3A4 and CYP3A5 and typical dose requirement. Increasing individualisation of initial dose is expected to increase the proportion of transplant recipients with tacrolimus concentrations within the acceptable range in the initial post-transplant week. Subsequently, maximum a posteriori Bayesian dosing can better maintain concentrations within the acceptable range over time. Together, this should lead to improved patient outcomes. Method and analysisBRUNO-PIC is an open-label trial with a prospective intervention arm and a retrospective standard of care comparator arm. The prospective arm evaluates covariate informed initial dosing combined with Bayesian dose adjustment in children undergoing kidney, liver or heart transplant. CYP3A5 and CYP3A4 genotyping will be combined with allometric size scaling to predict initial tacrolimus dose. Post-transplant dose adjustment will be guided by NextDose, a Bayesian dosing platform that incorporates genotype, clinical characteristics, measured tacrolimus concentrations and a population pharmacokinetic (popPK) model to inform initial dosing and guide dose adjustments following transplant. The primary objective of this study is to determine whether genotype-informed Bayesian dosing of tacrolimus leads to better achievement of tacrolimus concentrations within the acceptable range over the first 8 weeks post-transplant in paediatric solid organ transplant (SOT) recipients (kidney, heart and liver), when compared to a retrospective historical control group using standard of care dosing. The primary outcome is the proportion of each cohort with tacrolimus concentration (steady-state average concentration) within the acceptable range of 80-125% of target at post-transplant dosing day 4 (DD4), at week 3 and at week 8. Secondary outcomes include the proportion with trough concentration within the acceptable range on DD4, the median time to acceptable range, and the time within acceptable range over the first 8-weeks post-transplant. Ethics and disseminationThe ethics approval of the trial has been obtained from the Sydney Childrens Ethics Committee (2023/ETH02699). Findings will be disseminated through peer-reviewed publications and professional conference presentations. Trial registrationClinicalTrials.gov NCT 06529536 STRENGTHS AND LIMITATIONS OF THIS STUDYO_ST_ABSStrengthsC_ST_ABSThis is a prospective study in paediatric solid organ transplant recipients combining (a) pre-transplant CYP3A5/3A4 genotyping to improve initial tacrolimus dose, and (b) post-transplant Bayesian individualised tacrolimus dosing to increase time within the safe and effective range. Use of a target concentration approach based on average steady state concentrations is expected to increase exposure in individuals with low tacrolimus clearance and reduce overexposure in individuals with high tacrolimus clearance (e.g. CYP3A5 expressors). LimitationsThe lack of a randomised comparator arm in this prospective interventional trial precludes unconfounded determination of superiority over standard care. The intervention may not be generalisable to other transplant recipients (e.g. lung, intestinal, hematopoietic stem cell transplant). ADMINISTRATIVE INFORMATIONO_ST_ABSProtocol VersionC_ST_ABSThis trial is approved Sydney Childrens Ethics Committee (2023/ETH02699). The study is currently version 4, 26.05.2025 (Supplementary File 2) FundingBRUNO-PIC is funded by the 2023 Medical Research Future Fund - Genomics Health Future Mission (MARVEL-PIC (MRF/2024900). This funding source had no role in the design of this study and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results. SponsorshipMurdoch Childrens Research Institute

IntroductionTrans sodium crocetinate (TSC) is a synthetic carotenoid with a unique mechanism of action that improves the diffusion of oxygen by reducing oxygen transfer resistance within plasma, and it is currently being developed to enhance oxygen delivery to hypoxic tissues in multiple conditions. The goals of this study were to evaluate safety, pharmacokinetics, and pharmacodynamic properties of escalating doses of TSC on peripheral oxygenation utilizing transcutaneous oxygen measurements, when administered to healthy subjects breathing supplemental oxygen. MethodsThis was a dose-escalation, single-center, randomized, phase 1 study aimed at assessing the safety, pharmacokinetic and pharmacodynamic properties of TSC at doses of 0.5, 1.0, 1.5, 2.0, or 2.5 mg/kg as an intravenous bolus. Thirty healthy adult subjects of 18 to 55 years of age were enrolled and allocated to one of the five dose groups or placebo. Venous blood samples were collected for pharmacokinetic evaluations of TSC at 1, 10, 30 minutes, and 1.5 hours after the start of injection of the study drug. Pharmacodynamic assessment of tissue oxygenation was performed while the subjects breathed supplemental oxygen at 6 L/minute for 70 minutes prior to study drug administration: the first 10 minutes was to allow for equilibration, and the subsequent 60 minutes served as a baseline period (Period 1), followed by a time-matched 60-minute intervention period (Period 2). Tissue oxygenation readings were obtained by transcutaneous oximetry (TcpO2) measurement using four TcpO2 sensors placed on the lower limbs of subjects lying in a supine or semi-recumbent position. TcpO2 values were recorded over a 2-hour time period: 60 minutes prior to study drug administration (Period 1) and 60 minutes post administration of the study drug (Period 2). ResultsTSC was safe and well tolerated at all doses tested. The pharmacokinetic analyses demonstrated that clearance decreased at escalating doses of TSC. The results of the primary pharmacodynamic analysis revealed high levels of variability in the 60-minute baseline TcpO2 levels, however despite such variability, time-matched TcpO2 measurements demonstrated observed increases in median TcpO2 values in subjects who received TSC, relative to those who received a placebo. The high variability observed across the four sensors suggested that the data could not be pooled across all four sensors, therefore, additional supplemental analyses were performed. The results of the supplemental analyses indicated that the TcpO2 intra-subject slopes of the TSC treatment groups were consistently positive during the study intervention period, and therefore suggestive of an increase in TcpO2 levels. This was not observed in the placebo group. Based on this analysis, all TSC dose groups had a greater increase in TcpO2 levels than the placebo group, with the 2.5 mg/kg dose demonstrating the most notable increase over the 1-hour intervention period (Period 2). ConclusionsTSC administered as a single IV bolus dose ranging from 0.5 mg/kg to 2.5 mg/kg to healthy subjects breathing supplemental oxygen, was safe and well tolerated. Pharmacokinetic assessments demonstrated that TSC plasma concentrations increased with escalating dose and that increasing TSC dose was associated with a decrease in clearance. The high levels of variability in TcpO2 levels did not allow for pooling of sensor measurements for primary analysis; however, supplemental analysis of individual sensor measurements demonstrated an observed dose effect of TSC on peripheral tissue oxygenation relative to placebo.

