Clinical Contextualization and the Assessment of

Adverse Events in HBOC Trials

A. G. Greenburg, A. Pitman, B. Pearce and H. W. Kim
Biopure Corporation, Cambridge, MA, USA
Abstract: Establishing an acceptable safety and efficacy profile for hemoglobin based
oxygen carriers, HBOCs, is essential. Understanding the data that describes an HBOC
safety profile requires consideration beyond counting events typically associated
with intent to treat analysis. The imputation of causation from numerical counts alone,
without clinical context, is an incomplete description of a complex situation. Clinical
contextualization provides a greater understanding of the clinico-pathological processes
involved. Generating alternative hypotheses for the origin of the events, apart from the
drug, patient co-morbidities, situational and disease demands, could include protocol
design, failure to provide mitigation strategies, patient management issues, or
inadequate education of investigators. How clinical contextualization can provide
insight for the interpretation of significant safety profile events is discussed in the
context of a large phase III clinical trial where an appreciation of factors underlying the
differences between intent to treat analysis and other approaches is discussed.
Not everything that can be counted counts, and not everything that counts
can be counted.
A. Einstein
INTRODUCTION
The quotation from Albert Einstein has particular resonance when evaluating
the adverse event profiles obtained in clinical trials of hemoglobin based
Address correspondence to A. Gerson Greenburg, M.D., Ph.D., Biopure
Corporation, 11 Hurley Street, Cambridge, MA 02141, U.S.A. E-mail:
AGGreenburg@Biopure.com
Artificial Cells, Blood Substitutes, and Biotechnology, 36: 477486, 2008
Copyright # Informa UK Ltd.
ISSN: 1073-1199 print / 1532-4184 online
DOI: 10.1080/10731190802554000
477
oxygen carriers (HBOC). There is more to this evaluation than the accounting
of events. The integration of clinical contextualization into the analysis of
adverse events, as they reflect safety, is proposed as a necessary,
additional, vital part of post-hoc analysis important and critical to ascribing
causality. This construct would include in the safety analysis the totality of
clinical care including the expected morbidity and mortality for the underlying
disease and mode of treatment as well the impact of underlying co-morbidities
on which is superimposed the new treatment or therapeutic agent. The
objective of ascribing a causal relationship using clinical contextualization,
root cause, and subset analysis to explain the results of an intent-to-treat (ITT)
analysis is the prevention of misinterpretation of the results.
The issue of causality and the emergence of adverse safety signals in
HBOC trials evoke responses ranging from provocative to contentious,
depending on the perspective. HBOCs, more properly called oxygen
therapeutics, are recognized as a potentially useful class of drugs with the
capacity to deliver oxygen to tissue to maintain metabolism or reverse
ischemia. Before being dismissed as toxic or unsafe, these terms are not
synonymous, a thorough multidimensional evaluation is essential to establish-
ing a safety profile. Toxicity relates to drug properties while safety is assumed
associated with treatment related properties.
The evaluation of HBOCs in the treatment of acute anemia requires an
appreciation for the universe of factors underlying the outcomes; it requires
recognition and understanding of all the dimensions of the study, including the
protocol design and analytical methodology to which a clinical context must
be added. It is insufficient to rely only on the study design and analytical
methodology to explain the results; the former may be flawed and the latter
incomplete. The objective is to assure clinicians and regulatory agencies that
these solutions are safe and effective in clinical use. Whether there is a causal
relationship between the infusion of HBOC and the emergence of adverse
events depends not only on the properties and intrinsic toxicity of the HBOC
but also on the many aspects and dimensions of clinical care, the properties
associated with treatment variations.
UNDERSTANDING SAFETY & CAUSATION IN CLINICAL
CONTEXT
Demonstrating the efficacy and safety of HBOCs is essential for licensure and
clinical use. Exactly how those end points, particularly safety, meet the
regulatory criteria and standards for approval requires comment and discus-
sion. The generally recognized gold standard for evaluating new therapies,
especially drugs, is the double-blind randomized clinical trial with efficacy
and safety profile evaluation based solely on an intent to treat (ITT)
478 A. G. Greenburg et al.
analysis. While this established, scientifically sound, ideal model and
experimental design is desirable, its rigid application in all situations is
problematic. For a variety of well known reasons, maintaining a double blind
is complicated and resource intense when evaluating HBOCs.
