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Draft Systematic Review is UP

September 22nd, 2014 7 comments

The draft systematic evidence review on the Diagnosis and Treatment of ME/CFS has been published.

This review is extraordinarily important because it is being presented to the P2P Panel in a closed door session any day now. This review will be the only evidence presented to the P2P Panel in advance of the Workshop on December 9-10, 2014. Expert presentations at the Workshop may support, refute or expand upon the review, but it is likely that the Panel will ascribe very heavy weight to this report.

I have not read the report yet, and will hold off on commenting until I do. A group of advocates is working together to review the material and prepare highlighted issues that others can use in their comments.

Public comment on the review will be accepted through October 20th. Regardless of whether you plan to submit comment, please read at least the executive summary of this report if you are able to do so. It will be one of the most important documents on ME/CFS published by the government this year.

 

P2P: Taking Shape

June 20th, 2014 13 comments

p2p-advancing-research-banner

The P2P ME/CFS Workshop has been approved and is scheduled for December 9-10th, 2014. The focus of this post is on analyzing four components of the information released by NIH yesterday:

  • P2P is describing our disease as fatigue, without post-exertional malaise
  • P2P is trying to clarify questions on the multiple case definitions, measurement tools, effective therapies and innovative research methods
  • The P2P agenda uses questions beyond the evidence review, but not the most important question of all
  • The P2P Working Group includes members with and without ME/CFS expertise

 

How Does P2P Describe ME/CFS?

 
Huge red flag, folks. Here is how the P2P website describes ME/CFS:

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a complex, multifaceted disorder characterized by extreme fatigue and a host of other symptoms that can worsen after physical or mental activity, but do not improve with rest. In addition to extreme fatigue, people with ME/CFS may also experience:

Widespread muscle and joint pain

Sore throat

Tender lymph nodes in the neck or armpit

Headaches

Sleep problems

Difficulty with short-term memory or concentration

I added emphasis so you can’t miss the takeaway here. ME/CFS is characterized by extreme fatigue, and people with ME/CFS may also experience other symptoms. And what is missing from this list? POST-EXERTIONAL MALAISE. Even Fukuda lists post-exertional malaise as an optional symptom. But the way NIH has described the disease, it almost sounds like Oxford – extreme fatigue and maybe other symptoms.

The description also states, “sensitivity to environmental factors (e.g., noise, light, chemicals) may force many individuals with ME/CFS into seclusion or withdrawal from society.” These sensitivities can certainly be debilitating, but I think most (if not all) patients would agree that it is primarily PEM and all the other symptoms that keep us imprisoned in our homes or our beds.

Need more proof that NIH’s conception of ME/CFS does not question the assumption that they are the same fatiguing illness? They say the two names are for the same condition: “The name myalgic encephalomyelitis or ME is more commonly used in Europe and Canada, while the name chronic fatigue syndrome or CFS is used more often in the United States and Australia. Yet the acronym ME/CFS is increasingly being used worldwide.”

In all fairness, these descriptions do not automatically determine what the Panel’s report will say. But the paradigm of a single, fatiguing illness has been at the heart of my opposition to the way P2P was being put together, and this has not eased my concern.
 

What Will P2P Try To Do?

 
The P2P website describes four things that the Workshop will try to clarify, a weird sort of blend between the five questions presented by Dr. Susan Maier to IOM on January 27, 2014 (after the P2P Working Group planning meeting), and the Key Questions of the systematic evidence review protocol.

The first issue is how the research using multiple case definitions has contributed to the state of the current literature. It’s a good question, but the answer seems blindingly obvious. Perhaps there are more subtleties that outsiders would see that I do not. All I can see is the absolute muck of a contaminated evidence base that counts Oxford studies and CCC studies as one and the same, and has absolutely no consensus on how to diagnose or measure any of it. In my opinion, the use of multiple case definitions is responsible for the state of the current literature, which is why we are stuck in a hellish stalemate with no widely accepted criteria, biomarkers, or treatments.

The second issue is how measurements are able to distinguish among ME/CFS patients focused on subsets by duration, severity, onset, and “nature of the illness.” Two observations. First, what is “nature of the illness”? I do not understand whether this is referring to immunological vs. neurological, or something else. Second, this issue assumes that differences are automatically subsets! This is exactly what I’ve been harping on for months – that the failure to ask if ME and CFS are the same, different, or spectrum illnesses eliminates the most fundamental and foundational question of them all.

The third issue presents a big red flag. It asks how research on “therapies shown to be effective” will lead to an understanding the underlying pathology. What therapies have been shown to be effective? Are we talking CBT and GET? Rituximab? You will get two very different answers about underlying pathology if you consider CBT/GET to be effective instead of Rituximab (and vice versa). Just last week, the Solve ME/CFS Initiative told NIH that the search strategy will bias the evidence towards CBT and GET. If that prediction holds true, then asking what CBT and GET tell us about the underlying pathology is patently dangerous.

The fourth issue asks what “innovative research approaches” tell us about the pathophysiology of ME/CFS and how it can be used to develop treatments. What is an innovative research approach? Is this where Rituximab fits in? Or is this focused more on things like proteomics, microbiomics, or systems network analysis? Or something else? Without understanding the terms or context, it’s hard to tell.
 

Agenda Good or Agenda Bad?

 
You may recall that I got two draft agendas for the Workshop through FOIA. Circumstantial evidence suggested they were drafted at or soon after the January Working Group meeting. How do they stack up to the real thing posted on the P2P website? Answer: the draft agenda I got through FOIA is very very similar to the one posted yesterday.

A few overall observations: The time officially allocated to the “patient perspective” is 20 minutes. The Evidence Practice Center has a total of 1 hour, 20 minutes split between two days. Total time allocated for discussion: 2 hours, 40 minutes split between the two days. You may recall that Dr. Shirley said at CFSAC that there would be town hall-style discussion at the Workshop, and also said there would be “public testimony” but provided no details on that. With less than three hours for discussion, I expect tight facilitation as opposed to open mic. There is no indication of anything resembling “public testimony” as we know it from CFSAC or other federal meetings.

