{"id":43322,"date":"2018-10-26T12:18:48","date_gmt":"2018-10-26T11:18:48","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=43322"},"modified":"2018-11-06T21:54:21","modified_gmt":"2018-11-06T20:54:21","slug":"unreported-clinical-trial-of-the-week-study-of-indomethacin-capsules-to-treat-pain-following-surgery-in-children-aged-6-to-less-than-17-years-of-age-nct02633969","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2018\/10\/26\/unreported-clinical-trial-of-the-week-study-of-indomethacin-capsules-to-treat-pain-following-surgery-in-children-aged-6-to-less-than-17-years-of-age-nct02633969\/","title":{"rendered":"Unreported clinical trial of the week: Study of indomethacin capsules to treat pain following surgery in children (NCT02633969)"},"content":{"rendered":"<p style=\"font-weight: 400\">Georgia Richards, Nick Devito, and Ben Goldacre<\/p>\n<p style=\"font-weight: 400\"><strong>Background<\/strong><\/p>\n<p style=\"font-weight: 400\">The US FDA Amendments Act (FDAAA 2007) requires certain clinical trials to report their results onto ClinicalTrials.gov within one year of completion.\u00a0European Union (EU) guidelines are broader: they require all trials of medicinal products registered on their\u00a0<a href=\"https:\/\/www.clinicaltrialsregister.eu\/\">EU Clinical Trials Registry<\/a>\u00a0(EUCTR) since 2004 to report results within one year of completion.\u00a0Our\u00a0<a href=\"https:\/\/fdaaa.trialstracker.net\/\">FDAAA TrialsTracker<\/a>\u00a0and EU TrialsTracker\u00a0show all individual trials that\u00a0breach\u00a0these legal requirements. In each episode from this series we write about one unreported clinical trial: you can read more background\u00a0<a href=\"http:\/\/blogs.bmj.com\/bmj\/2018\/03\/29\/it-is-time-to-fix-the-problem-of-unreported-clinical-trials\/\">here<\/a>,\u00a0and past entries are\u00a0<a href=\"https:\/\/blogs.bmj.com\/bmj\/category\/unreported-trial-of-the-week\/\">here<\/a>.<\/p>\n<p style=\"font-weight: 400\"><strong>Trial NCT02633969<\/strong><\/p>\n<p style=\"font-weight: 400\">This week\u2019s unreported trial is titled: \u201cStudy of Indomethacin Capsules to Treat Pain Following Surgery in Children Ages 6 to &lt;17 Years of Age\u201d (<a href=\"https:\/\/clinicaltrials.gov\/ct2\/show\/NCT02633969\">NCT02633969<\/a>). This non-randomised Phase IIA clinical trial enrolled 30 children who were scheduled to undergo elective surgery across five states. The study was not blinded and used a parallel assignment, where two experimental groups received the same treatment (Indomethacin Capsules twice daily for up to three days) but at different doses: group 1 received \u201clow dose\u201d, and group 2 received \u201chigh dose\u201d. The primary outcome was plasma concentrations of Indomethacin 0-12 hours after the first dose using the \u201cestimated typical value for clearance (tvCL)\u201d. The secondary outcome was the safety of Indomethacin Capsules at \u201clow dose\u201d and \u201chigh dose\u201d measured by the incidence of adverse events from baseline to Day 3 or early termination.<\/p>\n<p style=\"font-weight: 400\"><strong><em>Clinical discussion<\/em><\/strong><\/p>\n<p style=\"font-weight: 400\">Pain is common in hospitalised children with\u00a0<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/24602421\/\">99% of paediatric patients<\/a>\u00a0who receive surgery reporting pain. Treatment options and dosing for postoperative pain in children can be challenging. The<a href=\"http:\/\/www.euroespa.com\/\">\u00a0European Society for Paediatric Anaesthesiology<\/a>\u00a0(ESPA)\u00a0<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/29635764\">recommends\u00a0<\/a>ibuprofen, diclofenac, or paracetamol as oral treatment options for systematic analgesia.\u00a0<a href=\"https:\/\/druginfo.nlm.nih.gov\/drugportal\/name\/Indomethacin\">Indomethacin<\/a>\u00a0is a nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen and diclofenac that reduces pain by decreasing the formation of prostaglandins.<\/p>\n<p style=\"font-weight: 400\">A Cochrane systematic review of indomethacin for the treatment of acute postoperative pain in adults (over 12 years old)\u00a0<a href=\"https:\/\/www.cochranelibrary.com\/cdsr\/doi\/10.1002\/14651858.CD004308.pub2\/full\">was published<\/a>\u00a0in 2004. They found only one study of 59 women that met the inclusion criteria and concluded indomethacin was \u201cnot significantly better than placebo in relieving postoperative pain\u201d. The review was updated in 2007 and identified no further studies. The authors state \u201cconclusions about the clinical efficacy\u2026 cannot be made unless more studies are conducted for a variety of surgical procedures, and different doses&#8230; are assessed\u201d. The review also recommended that appropriate study designs (such as a randomised, double-blind, placebo-controlled trial) are needed.<\/p>\n<p style=\"font-weight: 400\"><strong><em>Legislative discussion<\/em><\/strong><\/p>\n<p style=\"font-weight: 400\">We intend that this series should occasionally shed light on interesting issues around transparency rules, and how registry data is used. You can read some general background about the FDA Amendments Act 2007\u2014and why a trial is considered \u201cdue\u201d\u2014<a href=\"https:\/\/www.biorxiv.org\/content\/early\/2018\/03\/12\/266452\">here<\/a>\u00a0and\u00a0<a href=\"https:\/\/ebmdatalab.net\/why-is-this-trial-due-to-report\/\">here<\/a>.