Is Achieving Trial Success a Roll of the Dice? Dissecting

Is Achieving Trial Success
a Roll of the Dice?
Dissecting Trials with
Positive Outcomes to
Identify Strategies
for Success.
Sylvia Marecki, PhD
Senior Director,
Product Management & Strategy
1
2
Drug development is a risky endeavor—some might even say a gamble—but what are
the odds of running a successful trial? Although many studies have evaluated overall drug
development success rates, predominantly by assessing therapeutics’ phase transition rates
and probabilities of approval, none have reported trial-level success rates to date. Here,
we delve into this area to take a closer look at trial-level success with an eye toward
identifying strategies that may correlate with success.
Trialtrove and Trialpredict data were leveraged to identify Phase II – III, industry-sponsored trials completing
between January 1, 2008 and December 31, 2012 with a positive outcome, defined as the trial’s primary
endpoint(s) were met with statistical significance and/or the trial’s sponsor or investigator stated that it had
a positive outcome or was successful. A total of 7,005 trials were completed during this timeframe and 3,686
trials achieved a positive outcome for an overall success rate of 52.6%, slightly better than a roll of the dice.
The top 10 diseases spanned several major therapeutic areas but type 2 diabetes saw the most successful
trials completing during this period (Table 1). Major pharmaceutical companies occupied the top 10
sponsor slots, biologics factored heavily among top 10 drugs, and the US was the top location among
successful trials (Table 1). Notably, Poland and Russia were among the top 10 trial locations for successful
trials, suggesting country selection expanding into emerging markets may be starting to reap rewards and
may also signal one strategy for success.
Table 1. The Top 10 Most Successful Diseases, Companies, Drugs, and Trial Locations
Diseases
Sponsors
Drugs
Trial Locations
• Type 2 Diabetes
• Roche
• Bevacizumab
• US
• Respiratory
Infections, Vaccines
• GSK
• Erlotinib
• Germany
• Novartis
• Rituximab
• Canada
• Pfizer
• Docetaxel
• France
• Merck
• Indacaterol
• UK
• Sanofi
• Cetuximab
• Spain
• J&J
• Bortezomib
• Italy
• AstraZeneca
• Ranibizumab
• Poland
• BMS
• Linalidomide
• Russia
• Lilly
• Capecitabine
• Belgium
• Breast Cancer
• Asthma
• Chronic Obstructive
Pulmonary Disease
• Rheumatoid Arthritis
• Non-Small Cell
Lung Cancer
• Hypertension
• HIV
• Allergic Rhinitis
Source: Trialtrove ® and Trialpredict ®, August 2013
3
Some therapeutic areas experienced a higher proportion of successful trials than others (Figure 1). While
oncology and CNS had the greatest number of clinical trials completed 2008 – 2012 overall, their success
rates were 51.9% and 47.2%, respectively; both lower than the overall success rate of 52.6%. Meanwhile,
autoimmune/inflammation had the highest success rate of 56%, followed by metabolic and cardiovascular
areas. Many factors certainly underlie trial success. This analysis will explore some of them to begin to
understand factors that may correlate with success and how sponsors may be employing these strategies
to drive trial success.
Figure 1. Trial Success by Therapeutic Area
1800
Other completed trials
60
Positive outcome
Success (% of completed)
1600
56
1400
54
1200
52
1000
50
800
48
600
46
400
44
200
0
Success Rate
Number of Trials
58
42
ONC
CNS
A/I
MET
INF DIS
CV
OPHTH
GU
40
ONC = oncology, CNS = central nervous system, MET = metabolic and endocrine, INF DIS = infectious diseases,
CV = cardiovascular, OPHTH = ophthalmology, GU = genitourinary diseases
Source: Trialtrove ® and Trialpredict ®, August 2013
Which companies sponsored these successful trials and how was success distributed among top industry
sponsors? As noted in Table 1, Roche completed the most successful trials during the 2008 – 2012 period
overall. When trial success by therapeutic area is stratified by sponsor, Roche emerges as the top sponsor
within oncology, Novartis for autoimmune/inflammation and ophthalmology, and GSK for infectious
diseases but these sponsors as well as others in the top 20 typically experienced trial success across
multiple therapeutic areas.