I must call out one change in particular. You probably recall that I have been decrying the framing of Dr. Maier’s overview of the topic, described as “Overwhelming fatigue and malaise as a public health problem.” On the agenda posted by NIH, Dr. Maier still has 20 minutes to present an overview, but that description of the overview is gone.

The five Workshop questions are identical to the draft agenda I obtained through FOIA. Here they are, with their sub-topics (each one gets 20 minutes), but I’ve left off EPC presentations and discussion time.

I.  What is the Incidence and Prevalence of ME/CFS, and Who Does It Affect?
a) Incidence and Prevalence Data (Population-Based Studies)
b) Social Determinants of Health
c) Disease Across the Lifespan

II.  What Tools, Measures, and Approaches Help Define Individuals with ME/CFS?
a) Overview of Existing Tools and Measures
b) Measures: Patient-Reported and Physiologic
c) Measures: Omics, Biomarkers and Imaging
d) Innovative Statistical Approaches

III.  How Are Tools and Measures Used to Distinguish Subsets of Patients with ME/CFS?
a) Identification of Subsets of Individuals
b) Triangulating Quantitative and Qualitative Data (Quality of Life/Function)
c) What Outcomes Represent Improvement, Recovery, Prevention, Benefits, or Harms

IV.  Given the Unique Challenges to ME/CFS, How Can We Foster Innovative Research to Enhance the Development of Treatments for Patients?
a) Incorporating Multiple Study Designs into ME/CFS Research
b) Maximizing Approaches and Results from the Study of Other Illnesses and Complex Chronic Conditions
c) Using Research on Comorbidities to Understand ME/CFS

V.  What Does the Research on ME/CFS Tell Us About the Presentation and Diagnosis of ME/CFS in the Clinic?
a) Lessons from Current Treatments and Clinical Trials
b) Comparative Effectiveness Research
c) Health Services Research and Health Policy Relevant Research

I’m going to wave a few big flags here (you knew I would). First, this agenda does not ask if CFS and ME are the same illness, different illnesses, or different aspects of a spectrum. Does. Not. Ask.

You cannot answer a question if you refuse to ask it in the first place. If we have a pile of apples and oranges and we insist on talking about the incidence and prevalence of a fruit called “appanges,” for example, or the tools that will help distinguish the subsets of “appanges,” are we ever going to question whether “appanges” are actually a pile of apples and oranges????? No, we are not. We will continue to call them “appanges,” and argue about whether the number or shape or color of the seeds distinguishes subsets. We will not see what is right in front of us, because we did not bother to consider that “appanges” might be a made-up category of fruit truthiness.

Second, we keep hearing mixed messages about what this Workshop is really trying to accomplish. Is it to identify the gaps in research, as many people insisted at CFSAC? Is it to identify methodological weaknesses in the research, as Dr. Cook said on Tuesday? Is it to determine what treatment or clinical approach works best? I see shades of all three, with an emphasis on what is known and not what is unknown.

I must correct something I have been insisting was true. I have been saying that the agenda would mirror the questions for the systematic evidence review. That was incorrect. But while the agenda and systematic review questions are not identical, you can draw a lot of lines back and forth to connect one to the other.

When Carol Head (Solve ME/CFS Initiative) expressed concern at CFSAC about the elimination of the question of how CFS and ME differ, Dr. Collins Sharp – answering with the caveat that she is not at all involved in the P2P planning – said that the review questions are a subset of the Workshop questions. She said that any question that did not have sufficient literature to be included in the evidence review could still be addressed at the Workshop. This appears to be the case, but that most important and fundamental question is nowhere to be seen.
 

The P2P Working Group

 
The P2P Working Group is the committee that helps NIH plan the meeting. The Group met in person at NIH January 6-7, 2014 (that meeting agenda has been posted). Before now, the P2P Working Group roster was only available through FOIA. Here’s the breakdown of the full list:

Federal Employees, familiar with ME/CFS (6): Dr. Susan Maier (NIH), Dr. M. Katherine Jung (NIH), Dr. Janet Maynard (FDA), Dr. Eun-Chung Park (NIH), Dr. Leorey Saligan (NIH), and Dr. Mariela Shirley (NIH). The NIH employees are all members of the Trans-NIH ME/CFS Working Group. Dr. Park is the staff member contact for the Lipkin samples. Dr. Saligan’s research focus is acute and chronic fatigue, and he has done sample analysis for Dr. Baraniuk and others. Dr. Maynard is the FDA ex officio to CFSAC, and works in the FDA review division that handles ME/CFS drug applications.

Federal Employees, not familiar with ME/CFS (6): Jody Engel, Deborah Langer, Elizabeth Neilson, Wilma Peterson Cross, Paris Watson, and Dr. Jessica Wu all work at NIH’s Office of Disease Prevention. They also all serve on the P2P Working Group for the upcoming meeting on opioid use.

Non-Federal Members, familiar with ME/CFS (6): Dr. Mady Hornig (Columbia University), Dr. Leonard Jason (DePaul University), Dr. Nancy Klimas (NOVA Southeastern University), Robert Miller (Patient and Advocate), Dr. Peter Rowe (Johns Hopkins University), and Dr. Suzanne Vernon (Solve ME/CFS Initiative) are all familiar to the ME/CFS community.

Non-Federal Members, not familiar with ME/CFS (1): Dr. Carmen Green (University of Michigan) is an anesthesiologist and member of the HHS Interagency Pain Research Coordinating Committee. She is the chair of the P2P Panel.

Several names listed on the January roster (obtained through FOIA) as attending the meeting do not appear on this final Working Group roster. Missing are Dr. Suchitra Iyer (AHRQ), Dr. Heidi Nelson and Dr. Beth Smith (both of the Oregon Health & Science University Evidence Practice Center). I do not know for certain why they are not listed on the final Working Group roster, but they may have attended the meeting to discuss the evidence review questions rather than the planning as a whole.

Another odd omission: at the CFSAC meeting, Dr. Nancy Lee said that Marty Bond had attended “several” of the meetings for P2P. Yet Ms. Bond’s name is not listed on any of the documents posted or obtained through FOIA. So we cannot automatically assume that the only people attending Working Group meetings are the members themselves.

