Systematic review and meta-analysis: Placebo rates in induction and maintenance trials of ulcerative colitis

Vipul Jairath*, Guangyong Zou, Claire E. Parker, John K. Macdonald, Mahmoud H. Mosli, Reena Khanna, Lisa M. Shackelton, Margaret K. Vandervoort, Turki AlAmeel, Mohammad Al Beshir, Majid AlMadi, Talal Al-Taweel, Nathan S.S. Atkinson, Sujata Biswas, Thomas P. Chapman, Parambir S. Dulai, Mark A. Glaire, Daniel Hoekman, Andreas Koutsoumpas, Elizabeth MinasMark A. Samaan, Simon Travis, Geert D'Haens, Barrett G. Levesque, William J. Sandborn, Brian G. Feagan

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

29 Scopus citations

Abstract

Background and Aims: Minimisation of the placebo responses in randomised controlled trials [RCTs] is essential for efficient evaluation of new interventions. Placebo rates have been high in ulcerative colitis [UC] clinical trials, and factors influencing this are poorly understood. We quantify placebo response and remission rates in UC RCTs and identify trial design factors influencing them. Methods: MEDLINE, EMBASE, and the Cochrane Library were searched from inception through April 2014 for placebo-controlled trials in adult patients with UC of a biological agent, corticosteroid, immunosuppressant, or aminosalicylate. Data were independently doubly extracted. Quality was assessed using the Cochrane risk of bias tool. Results: In all, 51 trials [48 induction and 10 maintenance phases] were identified. Placebo response and remission rates were pooled according to random-effects models, and mixed-effects meta-regression models were used to evaluate effects of study-level characteristics on these rates. Pooled estimates of placebo remission and response rates for induction trials were 10% (95% confidence interval [CI] 7-13%) and 33% [95% CI 29-37%], respectively. Corresponding values for maintenance trials were 19% [95% CI 11-30%] and 22% [95% CI 17-28%]. Trials enrolling patients with more active disease confirmed by endoscopy [endoscopy subscore ≥ 2] were associated with lower placebo rates. Conversely, placebo rates increased with increasing trial duration and number of study visits. Conclusions: Objective assessment of greater disease activity at trial entry by endoscopy lowered placebo rates, whereas increasing trial duration and more interactions with healthcare providers increased placebo rates. These findings have important implications for design and conduct of clinical trials.

Original languageEnglish (US)
Pages (from-to)607-618
Number of pages12
JournalJournal of Crohn's and Colitis
Volume10
Issue number5
DOIs
StatePublished - May 1 2016
Externally publishedYes

Keywords

  • DAI
  • Disease Activity Index
  • Mayo Clinic Score
  • MCS
  • Randomised controlled trial
  • RCT
  • UC
  • Ulcerative colitis

ASJC Scopus subject areas

  • Gastroenterology

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