Complexity of the insulin signaling pathway
TNFα
Plasma membrane
TNFR
PTEN
p110α
p110β
p110γ
aPKC
IRS3
p85α
p55α
Akt2
Lipid
Synthesis
Akt3
GSK3
Glycogen
Synthesis
Jak
Ras
Erk1
Foxo1
Gluconeogenesis
Erk2
Cell growth,
differentiation
p90rsk
mTOR
Protein Synthesis
Stat
IRS4
p50α
p85β
p55γ
Akt1
SREBP
PTP1B
IRS2
Rac
cdc42
?
IRS1
Jnk
PDK 1,2
Glucose
Uptake
Rec
Shc
?
Cytokines
IGF1R
CAP
cbl
?
Insulin
IGF1
SOCS1,3
RET SIGNALING PATHWAYS
GFRα
Lipid Raft
membrane
kinase domain
GRB7/10
Y752 P
PLC-γ
Y928 P
P Y1015
P Y1062
Short Isoform (RET9)
Long Isoform (RET51)
Intermediate
isoform (RET43)
Enigma
IRS 1/2
P Y905
P Y1096
RAS
SHC
RAF
SOS
GRB2
MEK1
ERK1/2
GAB1
PI3K
FRS2
JAK
p85
RHO
Focal Adhesion
p110
CREB
ELK-1
Lamellipodia
RAC
JNK
STAT3
SHP2
Neoplastic Phenotype
Differentiation
MAPK
ACT
NF-B
Cell Proliferation
Cell Survival
Mitogenesis
Possible mechanisms of activation of wild-type RET
and MEN2-associated RET mutations
MEN 2A: MCT+FEO+PHPT
(T2095C/C634R)
I
II
1
2
31
32
1
2
31
35
1
1
5
8
1
37
1
2
12
7
2
5
MEN 2b: neurinoma phenotype
•Thick lips
•marfanoid habitus
•skeletal abnormalities
Genetic Screening
MTC and parafolicular C-cell
hyperplasia in a 5 yr old girl
Tatic S., Institute for Pathology, Medical School, Beograd
Age- related penetrances and probabilities
for gene carriers of MEN 2a
50
45
40
Gene carriar probability (%)
35
30
25
20
15
10
5
0.5
0.3
0.1
0.08
0.05
0
<10
20-30
30-40
40-50
>50
Age (years)
Clinical history
Biochemical screening
DNA markers +biochemical screening
Thakker et al. 1993
Patients with familial pheochromocytoma
in MEN 2
Analyzed patients for mutation in RET: 343
Total number of patients with pheochromocytoma due to mutation
in RET protooncogene: 36
25
25
20
19
15
Unilateral Pheo
14
10
8
RET carriers without
Pheo
6
5
2
2
3
1
1
c6
18
c6
20
c6
34
c6
49
c7
90
c7
91
c8
04
c8
26
c9
18
0
Bilateral Pheo
11
2
Oktobar 2007. – početak terapije ZD6474
April 2008. – progresija bolesti
Nova lezija
RECIST: Kompletan odgovor: povlačenje svih lezija
Parcijalni odgovor: smanjenje LD za >30%
Progresija: porast LD za >20% ili bar jedna nova lezija
Pacijent 1
Pacijent 1
April 2008: prelazak na “open label” studiju
Oktobar 2008: parcijalni odgovor
Pacijent 1
placebo
lek
3500
3000
2500
kalcitonin
(pmol/l)
CEA (g/L)
2000
1500
1000
500
.
08
O
kt
ju
l.0
8
ja
n.
08
A
pr
08
.
O
kt
07
.
0
VHL tip 2c; V84M (GTGATG)
1
I
42
1
2
13
11
II
3
Hypoxic and non-hypoxic regulation of HIF1a
Baldewijns MM, J Pathol, 2010
Protein expression of PHD1 in RCC
What is ICH GCP?
• A quality standard for the design,
conduct, performance, monitoring,
auditing, recording analyses and
reporting of clinical trials that provides
assurance that the data and reported
results are credible and accurate, and
that the rights, integrity and
confidentiality of the subjects are
protected.
• The ICH (International Conference
on Harmonization) develops standards on
the elaboration and presentation
of data so they are accepted worldwide (US, EU, JP).
Slide No. 15 • Basic GCP Facts • Sunday, 24 July 2016
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IRB/EC &
Authority
Subject
Investigator
Sponsor
ICH GCP Principles
1. Clinical trials should be conducted in accordance with the
ethical principles that have their origin in the Declaration
of Helsinki, and that are consistent with GCP and the
applicable regulatory requirement(s).
2. Before a trial is initiated, foreseeable risks and
inconveniences should be weighed against the anticipated
benefit for the individual trial subject and society. A trial
should be initiated and continued only if the anticipated
benefits justify the risks.