According to the P2P website, the Working Group drafted the questions for the evidence review, finalized the agenda, nominated speakers and panelists, selected the workshop date, and continue to be engaged in ongoing workshop planning. I am hearing conflicting things about that continued engagement and how extensive it will be.
 

Bottomline

 
Based on the information released yesterday, is P2P a worst case scenario? I have a vivid imagination, so I can definitely imagine something worse than this. But is P2P looking good? Absolutely not. If Mary Dimmock and I were writing our letter to Dr. Collins today, I would tweak some sections but all of my objections are basically unchanged.

 

Opportunity Lost

September 10th, 2013 21 comments

The CDC hosted a conference call for ME/CFS patients and advocates today. The highlight of the call was a presentation from Dr. Ian Lipkin about his pathogen and immunology work in ME/CFS. But we received an important update on the CDC multisite study, and it remains to be seen whether advocates will accept what we were given.

You may recall that at the May 2013 CFSAC meeting, advocates were aghast at Dr. Unger’s statement that the CDC multisite study would not use two-day cardiopulmonary exercise testing (CPET) despite the research showing that this protocol produces evidence of post-exertional malaise, metabolic dysfunction, and is a potential diagnostic marker for ME/CFS. When questioned, Dr. Unger said she had not discussed the protocol with Dr. Chris Snell or Staci Stevens (who created it). This seemed like yet another example of CDC having an opportunity to do good science and intentionally choosing not to do so.

On July 22, 2013, eleven groups and thirty-one individuals sent a letter to CDC requesting, among other things, that the multisite study use the two-day protocol. Here’s what they said:

The two-day CPET regimen known as the Stevens Protocol provides gas exchange and other objective and measurable results “which can’t be faked.” With properly trained personnel in place, this test can be done using technology which has been used in hospitals and other facilities for decades. Having CPET testing performed by trained personnel on subjects involved in the multi-site clinical assessment should be considered a TOP PRIORITY in order to maximize standardized data and take advantage of the opportunity provided by this important CDC-initiated study.

We cannot over-emphasize the importance of measuring and understanding post-exertional malaise (PEM) in this study. PEM is most often the largest obstacle to activities of daily living, gainful employment, exercise, and more. A combination of data from the two-day CPET test and the on-line cognitive test that is already planned will provide the data needed for effective analysis of this debilitating symptom.

Dr. Unger responded in writing on August 30th, but for unknown reasons the advocates did not receive her response until today. Both the letter and Dr. Unger’s comments on the call today explain why CDC has chosen to do one day of maximal effort testing, followed by 48 hours of cognitive testing and symptom measurements. Especially important (and highlighted in the excerpt below) is Dr. Unger’s representation of Dr. Snell’s opinion on the protocol:

To address concerns regarding the cardio-pulmonary exercise testing (CPET) in the second stage of the study, I would like to share additional details, and the rationale that we used to select the one-day maximal exercise test. Our primary objective is to measure the exercise capacity in as many of the enrolled patients as possible using a standardized protocol, and to monitor the post-exertional response for 48 hours with online cognitive testing and visual analogue scales of fatigue, pain, and symptoms. Maximal CPET with one day of testing and 48-hour follow-up of cognition was developed in consultation with Dr. Gudrun Lang (cognition) and Dr. Dane Cook and Connie Sol (exercise). The exercise protocol was discussed also with Dr. Chris Snell. Dr. Snell favors the two-day test because it gives more information, however he believes the one-day maximal CPET will provide useful information. We chose the one-day test so that more patients could be tested. The two-day test would require an additional overnight stay for those patients who travel long distances to attend clinic and excludes those who are most severely affected because of the heavy physical toll. In developing the protocol, we strived to find a balance between testing that would yield meaningful data in the broadest representation without placing an unnecessary burden on the patients.

I immediately asked Dr. Snell if this was an accurate representation of his comments, and he said it was. He commented:

As you know, we believe that the 2 day test provides important metabolic data as well as potential to objectively document fatigue following physical exertion. I do believe, for most patients, a single max test will elicit PEM which should affect the post-test cognitive scores and fatigue scale scores. The CPET data however may not be a true reflection of physiological function post exertion for all patients.

On balance, I am happy that the CDC chose to use a validated protocol for functional assessment that does incorporate objective measures of effort. This is infinitely preferable to dubious “sub-maximal” tests. I did indicate that the study was still worthwhile even absent the second test. On what may be a selfish note, I am disappointed that the study does nothing to validate the diagnostic value of repeated CPET testing for ME/CFS. It was briefly mentioned that this might be part of subsequent studies.

So is this CDC protocol a reasonable compromise? I’m sure it was influenced by budget, to some degree. CPET testing is expensive (as I can personally attest), and creates a serious burden of recovery. CDC is choosing to compromise by using a single maximal test and then measuring the effect on patients. Will a one day test be sufficient to demonstrate PEM, including the cognitive and physical symptoms of a crash? Will advocates be satisfied, especially in light of Dr. Snell’s support of CDC’s protocol for this study?

I think CDC will capture good data this way, but it won’t be a complete demonstration of PEM and the metabolic dysfunction that characterizes ME/CFS. The second day of testing captures the significant drop in VO2max, oxygen consumption at the anaerobic threshold, peak workload, and workload at the anaerobic threshold. The second day results differentiate ME/CFS patients from other illness groups. It is possible that the CDC multisite results will not do so without that second day of testing. In my opinion, that is a huge missed opportunity.

 

Two Is Better Than One

July 3rd, 2013 10 comments

My confidence in two-day cardiopulmonary exercise testing (CPET) is pretty obvious on this blog. A new study from ME/CFS experts Dr. Chris Snell, Staci Stevens, Dr. Todd Davenport, and Dr. Mark VanNess supplies hard data that shows how important a two-day maximal CPET is for diagnosis and documenting ME/CFS. The Physical Therapy Journal has made the author manuscript available (behind a paywall), and so that version I review here is not necessarily the final version that will be published by the journal.

The purpose of this study was to establish whether the objective measurements in CPET could distinguish patients with CFS from healthy controls. The study enrolled 51 female CFS patients and 10 female sedentary controls. The CFS patients were diagnosed using the Fukuda criteria, and they also reported symptom exacerbation after activity. All subjects completed two maximal effort CPETs conducted 24 hours apart. Unfortunately, the study did not include testing for post-exercise gene expression (like the Light study). No evaluation or follow up is reported, so we do not know how long it took the subjects to recover from the testing.

