title: Integrating indacaterol dose selection in a clinical study in COPD using an adaptive seamless design.
abstract: BACKGROUND
  The drug development process can be streamlined by combining the traditionally separate stages of dose-finding (Phase IIb) and confirmation of efficacy and safety (Phase III) using an adaptive seamless design. This approach was used in a clinical study of indacaterol, a novel once-daily (od) inhaled long-acting beta(2)-adrenoreceptor agonist bronchodilator for the treatment of COPD (chronic obstructive pulmonary disease).
  
  
  METHODS
  The study comprised a dose-finding stage with dose selection after 14 days of treatment, and a second stage evaluating efficacy and safety during 26 weeks of treatment. The dose-finding stage included seven randomized treatment arms: double-blind indacaterol 75 microg, 150 microg, 300 microg or 600 microg od, the beta(2)-adrenoceptor agonist formoterol 12 microg twice-daily or placebo, or the anticholinergic tiotropium 18 microg od open-label. An independent data monitoring committee selected two indacaterol doses based on unblinded results of an interim analysis performed by an independent statistician. The sponsor, investigators and patients remained blinded to the results. The indacaterol doses were selected using pre-set efficacy criteria for trough (24-h post-dose) and early (1-4 h post-dose) bronchodilator effect after 14 days, and all safety data. To qualify for selection, the doses had to exceed a threshold for clinical relevance or be superior to either tiotropium or formoterol, whichever was the highest value. Selected doses were continued into the second, 26-week stage. The two other indacaterol doses not selected, and formoterol, were discontinued following dose selection.
  
  
  RESULTS
  801 patients with moderate-to-severe COPD were evaluated. Indacaterol 150 microg was the lowest effective dose, exceeding criteria for trough FEV(1) (reference value 140 mL vs placebo) and FEV(1) AUC(1-4 h) (reference value 220 mL vs placebo). No safety signal was observed with any dose of indacaterol. Thus, indacaterol 150 and 300 microg were selected to continue into the second, 26-week stage.
  
  
  CONCLUSIONS
  The adaptive seamless design is a novel and efficient way to combine dose selection with efficacy evaluation and safety confirmation in a single trial.
authors.affiliation: Imperial College, London, UK. p.j.barnes@imperial.ac.uk
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Barnes
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Pocock
authors.forename: Helgo
authors.initials: H
authors.lastname: Magnussen
authors.forename: Amir
authors.initials: A
authors.lastname: Iqbal
authors.forename: Benjamin
authors.initials: B
authors.lastname: Kramer
authors.forename: Mark
authors.initials: M
authors.lastname: Higgins
authors.forename: David
authors.initials: D
authors.lastname: Lawrence
mesh_terms: D000328:Adult; D001993:Bronchodilator Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D004983:Ethanolamines / Q000627:therapeutic use; D005260:Female; D000068759:Formoterol Fumarate; D006801:Humans; D007189:Indans / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy*; D015363:Quinolones / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D012107:Research Design; D012129:Respiratory Function Tests; D012602:Scopolamine Derivatives / Q000627:therapeutic use; D012720:Severity of Illness Index; D000069447:Tiotropium Bromide
chemical_list: D001993:Bronchodilator Agents; D004983:Ethanolamines; D007189:Indans; D015363:Quinolones; D012602:Scopolamine Derivatives; C510790:indacaterol; D000068759:Formoterol Fumarate; D000069447:Tiotropium Bromide