4
Figure 2. Successful Trial Activity by Top 20 Sponsors
800
700
Number of Trials
600
500
400
300
200
100
0
ONC
MET
A/I
INF DIS
CNS
CV
OPHTH
GU
Daiichi Sankyo
Forest Laboratories
Novo Nordisk
Amgen
Astellas
Celgene
AbbVie
Bayer
Takeda
Boehringer Ingelheim
Eli Lilly
BMS
AstraZeneca
Johnson & Johnson
Sanofi
Merck & Co
Pfizer
Novartis
GSK
Roche
ONC = oncology, CNS = central nervous system, MET = metabolic and endocrine, INF DIS = infectious diseases,
CV = cardiovascular, OPHTH = ophthalmology, GU = genitourinary diseases
Source: Trialtrove ® and Trialpredict ®, August 2013
Were there any differences in country utilization across therapeutic areas among these successful trials?
What is striking is that despite differences in sponsorship across therapeutic areas, the relative utilization
of the top 20 countries within a given therapeutic area is generally consistent across therapeutic areas,
with the United States remaining the most-utilized country (Figure 3). This observation suggests that
country selection strategies are generally consistent across sponsors and therapeutic areas at a macro level
but that there is variation in the average number of countries utilized per trial within each therapeutic area,
as evidenced by autoimmune/inflammation jumping to the first position by count of country utilization
(compare Figure 1 and Figure 3).
It also is noteworthy that these top 20 countries include Eastern European, Latin American, and Asia Pacific
regions and their relative utilization is roughly proportional to other top 20 countries, apart from the United
States. It is clear that Eastern Europe has become an important region and that we are likely to see growth
in utilization of countries in Latin American and Asia Pacific regions in the future.
It is clear that Eastern Europe has become
an important region and that we are likely to
see growth in utilization of countries in Latin
American and Asia Pacific regions in the future.
5
Figure 3. Successful Trial Activity by Therapeutic Area: Top 20 Countries
3000
Number of Trials
2500
2000
1500
1000
500
0
A/I
ONC
MET
CNS
CV
INF DIS
GU
OPHTH
Romania
Mexico
Austria
Sweden
Japan
India
Hungary
Czech Republic
Netherlands
Australia
Belgium
Russia
Poland
Italy
Spain
United Kingdom
France
Canada
Germany
United States
ONC = oncology, CNS = central nervous system, MET = metabolic and endocrine, INF DIS = infectious diseases,
CV = cardiovascular, OPHTH = ophthalmology, GU = genitourinary diseases
Source: Trialtrove ® and Trialpredict ®, August 2013
Among the top therapeutic areas with the most successful trials, GSK, Lilly, and Roche are among the top 5
sponsors in three out of four areas presented in Table 2. The US and UK remain top locations across these
therapeutic areas but only within autoimmune/inflammation does Poland appear among the top 5 locations
for successful trials. It is intriguing to speculate that trial success may somehow correlate with country
utilization. Given that the trial success rate was highest within autoimmune/inflammation and that it was the
only therapeutic area where an Eastern European country appeared in the top five most utilized countries,
this area served as a case study to investigate the potential impact of country selection on trial success and
to investigate other potential strategies for success.
It is intriguing to speculate that trial
success may somehow correlate
with country utilization.
6
Table 2. Top Therapeutic Areas By Trial Success
Therapeutic
Area
Oncology
Success Rate
(% of Completed)
51.9%
(809/1,560)
Top 5
Sponsors
Top 5 Diseases
Top 5 Drugs
Top 5 Trial
Locations
Roche
Breast Cancer
Bevacizumab
US
Sanofi
Non-Small Cell
Lung Cancer
Erlotinib
France
Docetaxel
Germany
Cetuximab
UK
Bortezomib Italy
Celgene
Lilly
GSK
Non-Hodgkin’s
Lymphoma
Colorectal cancer
Multiple myeloma
Autoimmune /
Inflammation
56%
(713/1,274)
Novartis
Asthma
Indacaterol
US
GSK
Rheumatoid arthritis
Adalimumab
Germany
Roche
Chronic Obstructive
Pulmonary Disease
Tocilizumab
Canada
Olodaterol
UK
Tofacitinib Poland
Merck
AbbVie
Allergic Rhinitis
Psoriasis
CNS
Metabolic
47.2%
(650/1,376)
55.1%
(600/1,089)
Pfizer
Pain (nociceptive)
Pregabalin
US
J&J
Pain (neuropathic)
Paliperidone
Germany
GSK
Depression
Aripiprazole
Canada
Lilly
Schizophrenia
Pramipexole
France
Merck
Parkinson’s Disease
Duloxetine
UK
BMS
Type 2 Diabetes
Sitagliptin
US
AZ
Diabetic complications
Insulin degludec
Germany
Lilly
Osteoporosis
Exenatide
Canada
Roche
Constipation
Epoetin beta
UK
NovoNordisk
Obesity
Linagliptin
Spain
Source: Trialtrove ® and Trialpredict ®, August 2013
When trial success is evaluated at the disease level within autoimmune/inflammation, asthma, rheumatoid
arthritis, and chronic obstructive pulmonary disease (COPD) emerge as the top three diseases, both in terms
of the most successful trials and most overall completed trials during 2008 – 2012 (Figure 4). The success
rate for asthma (52%) was slightly lower than the 52.6% average for the full dataset and somewhat lower
than the average for this therapeutic area (56%); whereas rheumatoid arthritis and COPD trials experienced
success rates over 62%. Could country utilization provide insight into potential strategies for success?