3. The rights, safety, and well-being of the trial subjects are
the most important considerations and should prevail
over interests of science and society.
Slide No. 16 • Basic GCP Facts • Sunday, 24 July 2016
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ICH GCP Principles (2)
4. The available nonclinical and clinical information on an
investigational product should be adequate to support
the proposed clinical trial.
5. Clinical trials should be scientifically sound, and describe
in a clear, detailed protocol.
6. A trial should be conducted in compliance with the
protocol that has received prior institutional review board
(IRB)/independent ethics committee (IEC)
approval/favourable opinion.
Slide No. 17 • Basic GCP Facts • Sunday, 24 July 2016
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ICH GCP Principles (3)
7. The medical care given to, and medical decisions made
on behalf of, subjects should always be the responsibility
of a qualified physician or, when appropriate, of a
qualified dentist.
8. Each individual involved in conducting a trial should be
qualified by education, training, and experience to
perform his or her respective task(s).
9. Freely given informed consent should be obtained from
every subject prior to clinical trial participation.
10. All clinical trial information should be recorded, handled,
and stored in a way that allows its accurate reporting,
interpretation and verification.
Slide No. 18 • Basic GCP Facts • Sunday, 24 July 2016
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ICH GCP Principles (4)
11. The confidentiality of records that could identify subjects
should be protected,respecting the privacy and
confidentiality rules in accordance with the applicable
regulatory requirement(s).
12. Investigational products should be manufactured,
handled, and stored in accordance with applicable good
manufacturing practice (GMP). They should be used in
accordance with the approved protocol.
13. Systems with procedures that assure the quality of every
aspect of the trial should be implemented.
Slide No. 19 • Basic GCP Facts • Sunday, 24 July 2016
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Good Clinical Practice – Why?
• ICH GCP is a set of ethical and scientific
quality requirements
• to protect the rights, safety, & well-
being of trial subjects
• to guarantee reliability of data capture
& credibility of study results
• ICH GCP must be complied with in all
clinical studies.
Slide No. 20 • Basic GCP Facts • Sunday, 24 July 2016
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Who does GCP Affect?
• Sponsors of studies
• Companies, Academic Units, Contract research
organizations
• Investigators
• all members of the study team
• Ethics committees
• new EU Directive imposes responsibilities
Slide No. 21 • Basic GCP Facts • Sunday, 24 July 2016
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What does GCP do?
• Implementation of GCP can:
• improve patient protection
• facilitate good science
• ensure meticulous documentation
• improve quality of trials
• improve decision making reliability
Slide No. 22 • Basic GCP Facts • Sunday, 24 July 2016
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The investigator
• Has adequate qualification & appropriate experience
(documented in the CV).
• Has enough time to conduct the study (paperwork,
study visits, meetings, audits and inspections).
• Has suitable and sufficient trial subjects.
• Has adequately trained research staff and adequate
facilities.
• Has to comply with the requirements of GCP.
Slide No. 23 • Basic GCP Facts • Sunday, 24 July 2016
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Investigator’s Responsibilities
• Store signed and dated CVs of all who recruit
subjects, obtain informed consent, do
assessments, complete CRFs or handle trial
drugs.
• Set-up and maintain a log of site staff who has
significant trial related tasks. Keep it updated
and signed.
• Train/Inform research staff regularly about the
study and any changes (document by
minutes, notes etc.).
Slide No. 24 • Basic GCP Facts • Sunday, 24 July 2016
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Study equipment and laboratory
• Use suitable and correct equipment.
• Calibrate & maintain instruments regularly
(including ECG, centrifuges, thermometers).
Documentation must be available.
• Train research staff to ensure proper handling of study
equipment.
• Ensure correct collection and handling of samples,
different tests as per protocol & laboratory guidelines.
• Required documentation from the local lab are: reference
ranges, details of analytical methods, quality assurance
information, GLP-certificates/accreditation.
Slide No. 25 • Basic GCP Facts • Sunday, 24 July 2016
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Lab
The study Protocol
Know it and follow it!
• Read the study protocol and be familiar with it.
• Accept and sign the protocol (final version).
• Follow the protocol point by point.
• Deviations from the protocol should not occur. However, if a
deviation occur the sponsor must be informed. Any deviations
must be documented stating the reason and date.
• Provide the protocol to the whole research team.
Slide No. 26 • Basic GCP Facts • Sunday, 24 July 2016
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Trial subject enrolment
• Predict potential subject recruitment using both past
data and current information.
• Keep a log of all screened & recruited subjects.
• Take enough time for recruitment of subjects.
• Inform the subjects in word & writing about the trial
and document it!
• Answer all questions in detail.
• Give ample time to the subject to make her/his
decision and document it.