In Test 1, the CFS patients did not perform as well as controls. Multiple measurements were lower in the CFS group, including VO2max, peak workload, and workload at the anaerobic threshold. However, only the peak workload difference was statistically significant. In Test 2, the differences were quite dramatic. The controls performed the same or even better on the second test. But the CFS patients demonstrated a drop in VO2max, oxygen consumption at the anaerobic threshold, peak workload, and workload at the anaerobic threshold. The mean for the last value – workload at the anaerobic threshold – dropped by more than 50%. Respiratory measurements prove that all subjects gave a maximal effort in both tests, so the reduction is not due to lack of effort.

So what does this mean? The inability of people with CFS to reproduce their CPET results on day two is extraordinary. The authors state that it “could be utilized diagnostically as an objective indicator of abnormal post-exertional response, and possibly even a biomarker for this condition.” In fact, statistical analysis of the results correctly classified CFS patients and controls with 95.1% accuracy.

Healthy individuals stay below the anaerobic threshold most of the time. But this study showed that for many CFS patients, even activities of daily living require them to push past their anaerobic thresholds. My own test results demonstrated the same impairment. This could explain not only our limitations on good days, but why those limitations shrink during post-exertional malaise.

This study demonstrates the importance of using a two-day test protocol. While there were differences between patients and controls on the first day, only the CFS patients demonstrated a dramatic drop in performance on the second day. This significant reduction in performance appears to be unique to CFS. A recent study in patients with sarcoidosis (an inflammatory condition) failed to find any difference in CPET results between patients and controls, despite using a two day protocol.

One of the questions this paper cannot answer is: why? What do these results tell us about the underlying cause? The authors say, “It is very possible that a synergy of small effects across multiple systems is responsible for the poor exercise performance of the individuals with CFS in this study.” The results are consistent with reduced oxygen carrying capacity, possibly due to low blood volume, cardiac abnormalities, or autonomic dysfunction.

The conclusion of the paper is worth quoting at length:

In conclusion, a serial CPET protocol with measurement of expired gases demonstrates efficacy in distinguishing between individuals with CFS and sedentary, but otherwise healthy controls. As in the only other studies identified employing a dual CPET paradigm with measurement of expired gases, individuals with CFS showed a decrease in performance on the second test that was not seen in controls. This functional deficit may provide an objective indication of PEM. Despite considerable patient heterogeneity with respect to illness duration and type of onset, analysis of data from the second test was able to correctly classify 49 out of 51 individuals with CFS and 9 out of 10 controls. Non-invasive biomarkers for CFS do not currently exist. Physical therapists may consider the use of CPET performance measures to differentiate between individuals with CFS and otherwise non-disabled sedentary persons. Work efficiency (i.e. oxygen consumption and work output) at the ventilatory/anaerobic threshold appears to have diagnostic potential for CFS. (emphasis added)

This paper had a long journey to publication. The manuscript was submitted in October 2011, but was not accepted until June 2013. I hope its publication will lead to wider use of the two day maximal CPET protocol, particularly in research like the CDC’s multisite study. The suffering and agony of a two day test can be severe, as my own experience shows. But an objective way to diagnose CFS has held this field back for thirty years. If the two day CPET can provide objective diagnosis, then I say let’s go full speed ahead.

 

Quick Announcement

March 18th, 2013 7 comments

Finally (!) I am able to share the news that I’ve been invited to serve on a panel at the upcoming FDA Drug Development for ME/CFS Workshop. I’ve wanted to announce this for awhile, but panelists were asked not to publicize their participation.

I’m serving on a panel with clinicians and other patients to talk about symptoms, treatments, and possible outcome measures. The agenda and speaker list for the meeting should be released soon, and I’ll be writing more about the meeting in the coming weeks. I’m honored to be included on a panel of distinguished experts, and to have the opportunity to give voice to patients’ experiences.

More news to come . . . .

 

NIH Collaboration

December 17th, 2012 Comments off

The news didn’t make much of a splash, but NIH recently issued a funding opportunity announcement that could benefit people with CFS. This purpose of this funding opportunity is to support “collaborative translational research projects” aimed at turning basic discoveries into “clinical applications that improve health.”

Unlike other NIH program announcements for ME/CFS, this one is focused on collaborations between NIH investigators at the NIH Clinical Center and researchers at labs outside NIH. The NIH Clinical Center has pioneered many treatments, including the first trial of AZT in AIDS patients and many new chemotherapy treatments. Dr. Harvey Alter, known to many CFS patients because of his involvement in the XMRV saga, is Associate Director of Research in the Department of Transfusion Medicine at the Clinical Center and a member of the Trans-NIH ME/CFS Working Group.

The NIH Clinical Center has an extraordinary set of resources for translational research, including banked specimens, high grade equipment, healthy volunteers, and experience in clinical trials. How could this be relevant for ME/CFS? Imagine bringing patients into the clinic for a pathogen study or complete neurological workups. Imagine accessing the best equipment and researchers to analyze spinal fluid from patients and controls. Most projects into the causes, diagnosis, and treatment of CFS could be done in partnership with the Clinical Center.

Fourteen institutes at NIH joined together on this program announcement, including the Office of Research on Women’s Health which chose to highlight ME/CFS as an area of interest for this funding:

One of the goals of the WG is to increase focus on collaborative ME/CFS research by identifying NIH resources that may be useful to advance the translational research within this field. ORWH encourages applications from investigators to address research questions focused on the etiology, diagnosis, underlying mechanism, or treatment of ME/CFS.

Note that this announcement is not an RFA with dedicated money set aside, and many areas of interest are highlighted. However, this represents an extraordinary opportunity for CFS researchers. NIH is offering a pre-application webinar on January 11th for interested applicants. I hope we will see applications from institutions and researchers in the CFS world to collaborate with the Clinical Center.