It is argued that a negative ITT is insufficient of itself to stop drug
development; an analysis of why and how critical adverse events emerge is
required to understand them. The need to establish a correct data-supported
safety profile is not argued; the content and form of that profile is the major
issue. A well-grounded safety profile, based on trial emergent adverse events
and safety signals, is required to support proposed indications and proper
product labeling. It is an unfortunate fact that, based on counting numbers of
adverse events, safety profiles are constructed without clinical contextualiza-
tion to determine whether the HBOC will receive regulatory approval.
Alternative explanations for the observations, rational and logically sound,
formulated within the context of clinical medicine, must become a component
of this critical evaluation. To assist in the evaluation the known properties
observed in HBOC clinical trials, transient side effects of minimal clinical
impact, should be an element of sub-group analysis, excluded in the between
group analysis; residual differences in the subgroups are then assumed to
reflect intrinsic HBOC toxicity. It is how and why these differences in the sub-
groups differ from the ITT that needs exploration. Discrepancies between an
ITT analysis and sub-set analyses should be resolved with all available
analytical tools and approaches to confirm or reject hypotheses regarding
safety and efficacy.
To appreciate the differences requires clinical contextualization. One tool
often disparaged in the analysis of clinical trial data is root cause analysis. This
runs counter to the currently invoked and stressed data analysis approaches
proposed and used by the safety scientists in areas of quality assurance and
drug development where a full and complete understanding of all factors
contributing to the safety observations are sought and highly valued. Rejection
of post-hoc analyses, especially with respect to including clinical contextua-
lization and root cause analysis, given the complexity of modern medicine, is
inappropriate. It limits the potential for identification of critical clinical
alternative causality explanations. Clinical contextualization is in many ways a
model of root cause analysis as it gives context to answer the question why
beyond counting numbers.
Root cause analysis provides additional categories and options for
explaining the adverse events. This includes more detailed descriptions of
demographics, patient co-morbidities, the impact of the current disease on the
patients general health status and factors related to treatment and management
issues. Examples of these are introduced below. Furthermore, these same
factors play a role in assessing dose-response issues, also noted below.
Adverse Events in HBOC Clinical Trials 479
Assessment of whether the adverse events are the results of HBOC
toxicity or other clinically identified causes is both critical and essential to
understanding the safety profile. The inclusion of clinical context helps focus
and complements the analysis, preventing misinterpretation of results.
There are a number of problems in defining the safety profile through the
use of an integrated safety summary (ISS), an approach subject to the criticism
implicit in the Einstein quotation. Construction of the ISS includes data and
observations acquired during prosecution of all clinical studies with the
HBOC from all clinical phases of the development process. These studies are
inherently heterogeneous on many dimensions with different dosing, protocol
designs, controls and comparators, in different clinical settings with differing
populations and different outcome measures. Combining data with a high
degree of heterogeneity maximizes the identification and quantification of
safety signals without considering the clinical context. Only in retrospect,
using post-hoc analysis, can the key and essential elements clinical context be
identified and applied in the analysis. The de facto imposition of a predefined
statistical analysis plan with the requirement that it be the primary, if not only,
analytical model for defining safety is the procrustean bed of the ISS
approach. The ISS is useful in generating testable hypotheses. It does not,
however, permit translation of inferior safety arising from treatment to greater
toxicity of the drug. These are not comparable variables.
Moreover, it must be emphasized that in HBOC studies where packed red
blood cells (PRBC) are the comparator, achieving superiority would be
impossible; attaining equipoise in safety and efficacy would, however, be
possible when the comparator is a crystalloid or colloid solution. When
crystalloid or colloid solution is the comparator, HBOC has the inherent
advantage of oxygen carrying capacity and thus a capacity to minimize,
prevent, or modulate the ischemic injury concomitant with hemorrhagic shock
or low perfusion state. It must be recognized that, in terms of relative efficacy,
PRBCs have a distinct advantage over all current HBOCs in development.
The desired analytical requirement for data homogeneity is lost in a
broadly constructed ISS. Doing studies in surgery patients only does not
assure homogeneity. Combining the incidence of various adverse events into
sets thought to represent toxicity, physiologic compromise or organ
dysfunction without consideration of the intrinsic co-dependence of complex
clinical variables lacks face validity and exaggerates, overstating, the safety
people.