<\/p>\n<p style=\"font-weight: 400\">This study\u2019s sponsor\u00a0<a href=\"https:\/\/www.iroko.com\/press-releases\/iroko-pharmaceuticals-receives-fda-approval-for-tivorbex\/\">currently has FDA approval<\/a>\u00a0for 20mg and 40mg doses of indomethacin in adults. This trial was conducted in an entirely paediatric population. While we do not know the motivations behind this trial it is possible that the sponsor is seeking to expand the indication of their treatment to include children, or\u00a0<a href=\"https:\/\/www.stratagemipm.co.uk\/news\/posts\/2015\/july\/patent-term-extensions-and-market-exclusivity\/\">expand their patent protection<\/a>, or perhaps both. In any case, we suggest that the non-reporting of this clinical trial should be considered in future regulatory decisions regarding this treatment, and that the relevant authority should insist the sponsor complies with FDAAA 2007 and its requirement to report trial results within 12 months of completion.<\/p>\n<p style=\"font-weight: 400\">Furthermore, while publication in an academic journal does not meet the legal requirements of the FDAAA 2007, no publication related to this study could be found when searching\u00a0<a href=\"https:\/\/www.google.co.uk\/search?rlz=1C1SQJL_enGB786GB786&amp;ei=lK3MW8-lPIjWasmQo7AK&amp;q=%22indomethacin%22+%22children%22+or+%22NCT02633969%22&amp;oq=%22indomethacin%22+%22children%22+or+%22NCT02633969%22&amp;gs_l=psy-ab.3...7876.8371.0.10040.2.2.0.0.0.0.70.116.2.2.0....0...1c.1.64.psy-ab..0.0.0....0.4gbadWqbsJ4\">Google<\/a>,\u00a0<a href=\"https:\/\/scholar.google.co.uk\/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=%22indomethacin%22+%22children%22+or+%22NCT02633969%22&amp;btnG=\">Google Scholar<\/a>\u00a0or\u00a0<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/?term=%22NCT02633969%22+OR+(%22indomethacin%22+AND+%22children%22)\">Pubmed<\/a>. With the lack of evidence for or against the use of oral indomethacin for the treatment of acute postoperative pain, it is vital that this unreported trial publishes its results in accordance with the legal requirements of the FDAAA 2007: especially since the study is in children, a population where managing pain after surgery is challenging.<\/p>\n<p style=\"font-weight: 400\"><strong><em>Conclusion<\/em><\/strong><\/p>\n<p style=\"font-weight: 400\">This unreported trial was sponsored and conducted by\u00a0<a href=\"https:\/\/www.iroko.com\/\">Iroko Pharmaceuticals<\/a>\u00a0with no specific PI identified. As of October 24, 2018, this trial is currently\u00a0<a href=\"http:\/\/fdaaa.trialstracker.net\/trial\/NCT02633969\/\">266 days<\/a>\u00a0overdue to report. We hope the investigators will share the results of this trial soon.<\/p>\n<p><em><b><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-42794\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/08\/georgia_richards.jpg\" alt=\"\" width=\"130\" height=\"130\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/08\/georgia_richards.jpg 160w, https:\/\/blogs.bmj.com\/bmj\/files\/2018\/08\/georgia_richards-150x150.jpg 150w\" sizes=\"auto, (max-width: 130px) 100vw, 130px\" \/>Georgia C Richards <\/b><span style=\"font-weight: 400\">is a doctoral researcher at the Centre for Evidence Based Medicine at the<\/span> <span style=\"font-weight: 400\">University of Oxford.<\/span><\/em><\/p>\n<p><b>Competing interests<\/b><span style=\"font-weight: 400\">: GCR is <\/span><span style=\"font-weight: 400\">a joint NHS National Institute of Health Research (NIHR) School for Primary Care Research (SPCR), Naji Foundation, and Rotary Foundation Scholar, studying for a doctor of Philosophy (DPhil\/PhD) at the University of Oxford.<\/span><\/p>\n<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/ben_goldacre.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-41742\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/ben_goldacre.jpg\" alt=\"\" width=\"130\" height=\"130\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/ben_goldacre.jpg 160w, https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/ben_goldacre-150x150.jpg 150w\" sizes=\"auto, (max-width: 130px) 100vw, 130px\" \/><\/a><em><strong>Ben Goldacre<\/strong> is a doctor, author, and director of the EBM DataLab at the University of Oxford. He co-founded the AllTrials campaign for trials transparency.<\/em><\/p>\n<p dir=\"ltr\"><strong>Competing interests<\/strong>: BG has received research funding from the Laura and John Arnold Foundation, the Wellcome Trust, the Oxford Biomedical Research Centre, the NHS National Institute for Health Research School of Primary Care Research, the Health Foundation, and the World Health Organization; he also receives personal income from speaking and writing for lay audiences on the misuse of science.<\/p>\n<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/nick_de_vito.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-41743\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/nick_de_vito.png\" alt=\"\" width=\"130\" height=\"130\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/nick_de_vito.png 160w, https:\/\/blogs.bmj.com\/bmj\/files\/2018\/03\/nick_de_vito-150x150.png 150w\" sizes=\"auto, (max-width: 130px) 100vw, 130px\" \/><\/a><\/p>\n<p><em><strong>Nicholas J DeVito<\/strong> is a researcher at the EBM Datalab at the University of Oxford.<\/em><\/p>\n<p><strong>Competing interests<\/strong>: ND is employed on BG\u2019s LJAF grant and is a Naji Foundation scholar at the University of Oxford.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Georgia Richards, Nick Devito, and Ben Goldacre Background The US FDA Amendments Act (FDAAA 2007) requires certain clinical trials to report their results onto ClinicalTrials.gov within one year of completion.\u00a0European [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" 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