Complexity of the insulin signaling pathway

Complexity of the insulin signaling pathway

TNFR

TNFα

Plasma membrane IGF1R

IGF1

Rec

CytokinesInsulin

IRS1

IRS2

IRS3

IRS4

Erk1

Erk2

Ras

p90rsk

Protein Synthesis

PTP1B

SOCS1,3

Jak

Stat

Cell growth,differentiation

p110α

p110β

p110γ

p85α

p55α

p50α

p85β

p55γ

JnkShc

cblCAP

Glucose Uptake

?

Raccdc42

?

PDK 1,2

PTEN

aPKC?

Akt1

Akt3

Akt2

mTOR

Foxo1GSK3

SREBP

LipidSynthesis

GlycogenSynthesis

Gluconeogenesis

Y1062

Y905

Y1096

SHC

GAB1

ACT

EnigmaEnigmaIRS 1/2IRS 1/2

GRB7/10

SOS

RAS RAFRAF

MEK1MEK1

ERK1/2ERK1/2

CREBCREB

ELK-1ELK-1

RHO

RAC

PI3K

p85

p110

NF-NF-BB

Y1015

FRS2

GFRα

PP

PPPP

PP

kinase domain

Long Isoform (RET51)Long Isoform (RET51)

ShortShort Isoform (RET9)Isoform (RET9)

GRB2

NeoplasticNeoplastic PhenotypePhenotype

Cell ProliferationCell SurvivalMitogenesis

JNK

SHP2

MAPKMAPKDifferentiationDifferentiation

membrane

Intermediate Intermediate isoform (RET43)isoform (RET43)

Focal AdhesionFocal Adhesion

Lipid RaftLipid Raft

PP

PPY752Y752

Y928Y928

STAT3

JAK

PLC-PLC-γγ

LamellipodiaLamellipodia

RET SIGNALING PATHWAYS

Possible mechanisms of activation of wild-type RET and MEN2-associated RET mutations

MEN 2A: MCT+FEO+PHPT (T2095C/C634R)

I

II

1

31

2

32

1

31

2

35

1

5

1

12

2

7

1

37

1

8

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

0.5 0.3 0.1 0.08 0.050

5

10

15

20

25

30

35

40

45

50

<10 20-30 30-40 40-50 >50

Age (years)

Gen

e c

arr

iar

pro

bab

ilit

y (

%)

Clinical history Biochemical screening DNA markers +biochemical screening

Age- related penetrances and probabilities for gene carriers of MEN 2a

Thakker et al. 1993

Analyzed patients for mutation in RET: 343Total number of patients with pheochromocytoma due to mutation in RET protooncogene: 36

Patients with familial pheochromocytoma in MEN 2

2 2

19

14

8

1

6

25

1

11

3 20

5

10

15

20

25

Unilateral Pheo

Bilateral Pheo

RET carriers withoutPheo

Oktobar 2007. – početak terapije ZD6474

April 2008. – progresija bolesti

Nova lezija

Pacijent 1

RECIST: Kompletan odgovor: povlačenje svih lezija Parcijalni odgovor: smanjenje LD za >30%

Progresija: porast LD za >20% ili bar jedna nova lezija

April 2008: prelazak na “open label” studiju

Oktobar 2008: parcijalni odgovor

Pacijent 1

0

500

1000

1500

2000

2500

3000

3500

kalcitonin(pmol/l)

CEA (g/L)

placebo lek

Pacijent 1

VHL tip 2c; V84M (GTGATG)

I

II

1

42

1

13

2

11

3

Hypoxic and non-hypoxic regulation of HIF-1

Baldewijns MM, J Pathol, 2010

Protein expression of PHD1 in RCC

Slide No. 15 • Basic GCP Facts • Friday 21 April 2023 • GVe

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 world-wide (US, EU, JP).

Subject

SponsorInvestigator

IRB/EC &Authority


ICH GCP Principles1. 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.


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.



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.



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.


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.


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


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


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.

YOU


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.).


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.

Lab


The study Protocol

• 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.

Know it and follow it!


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.


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.


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).

Date of Birth22 02 19 5617 APR 2003

PTie

6!


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.

Date of Birth22 02 19 5617 APR 2003

PTie

6!


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

Document exactly

drug accountability


Adverse Events (AEs)

• Adverse Event (AE) =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.

SA

FETY

!


Serious Adverse Events (SAEs)

• 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

! SA

FETY

!


Adverse Drug Reactions

• 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.

!

! SA

FETY

!


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.

What’s not documented,

doesn’t exist.


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


Benefits of GCP: Investigator

•Those who comply with GCP will be deemed acceptable – those who do not comply will not be invited to participate!


“Disadvantages” of GCP

• Greater demands of time and costs

• Perception of irritating bureaucracy

• Increasing of costs

• Possibility of more frequent controls


GCP stays in Clinical TrialsGCP stays in Clinical Trials! !

GCP GCP requirements MUST be metrequirements MUST be met!!

Only those who respect Only those who respect GCPGCP will will participate in Novo Nordisk Clinical participate in Novo Nordisk Clinical

TrialsTrials!!

Complexity of the insulin signaling pathway

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