 

Speeding Things Up

December 10th, 2012 1 comment

In my previous post, I explained the definitions FDA used to determine that CFS is a serious or life-threatening condition. But the true significance of FDA’s decision is that it makes CFS treatments eligible for programs that speed up the process of getting those treatments to patients. To understand these programs, you first have to understand the drug approval process.

The Pipeline: A Hypothetical

Let’s say that XYZ drug company has created a drug called PemX to treat CFS, and has tested that drug in animals to show that it is not toxic. XYZ then files an Investigative New Drug (IND) application with FDA and includes information on the drug and the plans for clinical trials in humans. XYZ conducts a Phase 1 clinical trial in 75 patients to test the safety of PemX. The results show PemX is safe, so XYZ conducts a Phase 2 clinical trial in 300 patients. The Phase 2 trial is designed to test whether PemX is effective in treating CFS, so half of the patients get PemX and half receive placebo. Since Phase 2 was a success, XYZ and the FDA discuss the design of Phase 3 trials. Phase 3 trials typically involve thousands of patients, and are designed to test appropriate dosages, side effects and drug interactions.

XYZ believes that the Phase 3 trials are a success, and files a New Drug Application (NDA). This is a request to FDA to approve PemX for sale in the United States, and the application includes all the data from all the studies. FDA has 60 days to decide whether to file the NDA for review. If the NDA is filed for review, then an FDA review team is appointed to examine all the data, the proposed labeling, and the manufacturing facility. FDA may also ask an advisory committee to examine the data. After all the reviews, FDA decides whether to approve PemX, including what dosages should be available.

Fast Track

Fast Track is an expedited process for drugs that treat serious diseases and fill an unmet medical need. Serious diseases include cancer, heart disease, AIDS, and now includes CFS as well. An unmet medical need is a condition for which there are no approved treatments (like CFS) or when the proposed drug is potentially superior to existing drugs.

Fast Track designation must be requested by the drug company, and the request can be made at any point in the drug review process. In our hypothetical, XYZ requests Fast Track status after the Phase 2 trials, and FDA has 60 days to make that determination. FDA approves Fast Track for PemX, and so now XYZ will have more meetings and more correspondence with FDA about the clinical trials. PemX is now eligible for rolling review, meaning that XYZ can submit portions of the NDA as they are completed rather than waiting to the end and submitting all at once. PemX is also now eligible for Accelerated Approval.

Accelerated Approval

There are many potential treatments that can take years to show true effectiveness. For example, a chemotherapy drug may be intended to extend the lives of cancer patients but it could take a decade or more to prove that the drug does in fact do so. To address these situations, FDA uses Accelerated Approval to base review on a surrogate endpoint. For cancer, that endpoint might be tumor shrinkage. The chemotherapy drug could be approved because it successfully shrinks tumors, and FDA would require post-approval studies to verify that the drug does in fact extend the lives of the cancer patients.

In my example, PemX is intended to treat CFS, but it could take years to be certain that patients experience long-lasting benefits that make it possible to return to work or normal life. In the Accelerated Approval process, XYZ proposes that exercise testing be used as a surrogate endpoint. Patients are put through two-day exercise challenges before treatment and then at six and twelve months post-treatment. Improvement in exercise capacity and reduction in recovery time are used as surrogate endpoints, and longer term studies would be needed to prove that PemX really did enable patients to return to work. If PemX is approved in the accelerated process, then FDA can require post-approval studies and restrictions on use of the drug.

Priority Review

Normally, FDA has a goal of ten months to review an NDA for approval. But a drug company can request Priority Review for a treatment that offers a major advance over existing therapies or where no treatment exists. If FDA assigns Priority Review for a drug, the goal timeline for review is six months. Priority Review does not change the requirements for clinical trials or drug safety and effectiveness. In our hypothetical, XYZ requests Priority Review for PemX because there are no existing therapies for CFS. FDA grants the request and the review process for the PemX NDA is now six months.

On Speed

Because FDA has determined that CFS is a serious or life-threatening condition, my hypothetical drug PemX gets to market faster. First, XYZ requests Fast Track status and this means that FDA has more contact with XYZ during the trials process, and XYZ can submit sections of its final NDA as they are completed. PemX also becomes eligible for Accelerated Approval, meaning that exercise testing is used as a surrogate endpoint for treatment success. As a result, clinical trial data can be collected for 12 months instead of many years. XYZ also requests and is granted Priority Review for PemX, and the final NDA review process takes only six months instead of ten. These three programs shorten the time it takes for PemX to move from “bench to bedside,” and it all happens because FDA determined CFS is a serious or life-threatening condition.

Note: PemX is a drug invented in my imagination, and all the examples in this post are purely hypothetical. The FDA website has an incredible amount of information on the drug approval process, and I relied heavily on the FDA’s descriptions of these programs in writing this post.

 

Puzzle Pieces

October 30th, 2012 13 comments

Let’s play a game. Imagine you have a large puzzle that makes an Impressionist picture of a colorful cottage-style garden. You can put it together as long as you have the picture on the box. First you assemble the lower left corner, all lavender and yellow flowers. Another section of red roses sits somewhere in the middle. Near the upper right corner is a section of white and gray paving stones, and you also put together an area of green herbs although you are not sure where it goes yet. This puzzle will take a lot of time to solve, but with the finished image on the box you know that you’ll put it together eventually.

Now imagine the box is gone. All you have is a white/gray blob, and lavender/yellow section, the red rose section and another green blob. The rest of the pieces are all mixed up together, and while you can separate out some edge pieces and consolidate others by color, without the box you cannot even be certain what the final picture should look like. It’s frustrating, isn’t it, to have all those pieces on the table and not see how it fits together or even know for certain that you have all the pieces. That’s the feeling I got reading the American Family Physician’s article on Chronic Fatigue Syndrome: Diagnosis and Treatment. I dissected the AAFP patient information sheet on CFS in a recent post, but now I think it’s important to examine this review article by the same authors. The article attempts to present a finished picture of CFS for family practitioners, but so many pieces are missing that the paper bears little resemblance to the CFS I live with.