Establishment of the best possible risk assessment used to calculate an
accurate benefit-risk ratio requires an accurate safety profile. In attributing all
trial emergent adverse events to the HBOC, using a purely numerical approach
without considering known clinical uncertainties, represents a significant bias.
To the extent that medicine remains very much an art and not yet a hard
scientifically evidenced practiced discipline, this approach poses a concern.
480 A. G. Greenburg et al.
While a correlation between HBOC administration and the emergence of
adverse events exists, it is proffered that this relationship does not, by itself,
reflect causation. It is when clinical contextualization is added that the
question of causation is directly and clearly addressed. Outcomes are impacted
by many variables, some predictable and others not. Clinical trials impose
onto this complexity an additional complicating and confounding variable: the
experimental treatment. An assumption of the ideal trial design, with sufficient
power to show differences in variables of interest, is that randomization
creates equal comparable populations of patients except for the use of test
material.
Unfortunately, many of these clinically associated variables are idiosyn-
cratic, not readily predictable and cannot be assumed to randomize out
even when known. The clinical context in which the adverse events emerge
can be neither denied nor excluded in the analysis when establishing the
HBOC safety profile.
AN EXAMPLE FROM AN HBOC CLINICAL TRIAL
These issues come into sharp focus in the data analysis of a Phase III pivotal
trial with Hemopure

, in elective orthopedic surgery when applying the

aforementioned concepts of clinical contextualization to this trial, with cases
for emphasis as an example. This randomized, single blind trial conducted at
47 sites on 3 continents involved 688 patients. HBOC-201(Hemopure) or
packed red blood cells (PRBC) were administered at the first clinical
transfusion decision. The primary efficacy end-point of the HBOC arm was
PRBC avoidance within 6 weeks and was attained in 60% of patients, a
significant achievement with implications for blood conservation and blood
banking in general. Cross over to PRBC within the HBOC-201 arm was
permitted, and 40% of the patients did so within hours to days after initial
randomization. There was no comparable population in the PRBC study arm,
complicating the safety analysis. Developing an understanding of how a
concentration of adverse events emerged in this subset of patients demon-
strates how clinical contextualization can address the correlation or
causation question, given that exposure to both test agents confounds any
assessment. An unequivocal bias introduced by the asymmetrical design
compromised assessment of the intrinsic safety of HBOC-201 in this study.
The HBOC-201 crossover group differed from those avoiding PRBC in a
number of different, statistically significant variables. Selected examples from
a list of nearly 20 were: total fluid (crystalloid/colloid) administered; higher
estimated blood loss; longer anesthesia time; longer operating time; lower
baseline hemoglobin concentration at first treatment (32%B8 gm/dL); greater
incidence of history of cardiac disease; first treatment in the OR; more cell
Adverse Events in HBOC Clinical Trials 481
saver blood. Interestingly, the volume of PRBCs administered was greater
than that given PRBC patients. In surgery, it is difficult to predict which
patients and for which surgeons these differences will occur; moreover, it is
impossible at randomization to assure equal distribution of these variables in a
relatively homogeneous trial let alone a multicenter multinational trial.
Recognizing the incidence of both surgical procedure related morbidity
and mortality and the risks surgical intervention superimposes on underlying
co-morbidities, a method for integrating appropriate values or their carefully
designed surrogates into the protocol and statistical plan would add a
significant and necessary frame of reference for comparison not now available.
Surgical procedures have complications whose incidence varies from site to
site and surgeon to surgeon; similarly, practice patterns and standards of
care vary from country to country and continent to continent. Attribution of
causation is complicated and confounded in these high entropy situations.
Randomization in clinical HBOC trials is assumed to accomplish this, yet it
may not yield the desired results in large part because the trials are not large
enough to achieve that goal.
CLINICAL CONTEXTUALIZATION: CASE EXAMPLES
Underlying analysis of HBOC trial data is the assumption that adverse events
and hence the safety profile reflect HBOC toxicity, terms not synonymous. An
equally plausible alternative assumption is that the safety profile, composed of
the amassed adverse events, very much reflects patient and treatment based
variables. The following case examples demonstrate how the addition of
clinical context confirms the principles outlined, permitting a more appropriate
assessment of safety and challenges HBOC toxicity as the causative factor.
. 79 year old male, total hip replacement, received 3 units of HBOC-201 in
the recovery area. 14 hours later, bleeding from the operative site,
hypotensive with low hemoglobin experienced a cerebral vascular accident.