7
Figure 4. Top 10 Diseases in Autoimmune/Inflammation, 2008 – 2012
250
70
Other completed trials
Positive outcome
Success (% of completed)
65
60
150
55
100
50
50
Success Rate
Number of Trials
200
as
e
is
ce
Ul
ise
D
s
n’
oh
ra
st
Cy
Cr
ic
tiv
e
Fi
Co
br
os
lit
is
n
nt
at
io
la
sp
an
Tr
eo
ar
th
rit
is
sis
O
st
Rh
ic
rg
le
Ps
or
ia
in
PD
CO
Al
40
Rh
eu
m
at
oi
d
As
th
m
ar
th
rit
is
a
0
iti
s
45
Source: Trialtrove ® and Trialpredict ®, August 2013
The relative impact of Eastern Europe becomes even more apparent in autoimmune/inflammation, with
four of the top 15 countries coming from this region: Poland, Hungary, Russia, and Romania (Figure 5).
Furthermore, Mexico and Argentina appear among the top 20 countries, providing further evidence to
suggest that expanding geography may play a role in trial success.
Success rates in trials involving any of these top 20 countries was above average for this therapeutic area,
highest among trials involving South Korea, where nearly 76% of trials involving this country were successful.
Clearly, simply including a particular country in a clinical trial is no guarantee for success but a closer look
at trials that involved this country may provide some insight into successful strategies.
Figure 5. Trial Success Rate Among Top 20 Countries in Autoimmune/Inflammation, 2008 – 2012
700
Other completed trials
80
Positive outcome
Success (% of completed)
500
70
400
65
300
60
200
55
0
50
Un
Un ited
ite
St
d
a
Ki tes
ng
d
G om
er
m
an
Ca y
na
d
Po a
la
nd
Fr
an
ce
Sp
H ain
un
ga
ry
Ita
ly
Ru
s
Be sia
N lgi
um
e
Cz th
ec erl
a
h
Re nds
pu
b
Au lic
st
ra
Ro lia
m
an
Sw ia
So ed
en
ut
h
Ko
r
M ea
So ex
ut ico
h
A
Ar fric
ge a
nt
in
a
100
Source: Trialtrove ® and Trialpredict ®, August 2013
8
75
Success Rate
Number of Trials
600
Not only were asthma, COPD, and rheumatoid arthritis the top three indications in autoimmune/inflammation
overall, they also accounted for 68% of all successful trials involving South Korea. In fact, South Korea was
the only country among the top 20 in autoimmune/inflammation that was utilized in clinical trials for all
three indications where there was a success rate of more than 75% (Figure 6). Success rates in Estonia and
the Philippines also exceeded 75% in these three indications but because of the smaller sample size, they
were not analyzed. To gain clarity around the types of trials that were conducted in South Korea, a deeper
analysis of these highly successful trials was undertaken.
Figure 6. Top 30 Countries In Asthma, COPD, And RA
100
Other outcome
Positive outcome
100
Success rate
90
80
80
70
60
60
50
40
40
20
30
20
100
90
80
70
60
50
40
30
20
10
0
100
120
100
90
80
70
60
50
40
Success Rate
Number of COPD Trials
0
30
20
90
100
80
80
70
60
60
50
40
Success Rate
Number of RA Trials
Success Rate
Number of Asthma Trials
120
40
20
30
20
Un
ite
d
G Sta
er te
m s
Un
Po any
ite
la
d Ca nd
Ki na
ng d
d a
Ru om
H ss
un ia
Ro ga
m ry
Uk ani
ra a
Fr ine
an
c
Pe e
r
Ita u
Ja ly
M pa
e n
So Bu xic
ut lg o
h ari
Af a
ri
N
et Cz ca
he e
Ar rla ch
g nd
Co ent s
lo ina
Au mb
st ia
ra
l
In ia
di
D Spa a
en in
Sl ma
ov rk
So Sw ak
ut e ia
h de
Ko n
N
ew Es rea
Z ton
Ph eal ia
ili an
pp d
in
es
0
Source: Trialtrove ® and Trialpredict ®, August 2013
9
Top drug mechanisms of action for these South Korean trials included long-acting beta-2 adrenergic
(LABA) agonists, long-acting muscarinic antagonists (LAMA), CD80/CD86 antagonists, Jak inhibitors,
and TNF alpha antagonists, reflecting drugs with more novel as well as established mechanisms of action.