Generally Speaking

“Chronic Fatigue Syndrome: Diagnosis and Treatment” by Dr. Joseph Yancey and Dr. Sarah Thomas gives an overview of CFS for family physicians. They review the Oxford and Fukuda criteria, the basic lab workup recommended by CDC, and a list of exclusionary conditions. In a section on etiology of CFS, the authors quickly cover the immune system, genetics, psychosocial, adrenal system, and sleep/nutrition. Finally, the treatment section focuses on cognitive behavioral therapy (they say it works), graded exercise therapy (this works too), nonpharmacological (nothing really helps) and pharmacological treatments (these don’t work either).

In the authors’ defense, there are significant space limitations in the American Family Practitioner journal: 1,500 to 1,800 words in the case of clinical review articles like this one. There is no way to include all the information about CFS that family doctors need in such a limited space. It also appears that neither Yancey nor Thomas are CFS experts, based on the very limited information I could find online. I emailed Dr. Yancey, the corresponding author for the paper, on October 24th with a few questions but to date I have not received a response.

Method Madness

Drs. Yancey and Thomas describe their research methods as follows:

A PubMed search was completed using the MeSH term chronic fatigue syndrome. The search included randomized controlled trials and clinical trials in English from the past 10 years. We also searched the Cochrane database, Essential Evidence Plus, the National Institutes for Health and Clinical Excellence guidelines, and the Centers for Disease Control and Prevention Web site. Search date: August 26, 2011.

This methodology accounts for some of the missing pieces. First, anything published after August 26, 2011 was not captured in the search. That includes the IACFS/ME Primer, NCI’s paper on the risk of cancer among elderly CFS patients, the ME-ICC criteria, and the Rituximab trial. But before we forgive the authors’ oversight of these papers based on the date of their literature search, consider a curiosity I found in the paper references. The authors cite one paper published after August 26, 2011: The FITNET trial of internet based CBT for adolescents with CFS is included as reference Number 27. Does that strike you as odd? If the authors truly limited themselves to the references found on August 26, 2011 then this paper should not be included. Furthermore, of all the papers published after August 2011 to include in a review of CFS treatment and diagnosis, why was a CBT paper the one cherry-picked by the authors?

Even within the boundaries of the search methodology, the authors missed some papers that would have been helpful in their overview sketch of CFS. I attempted to recreate the authors’ search in PubMed, and found more than 1,300 clinical study papers alone. These include all of the letters critical of the PACE study and Tom Kindlon’s many letters and papers on the potential harms and inaccuracies in CBT/GET studies. Other important papers such as the spinal fluid proteome by Schutzer, et al., the differential gene expression post-exercise paper from Light, et al., and the cytokine network modeling by Broderick, et al. were captured in the PubMed search but did not make it into this review paper.

Finally, there are several seminal papers that are not returned in the PubMed search. The Journal of Chronic Fatigue Syndrome published the Canadian Consensus Criteria by Caruthers, et al., in 2003. This case definition is gaining broad acceptance among policy makers and researchers, but it does not show up in a PubMed search because the journal was never indexed in Medline. Another example is the Van Ness, et al. study showing the significance of two-day exercise testing in differentiating CFS patients from controls. This is a critical paper, suggesting a possible diagnostic test (albeit an extremely unpleasant one) for CFS. But because the journal was never indexed, these papers do not show up in a PubMed search and so non-experts like Yancey and Thomas never see them.

Cognitive Bias

I do not know what Dr. Yancey and Dr. Thomas believe about CFS, including whether they believe the illness is primarily psychological in origin. After reading this paper, however, I fear this may be the case. I can best illustrate this through examples.

In the opening paragraph of the article, the authors say “CFS is often mentally and emotionally debilitating, and persons with this diagnosis are twice as likely to be unemployed as persons with fatigue who do not meet formal criteria for CFS.” What about physically debilitating? If the authors recognized the physical disability experienced by many CFS patients, and the physical suffering of all of us, wouldn’t they mention it in this paragraph? This simple omission is a very subtle way to communicate that people with CFS are not physically ill.

There is a brief discussion of the case definition in the paper. According to the authors, the 1988 CDC definition focused on physical symptoms, and the 1991 Oxford definition “emphasize mental fatigue over physical symptoms.” But the criteria, printed as Table 1 in the article, require fatigue to be “severe, disabling, and affects physical and mental functioning.” I’m no fan of the Oxford definition, but even I can see the requirement of physical disability. Again, Yancey and Thomas gloss right over the fact that CFS has serious, physical symptoms.

In discussing the biopsychosocial model of CFS etiology, the authors say: “CFS is often associated with depression, which has led many physicians to believe that CFS is a purely psychosomatic illness. Evidence supporting this conclusion is lacking.” Fair enough. But then they say, “Strong evidence suggests that childhood trauma increases the risk of CFS by as much as sixfold.” Sigh. I covered this in my dissection of the patient information sheet. Childhood trauma may have physical systemic affects, but I am not aware of any evidence showing that CFS patients have higher rates of trauma compared to patients with other illnesses like MS or lupus or diabetes or cancer. In my opinion, it is misleading to single out childhood trauma as a risk factor for CFS in the absence of such evidence.

The authors devote space and attention to CBT and GET studies, and this is understandable given the fact that CBT and GET treatments have received the most study in CFS. CBT “can help persons with CFS recognize how their fears of activity lead to behaviors that ultimately cause them to feel more fatigued and disabled.” It is true that CBT can help patients correct activity avoidance behavior, but in my experience this is a very small minority of patients. Even the CDC, target of so much criticism, does not describe CBT this way. The CDC says: “CBT can be useful by helping them pace themselves and avoid the push-crash cycle in which a person does too much, crashes, rests, starts to feel a little better, and then does too much once again.” This is a more appropriate description of CBT that acknowledges the importance of self-management and the prevalence of the push-crash cycle, as opposed to the activity avoidance highlighted by Yancey and Thomas.

Graded exercise therapy is very controversial for CFS patients, mainly because traditional GET uses a scheduled increase process as opposed to a patient-driven increase process based on symptoms. Not surprisingly, this issue is not discussed in the paper. The authors do mention that a heart rate monitor can be used to avoid overexertion during exercise, but there is no mention of the body of evidence on CFS exercise testing and pacing methods. They even cite a study that suggests improvements in GET do not correlate with increases in exercise capacity, suggesting that GET may actually work by “decreasing symptom-focusing behavior in persons with CFS.” Pacing, the only behavioral technique that truly helps CFS patients, is not mentioned by name, although the authors do say:

Patients should be encouraged to take rest periods as necessary, and to practice relaxation techniques. Although there is no evidence these modalities are effective, they are unlikely to be harmful and may be helpful.