He had received 7 additional units of HBOC-201 (maximum allowable
dose in the study) and 7 units of PRBC. Persistent hypovolemia from
ongoing bleeding and decreased tissue perfusion contributed significantly
to the adverse event.
. 69 year old female, spine surgery, received 2 units of HBOC-201 in the OR
and 16L of other fluids. Not given diuretics over the next 3 days. On post-
op day 3 experienced pulmonary edema. Fluid overload contributed
significantly to the emergence of the adverse cardiovascular event.
. 62 year old female, total hip replacement, received 4 units of HBOC-201 in
OR and recovery area. Experienced a post-operative bleed with Hb to
4.5gm/dL that evening. Received 2 units of PRBC. Sustained period of
482 A. G. Greenburg et al.
hypoperfusion. 3 days hence had myocardial infarction and cerebral
vascular accident. Delay in treating bleeding a significant factor.
. 86 year old male, total hip replacement, received 4 units of HBOC-201, 500
ml of cell saver infusion and 500 ml of albumin. On first post-op day Hb
was 6.4gm/dL and patient reported chest pain followed by a cardiac arrest.
5 units of PRBCs given. Patient had cardiac catheterization with stent
placement. Myocardial infarction is a known complication in orthopedic
surgery, especially in elderly patients.
. 87 year old female, total knee replacement, received 2 units HBOC-201 on
post-operative day one and 2 units of PRBC on post-operative day 2.
Became hemodynamically unstable on post-operative day 3 and experi-
enced a myocardial infarction, pulmonary edema, with a papillary muscle
rupture. Post operative cardiac complication in an elderly patient.
An example from the PRBC arm of the study:
. 65 year old male, redo-total hip replacement. Long surgery with estimated
blood loss of 5000 ml; received 8 L crystalloid, 7.4 L colloid and 14 units
of PRBC. Experienced hypotension for 48 hours while on pressors.
Cerebral vascular accident on post-op day 3.
Each of these patients had received various doses of HBOC and
experienced adverse events. When clinical context is considered for each
there is an alternative, plausible, clinically based explanation for the
emergence of the adverse events. Similar events were observed in the
PRBC arm of the study.
There were 37 significant CNS-cardiovascular adverse events in the cross-
over group of the HBOC-201 study arm and 13 in the PRBC arm considered to
be ischemia associated. Of note, these events are of particular regulatory
concern. If patient oxygen delivery and tissue perfusion needs are not met,
ischemic events or the inability to attain physiologic compromise ensues with an
emergence of these adverse events. Thought to represent an intrinsic HBOC
toxicity, the clinical contextualization of these adverse events actually provides
an alternate explanation. Expert clinical review by cardiologists, surgeons and
anesthesiologists identified five clinically relevant root causes that could
account for the emergence of these adverse events. For each patient, one or
more of the following, clinically related root causes could be assigned as
causative: (a) under-treatment/resuscitation; (b) delay in adequate treatment; (c)
volume overload; (d) patient need exceeded product capability; and (e) patient
age. Under-treatment could be related to a lack of efficacy to be noted below.
These factors accounted for the greatest differences in safety analysis in the ITT
analysis. They were concentrated in the unique asymmetrical HBOC-201 group
for which there was no comparable control in the PRBC group. It is the
Adverse Events in HBOC Clinical Trials 483
excess of these events in this sub-set that represents the difference in safety. All
other adverse events in these groups were balanced.
Transfusion in the PRBC arm maintained Hgb concentrations above the
protocol defined transfusion trigger. In the HBOC-201 arm, 60% of
patients were maintained and managed safely without PRBC transfusion with
Hgb concentrations maintained just below the trigger. For 40% of HBOC-201
patients, the crossovers, sufficient levels of Hgb were not maintained and thus
emerged an increased incidence of ischemia-related adverse events.
Clinical contextualization must become an evaluation element, part of the
assessment of benefit-risk and risk-tolerance considerations. Clinical con-
textualization identifies factors that could account for the emergence of the
adverse events. Clinical interventions, or their absence, could be responsible
for the observations. In evaluating a safety profile, it is essential to identify all
factors that could contribute to the unexpected outcomes.