Slide No. 27 • Basic GCP Facts • Sunday, 24 July 2016
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Source documents & SDV
• Source Documents are all original documents, data,
records (e.g. hospital records, laboratory notes,
memoranda, diaries, X-rays ...).
• Data to be recorded in source documents are
defined in the study protocol.
• Source Data Verification (SDV) is a mandatory
review that checks consistence between source
documents & CRF.
• What must be recorded in the medical records:
• All data asked in the CRF must be documented in the
•
medical records, unless otherwise described in the
protocol.
Furthermore, date of Informed Consent, trial no.,
screening no., randomization no., visit dates should
be recorded.
Slide No. 28 • Basic GCP Facts • Sunday, 24 July 2016
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Case Report Form (CRF)
• Ensure that only authorized staff
makes entries into the CRF.
• Complete the case report form
(CRF) entirely, legibly & accurately.
• Use abbreviations as little as
possible.
• Date and initial all changes
(crossing with a single line only!)
and give reason for correction
(transparency of correction
process).
Slide No. 29 • Basic GCP Facts • Sunday, 24 July 2016
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Case Report Form (CRF)
• Do not use any correcting fluids on any
trial related documents.
• Missing data or data not assessed
should be correspondingly marked, i.e.
N/D, N/A
• Give monitors, auditors, and regulatory
authority inspectors access to all source
documents and CRF.
• Keep the CRFs, investigator file in a
locked cupboard during the trial.
Slide No. 30 • Basic GCP Facts • Sunday, 24 July 2016
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Trial product management
• Explain drug administration
to the subjects.
• Keep detailed records of trial
product handling, including storage and
temperature log.
• Ensure that the subject returns
all used, empty and unused
treatment packs.
• Return all used & unused trial
products to Novo Nordisk.
• Ensure appropriate use of Investigational
Product according to the Protocol (dosing,…)
• Full responsibility for the appropriate
management of the Investigational Product at
the Site is with the Investigator
Slide No. 31 • Basic GCP Facts • Sunday, 24 July 2016
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Adverse Events (AEs)
Any untoward medical occurrence in a patient or
clinical trial subject administered a medicinal
product and which does not necessarily have a
causal relationship with the treatment. This
includes AEs from the first trial related activity
after the subject has signed the informed
consent.
• Document all AEs in the CRF.
Slide No. 32 • Basic GCP Facts • Sunday, 24 July 2016
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SAFETY !
• Adverse Event (AE) =
• Serious Adverse Event (SAE)
An experience that at any dose results in any of the
following
• Death
• A life-threatening experience
• Patient hospitalization or prolongation of existing
hospitalization
• A persistent or significant disability/incapacity
• A congenital anomaly/birth defect
• Important medical events (jeopardizing the subject &
possibly requiring medical/surgical intervention to
prevent one of the outcomes listed above).
• Immediately report all SAEs to the sponsor
Slide No. 33 • Basic GCP Facts • Sunday, 24 July 2016
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! SAFETY !
Serious Adverse Events (SAEs)
• All noxious and unintended responses to a medicinal
product related to any dose should be considered
Adverse Drug Reactions.
• “responses to a medicinal product” = a causal
relationship between a medicinal product and an
adverse event is at least a reasonable possibility, i.e.
the relationship cannot be ruled out.
!
Slide No. 34 • Basic GCP Facts • Sunday, 24 July 2016
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! SAFETY !
Adverse Drug Reactions
Files & Archives
• Document every study-related
action. Store all study files in a
safe and secure place.
• Archive the study-related
documents for at least 15 years.
Slide No. 35 • Basic GCP Facts • Sunday, 24 July 2016
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Benefits of GCP
•
•
•
•
•
•
•
•
•
•
•
More reliable data
Greater protection of trial subjects
Better performance and training
Uniformity of methods among companies and Investigators
Trust of regulatory authorities and inspectors
Quality design of trials
Ethics Committees’ approvals
Appropriate statistics
Authorities’ trust
Validity of data
Faster availability of new drugs on the markets
Slide No. 36 • Basic GCP Facts • Sunday, 24 July 2016
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Benefits of GCP: Investigator
• Those who comply with GCP will be deemed
acceptable – those who do not comply will not
be invited to participate!
Slide No. 37 • Basic GCP Facts • Sunday, 24 July 2016
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“Disadvantages” of GCP
• Greater demands of time and costs
• Perception of irritating bureaucracy
• Increasing of costs
• Possibility of more frequent controls
Slide No. 38 • Basic GCP Facts • Sunday, 24 July 2016
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GCP stays in Clinical Trials!
GCP requirements MUST be met!
Only those who respect GCP will
participate in Novo Nordisk Clinical
Trials!
Slide No. 39 • Basic GCP Facts • Sunday, 24 July 2016
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