Neither CBT nor GET is curative because it does not target the underlying mechanism of illness. CBT is not curative for cancer or heart disease either, for the same reason. Drawing the conclusion that these therapies are not curative because of the patient is a fallacy, but this is the conclusion that Yancey and Thomas suggest:

Despite the positive results of CBT and graded exercise therapy, the effects are usually moderate and rarely lead to resolution of CFS. Patients with poor social adjustment, a strong belief in an organic cause for fatigue, or some sort of sickness benefit (i.e. financial incentive) tend to have worse responses to therapy. Unlike with many other illnesses, membership in a CFS support group was associated with worse outcomes.

The study cited by the authors in support of these statements is this one from 2002. That study points out its own limitations: it uses the Oxford definition, lost 17% of the patients to follow-up, and did not actually measure the exercise capacity of the patients. But this is the kind of evidence that is sufficient for Yancey and Thomas.

The overall tone, selective quotation, and reference choices give me the impression that the authors believe CFS to be a psychological condition, at least in part. I do not know this for a fact, but if I read only this article about CFS and nothing else, I would believe that it is an emotional problem. It’s not just the amount of space devoted to the psychosocial research. The authors focus on the psychological elements to the exclusion of discussion of physical disability, post-exertional malaise, and the well-documented physiological findings in this illness.

Missing Pieces

There are huge gaps in this paper. Orthostatic intolerance, an issue for most CFS patients, is not mentioned at all. Post-exertional malaise is not explained, and no CFS exercise studies are referenced. The importance of medications and other treatments in managing sleep and pain issues is ignored, and pain is barely discussed at all.

This article illustrates a few pieces of the puzzle, mainly CBT, GET and the psychosocial model of CFS. A family physician reading only this article would not be able to separate chronic fatigue from CFS patients, and would understand almost nothing about the complexity of CFS. I found the tone to be generally hopeless: try therapy and exercise but it probably won’t help you much. Maybe a motivated physician would visit the CDC website (and this illustrates the importance of fixing problems in those materials).

No one will be able to assemble the CFS puzzle using the pieces in this article. Too much evidence is ignored, too much emphasis is placed on the psychosocial pieces, and there is very little information about how to manage the other symptoms of the illness. I know the full picture exists and I can identify the gaps. But a family physician who does not have the picture of the box will not recognize all that is missing and will never be able to assemble the pieces in a way that will help CFS patients.

I fear that doctors will rely on this article to provide the same kind of advice I received from doctors in 1994: keep going to the gym, staying in bed is the worst thing you can do, get some counseling, there is nothing else we can do to help you. This bad advice and hopelessness did not help me, and may have even hurt me by keeping me much more active than my body could tolerate. It was years before I found and received adequate care for pain, sleep, and orthostatic intolerance, and even more years before I found expert help for pacing and activity management. This article will do nothing to change the way doctors treat CFS, and will reinforce the destructive pattern already in place.

Patient Focused Drug Development

October 25th, 2012 7 comments

The FDA hosted a public meeting this morning to discuss the Patient Focused Drug Development (PFDD) initiative. The meeting was available via webcast, and a transcript will be published on the FDA website. CFS is on the list of candidate diseases to be included in this process, so the meeting was of great relevance to us as patients and advocates.

The goal of the Patient Focused Drug Development Initiative is to create a more systematic way for FDA to collect and use patient perspectives on the burden of disease and the risk/benefit ratio of treatments. While patient input is used in a variety of ways in the drug approval process, it is not as systematic and comprehensive as is needed. Dr. Janet Woodcock, the director of FDA’s Center for Drug Evaluation and Research, explained that FDA wants to understand patients’ perspectives on the burden of illness, how it affects daily life, how treatments affect those symptoms and outcomes, and what degree of risk is acceptable for the benefits. Every patient has a different experience of disease burden and tolerance for risk, so collecting single patient input on these questions may not capture the full spectrum of patient experience. The selection of twenty conditions (from the proposed list of thirty-nine) is intended to be a pilot program to help the FDA figure out how best to collect this input more generally.

Dr. Teresa Mullin, Director of the Office of Planning and Informatics, explained that making a determination of the balance between treatment risk and benefit requires an analysis of the condition and the current treatment options. Patients can speak to the clinical manifestations of the condition that have the most significant impact on them, as well as other aspects of the condition that affect daily life. Patients can also speak to how those impacts change with disease progression, and share their own experiences of the current standard of care and all treatments being used (including non-pharmacological treatments). While many of these issues have been considered and discussed from the clinicians’ point of view, it is very common for patients to have a very different view of the symptoms they feel most affect daily life or how well treatments work (or not) over time. Dr. Mullin said that the objective of this PFDD process is to create a systematic way to collect broad patient input and capture it in a usable and useful format to be used by review panels when considering products for approval.

In discussing why the FDA selected the thirty-nine candidate diseases, Dr. John Jenkins, Director of the Office of New Drugs, said that collective patient community input was essential throughout the approval process from the oversight of trials through post-approval safety issues. He pointed out that the patient perspective is very different from that of consumer safety advocates. For example, patients with asthma have a very different risk tolerance with inhaler medications compared to safety advocates who do not have asthma. Several division directors explained why their divisions had proposed specific diseases, including Dr. Theresa Michele from the Division of Pulmonary, Allergy and Rheumatology Products. Dr. Michelle is also FDA’s ex officio representative to the CFS Advisory Committee, and she spoke about the severity of CFS and why her division recommended its inclusion in the PFDD process.

Most of the remaining time of the meeting was devoted to hearing public comment. In an attempt to give everyone time to speak, comments were limited to two minutes but this was not enforced by the meeting moderator. Patients and advocates representing diverse conditions spoke about why their disease should be part of this process, including Alpha-1 antitrypsin deficiency, alopecia, ALS, Alzheimer’s, amyloidosis, arthritis, angioedema, Batten disease, blood cancers, brain tumors, dystonia, gastroparesis, hereditary cancers, inflammatory bowel disorders, interstitial cystitis, kidney diseases, lung diseases, melanoma, migraine,  muscular dystrophy (including Duchenne), and narcolepsy. Four members of our CFS community spoke: Mary Dimmock, Joe Landson, Amy Squires, and Mary Schweitzer.