THE DOSE RESPONSE RELATIONSHIP IN HBOC CLINICAL
TRIALS
The classic dose-response relationship is not a valid representation of
events in HBOC trials. Assuming the incidence of adverse events represents
toxicity, in reality worse safety, then dose in reality must represent
patient need. The need for additional oxygen carrying capacity for
treating acute anemia, a transfusion, most often reflects a physicians clinical
judgment and decision*based on a perception and perhaps an experiential
heuristic, conditioned by the clinical situation at hand*of a requirement to
meet a patients need at the moment. Dose becomes a surrogate for clinical
need, recasting the classical dose-response model in which decreasing doses
result in fewer adverse events. However, when replacing dose with its
surrogate, need, decreasing the amount of oxygen carrier deemed needed,
whether PRBC or HBOC, would be the antithesis of intent likely to incur
some additional degree of ischemic insult. Paradoxically, there would be an
increase in ischemic related adverse events arising from under-treatment, a
clinically unacceptable outcome.
The cross-over group represents a population with high needs for
additional oxygen carrier infusion. Their need could not be met by the HBOC-
201 and, critically, the majority of the safety imbalance between the arms of
the study resides in this population. Clinical contextualization provides
insight, the clinically relevant explanation and reasons underlying this
difference. Another possible explanation is a lack of HBC-201 efficacy
contributing to the emergence of adverse events and not HBOC toxicity. It is
possible that patient needs could not be met with a solution whose hemoglobin
concentration is significantly less than that of PRBCs.
484 A. G. Greenburg et al.
The magnitude of the relationship between dose (need) and adverse
events/patient*a measure of safety*can be defined using identifiable
clinical elements, each contributing to the emergence of adverse events. They
may not be the only ones; however, they are of sufficient clinical importance
to be considered when seeking causation within a correlation. In no particular
order these elements are: (a) patient co-morbidities; (b) age; (c) acute or
chronic disease state; (d) protocol design; (e) local and regional patient
management preferences; (f) inadequate education of investigators; and (g)
failure to provide mitigation strategies.
A simple correlation model based on the counting events cannot address
the causation issue; including clinical contextualization is essential to
understanding the observations. Specification of causation requires a more
complex multidimensional approach that permits dissection and attribution of
causative elements from correlative ones.
SUMMARY AND CONCLUSION
The relationship between dose, reflecting need, and the emergence of
adverse events, measures of safety and not measures of HBOC toxicity, is one
of great complexity. Clinical contextualization of the adverse events observed,
e.g. under-treatment, delays in treatment, fluid overload, provides non-
numerical insight, an alternative hypothesis, to explain their origin and
emergence. An essential, predictable lack of HBOC efficacy of the HBOC to
meet high needs when compared to PRBCs, clarifies the picture. Any
outcome difference between a subset analysis and the ITT analysis requires
explanation. Clinical contextualization is proposed as a necessary, additional
approach, an applicable methodology for providing a rational and plausible
explanation. Many of the significant adverse events observed in trials with
HBOCs reflect the patients state of health, the disease state, medical or
surgical interventions, and treatment and clinical management variations onto
which HBOC treatment has been imposed. An appreciation of the clinical
aspects and elements underlying the observations is essential even at the cost
of introducing another layer of analytical complexity. However, adding
clinical context is necessary to establishing a causal relationship between
HBOC use and the incidence of adverse events comprising the safety profile.
Clinical contextualization, understanding the clinical elements at play
associated with the emergence of the significant adverse events, must become an
essential component of trial design, prosecution and data analysis for HBOCs.
These unique solutions hold enormous potential to do well in many clinical
situations, especially when blood is not an option or readily available and in
applications involving ischemic rescue. There has been for decades a recognized
need for an HBOC in trauma, elective surgery and in underdeveloped nations
Adverse Events in HBOC Clinical Trials 485
where the blood supply is either tainted or just not available. HBOCs, based on
analysis of their clinical data, may have relatively benign, clinically acceptable,
safety profiles once there is an appreciation of the multitude of clinical factors
that contribute to the emergence of adverse events.
A simple correlation model based on the counting of events cannot
address the causation issue; including clinical contextualization is essential
to understanding the observations. Specification of causation requires a more
complex multidimensional approach that permits dissection and attribution of
causative elements from correlative ones.
Not everything that counts can be counted.
This paper was first published online on iFirst on 9 December 2008.
486 A. G. Greenburg et al.