In addition, Boehringer Ingelheim, GSK, Novartis, and Pfizer conducted 60% of these successful South
Korean trials. Therefore, it is unlikely that success was driven solely by established drugs or a single
drug development program.
The vast majority of successful trials involving South Korea were multinational; only 20% were conducted
exclusively in South Korea. Among these multinational trials, 70 different countries were utilized alongside
South Korea, the top 20 of which appear in Figure 7. In 62% of these South Korean trials, sites within the
United States also were involved; consistent with the observation already noted that most clinical trials
tend to involve the United States. What is intriguing is that among these top 20 countries, many more
countries in Latin America, Eastern Europe, and Asia Pacific were utilized along with South Korea as
compared with the dataset overall (Figure 3). This trend suggests that country selection spanning a wider
geography is taking hold and that these countries in emerging regions are playing an increasingly important
role in trial success, hinting at one strategy for success.
Figure 7. Country Selection Strategies in Autoimmune/Inflammation Trials Involving South Korea
% South Korean Trials
70%
60%
50%
40%
30%
20%
10%
ru
ly
Pe
Ita
da
G
er
na
Ca
m
an
Ru y
ss
ia
Po
Ar lan
ge d
nt
in
a
Fr
an
ce
Un
ite Me
xi
d
c
Ki
ng o
do
Au m
st
ra
lia
Br
az
il
So Sp
a
ut
in
h
Af
ric
Cz
a
B
ec elg
h
Re ium
pu
bl
ic
H
un
ga
ry
In
di
a
Ta
iw
an
Un
ite
d
St
at
es
0%
Source: Trialtrove ® and Trialpredict ®, August 2013
Expanding to a wider geography for country selection is one strategy sponsors are employing that
appears to correlate with trial success. Indeed, when we look at asthma, COPD, and rheumatoid arthritis,
successful trials involved more countries on average than trials completed during this same timeframe that
were not successful (Figure 8a) and they also involved more sites per trial than trials that were not successful
(Figure 8b). Intriguingly, the target accrual for successful trials was higher than for other trials completing
during this timeframe, suggesting that these were larger trials. Despite the expanded geography of these
trials, the increased number of sites and higher average target accrual, the average enrollment period was
shorter among successful trials in all three diseases compared with other trials completing during this timeframe
in these diseases. Future analyses are required to gain clarity around other factors influencing trial success.
10
Figure 8. Average Enrollment-Related Metrics for Successful Trials and Other
Trials Completed 2008 – 2012 in Asthma, COPD and Rheumatoid Arthritis
Figure 8a
Figure 8d
Average Target Accrual per Trial
8
7
6
5
4
3
2
1
0
Asthma
COPD
Average Reported Sites per Trial
Figure 8b
80
70
60
50
40
30
20
10
0
Asthma
COPD
RA
Positive outcome
Other outcome
600
500
400
300
200
100
0
Asthma
RA
Average Enrollment Period (mo.) per Trial
Average Countries per Trial
9
COPD
RA
COPD
RA
Figure 8c
20
15
10
5
0
Asthma
Source: Trialtrove ® and Trialpredict ®, August 2013
Trials completing during the 2008 – 2012 period had a slightly better rate of achieving success than a roll
of the dice but at 52.6%, it was only slightly better than chance overall. These odds are much better than
the drug development success rates reported in recent analyses from Tufts Center for the Study of Drug in
a recent analysis conducted by Hay and colleagues where the likelihood of approval for a drug in Phase I
development was a mere 10.4% (Hay, M., et al Nature Biotechnol. 2014 Jan 9, 32(1): 40 - 51). With everincreasing drug development costs and lower-than-house odds of drug approval, insight into successful
clinical trial strategies can help drive the odds of trial success in a more favorable direction.
While country selection may be one factor influencing success of clinical trials, trial design, the nature of
the therapeutic tested, and site/investigator selection are all likely to impact the potential for trial success
and will be investigated in future analyses. This insight then can be leveraged to design and conduct
better trials, improving trials success rates and potentially driving overall drug approval rates higher.
11
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