Several things struck me during all the public testimony. First, I found it heart-breaking to listen to so much suffering. Dealing with CFS, we sometimes have blinders on and I think we forget how many other millions of people are suffering from poorly understood diseases with no treatment and no help. One man with ALS said he would celebrate if he had some of the other diagnoses on the proposed disease list, and did not understand why ALS was missing from the list. A woman with gastroparesis described her suffering in brutal detail, and drew a parallel between her experience and having the stomach flu every day. How many times have we CFS patients described our illness as having the worst influenza every day? It quickly became clear that for all the advances in medical care, there are too many diseases and too many patients and too many families suffering.

Second, a number of advocates pointed out that by selecting individual diseases, FDA had caused a “disease war,” in which groups were competing to get on the list. As an alternative, they proposed hosting PFDD meetings on body systems (lungs, nervous system, immune system, etc) or other factors (such as severity or availability of treatments). They reasoned that the combination approach would allow more diseases to be represented and capture more diverse patient input.

My personal opinion is that this would be a mistake. This is intended to be a pilot process to collect input that will be useful to drug review panels. I do not believe that a systems approach will collect the level of detail on CFS or other illnesses that is necessary for reviewers. How can a meeting on gastointestinal disorders capture a sufficient level of detail on patients with Crohn’s disease and gastropareisis that can be used in the drug approval process for a treatment for only one condition? And what about diseases like CFS and amyloidosis that do not have a single body system “home”? I believe FDA needs to drill down to a fine level of detail in collecting and understanding patient perspectives, so I hope they will not start combining conditions in an effort to cram more disease groups into these meetings.

Your input is necessary now! The public docket to submit comments on the disease list closes on November 1st. If you can, please write to FDA and give your perspective on how CFS meets the following criteria:

  • Disease areas that are chronic, symptomatic, or affect functioning and activities of daily living;
  • Disease areas that reflect a range of severity;
  • Disease areas for which aspects of the disease are not formally captured in clinical trials;
  • Disease areas that have a severe impact on identifiable subpopulations (such as children or the elderly);
  • Disease areas that represent a broad range in terms of size of the affected population
  • Disease areas for which there are currently no therapies or very few therapies, or the available therapies do not directly affect how a patient feels, functions, or survives.

FDA will take several months to review the collected input and decide upon the first twelve diseases for PFDD meetings in 2013 through 2015.

Mary Dimmock’s Comments to the FDA

October 25th, 2012 3 comments

Mary Dimmock presented a shortened version of these comments at the FDA meeting today on the Patient Focused Drug Development initiative. She has kindly given me permission to post her comments in full here.

My name is Mary Dimmock and I am a member of a national alliance of patient organizations and patient advocates representing patients with Chronic Fatigue Syndrome, also known as myalgic encephalomyelitis or ME/CFS.

The popular misconception is that ME/CFS is chronic tiredness due to deconditioning, depression or poor diet. That is what I thought until my energetic, smart, adventurous 23 year old son was struck down by ME/CFS after contracting Giardia while backpacking across Asia. Overnight, he went from academic excellence and scaling mountains to being unable to work, seldom able to leave the house and too often unable to do more than lay on his side in a dark room, in constant pain.

He is not alone. One million Americans of all ages, races and socioeconomic groups and 17 million people worldwide have been struck down overnight by this complex, multi-system disease that causes significant immune and neuroendocrine abnormalities; brain dysfunction and neurocognitive defects; cardiovascular and autonomic disturbances and abnormalities in energy production including mitochondrial dysfunction. As a result, patients suffer devastating functional impairment that results from the profound exhaustion, unrefreshing sleep, joint and muscle pain and cognitive problems that include difficulty thinking, slower processing speed and impairment of memory. These symptoms are exacerbated after even minimal mental or physical activity and can result in a relapse called post-exertional neuroimmune exhaustion that can last hours, days, or weeks. For some, even minimal activities like talking to a friend on the phone for a few minutes, taking a bath or making a meal for themselves can cause post-exertional neuroimmune exhaustion.

The CDC has said that ME/CFS can be as disabling as multiple sclerosis, lupus, rheumatoid arthritis, heart disease, end-stage renal disease… and similar chronic conditions.”  Patients can be sick for decades and many have been sick since outbreaks in the mid-1980s. Twenty-five percent of patients are bed-bound, house-bound or wheel-chair bound. Ten percent of patients are pediatric, some as young as 5. The inability to attend school, play with friends or even participate in family activities during their developmental years has a particularly harsh and lifelong effect on children. Overall recovery is rare and one study found that patients are more likely to die prematurely from cancer, heart disease or suicide.

And yet, today, there are no treatments for ME/CFS that are capable of even minimally improving patient functionality of changing the long-term outcome of the disease. There is only one ‘disease modifying’ drug being progressed through the FDA review process. The lack of agreement on definition, endpoints and how to measure treatment outcomes has impeded drug development. The drugs that are used provide only very limited relief for specific symptoms like pain but have little impact on the overall level of functioning. There are a small handful of experts nationwide who will prescribe antivirals or immune modulators to try to change the course of the disease but most doctors are unwilling to prescribe such drugs. Some of this reluctance is because they do not recognize that for patients, the disease severity warrants the risk.

The resultant reality for many patients is that they will spend every one of the rest of their days in pain, disability and isolation, functionally so limited that they are unable to work, care for their families or even sometimes take care of themselves.

It is time that we peeled back the misunderstanding and looked closely at the severity of this disease, the dramatic loss of functionality that these patients experience and the total lack of approved treatments. It is time we looked at how these patients would view the benefit-risk of a drug that would give them back even a small portion of their lives.

Please include ME/CFS for the one million Americans who suffer from this terrible disease. Please do this for all those sons and daughters who are not yet sick so that they never have to experience the nightmare that my son lives every single day.