In this paper, we investigate what conditions need to be in place to make progress in combating a disease using a case-control design: we compare cases (diseases with a successful therapy) to controls (diseases without a successful therapy). We find five conditions ("hurdles") must typically be cleared for success: (A) understanding of biological drivers, (B) ability to modulate biology, (C) availability of translational models, (D1) ability to identify patients, and (D2) ability to measure clinical response. This framework is similar to ones deployed to evaluate individual drug candidates but is employed here to make inferences about entire diseases. It can be used to identify diseases most ready for progress, where efforts should be focused to make progress in diseases that are currently intractable, and where the industry could benefit from development of tools to address the hurdle that is most commonly the last to be cleared across diseases--namely, (C) translational models.

STRUCTURED ABSTRACTO_ST_ABSObjectivesC_ST_ABSTo expose the potential impact of residual confounding in common observational study designs investigating metformin using a type 2 diabetes cohort; to propose a more robust study design for future observational studies of metformin. DesignRetrospective cohort studies using a prevalent user design conducted in two distinct cohorts: individuals with type 2 diabetes and individuals with prediabetes. SettingInsurance claims database for Medicare Advantage beneficiaries in the United States, 2018-2019. An identical analysis of commercial insurance beneficiaries appears in the supplement. Participants404,765 individuals with type 2 diabetes, 81,791 individuals with prediabetes. Main outcome measuresTotal inpatient admission days in 2019, total medical spend (excluding prescription drugs) in 2019. Each of these measures is treated as a binary outcome: greater than zero inpatient days and top 10% medical spend. ResultsWe implement a common observational study design and observe a strong metformin effect estimate associated with reduced inpatient admissions and reduced medical expenditures; we also implement a more robust study design that suggests any estimated effect is attributable to residual confounding related to individuals overall health. ConclusionsCommon observational study designs examining metformin in a type 2 diabetes population are likely impacted by significant residual confounding. By additionally considering numerous negative control outcomes and a complementary prediabetes cohort, the study design proposed here demonstrates efficacy at exposing residual confounding related to overall health, nullifying the claim derived from a standard study design. Trial registrationPreregistration available at https://osf.io/qf49p.

The Veterans ECS21 (Exploring Cannabigerol for Sleep) Study is the first clinical trial of Cannabigerol (CBG), a non-psychoactive cannabinoid (ClinicalTrials.gov Identifier: NCT05088018). This study investigates if CBG improves sleep for U.S. Veterans in California using a fully remote (decentralized), randomized, placebo-controlled, triple-blind, pre-post study design. Over 100 participants will be recruited through Veterans advocacy organizations, email campaigns, and point-of-sale displays at cannabis dispensaries. Participants will be provided with a study application to assess sleep quality, quality of life, and PTSD-related symptoms. A Fitbit Inspire 2 will be used to collect sleep, activity, and cardiovascular biometrics. After a two-week run-in phase, participants will begin a four-week treatment phase with a dose escalation from 25 mg daily CBG (CBG Protab by LEVEL) up to 50 mg CBG daily. The present paper describes how we designed this study to overcome specific challenges. We held participant insight panels to learn Veterans lived experience and design ways to lower their obstacles to clinical research participation. We designed digital engagement strategies to maintain high participation and retention for a fully remote (decentralized) study, selected fit-for-purpose passive data collection mechanisms, and addressed common reproducibility issues in cannabis research.