James P. Crowley’s Post

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Professor of Medicine emeritus at Brown University

Recognizing the imprecision of initially establishing a drug dose, the FDA initiated Project Optimus in 2021, the goal of which is to optimize the treatment dose in relation to tolerability. The author and colleagues conducted a clinical trial of the "less is more" approach to drug dosing. Azacitidine (Vidaza) is approved by the FDA to treat myelodysplastic syndromes (MDS) with 7-day dosing on a 28-day chemotherapy cycle. It prolongs survival in patients with higher-risk MDS, but the 7-day dosing schedule is probably too toxic for patients with lower-risk MDS. Decitabine (Dacogen) is also approved to treat MDS, with 5-day dosing on a 28-day chemotherapy cycle. Bottom line: 3 day dosing was just as effective. More such studies are needed for treatments with high real life levels of discontinuation due to intolerability. But where will funding come from? Big Pharma is unlikely to promote research that may negatively affect it’s bottom line. #chemotherapydosing #myelodysplasticsyndrome #mds

Opinion | Ending Oncology's Toxic Relationship With High Chemotherapy Doses

Opinion | Ending Oncology's Toxic Relationship With High Chemotherapy Doses

medpagetoday.com

Phase I/II clinical trials have the main objective of evaluating the safety of a new drug at different doses. This allows determining the maximum tolerated dose (MTD) and the recommended dose (RD), which is the one that has shown the greatest benefit with the lowest risk of side effects. The dose used in phase III is based on the results of phases I/II, where the efficacy and safety of the drug has been demonstrated. The FDA only approves a drug if it has been shown, at the recommended dose, to be safe and effective for the target population. Deviating from the recommended dosage without a clinical trial is a risky and unethical practice. There is no way to know if a lower dose will be effective or safe for the individual patient. Furthermore, the patient is not giving informed consent to participate in an experiment, as he or she is not informed of the potential risks and benefits of the reduced dose.

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