Overview

Pharmacodynamic (PD) biomarkers indicate how a drug affects its target, like a receptor triggering a signalling cascade. They reflect the drug’s impact on the body’s biological or physiological functions. Unlike pharmacokinetics, which focuses on how the body processes a drug, pharmacodynamics explores its effects and mechanisms. These markers are vital in clinical trials, helping assess a drug’s efficacy, safety, and optimal dosage, and in individualizing treatments. They’re crucial in drug development, aiding researchers and healthcare pros in understanding a drug’s interactions and suitability for its intended use. Developing New Chemical Entities (NCE) involves discovering, designing, and synthesizing novel compounds for therapy. Bioanalysis, quantitatively measuring drugs and their metabolites in biological samples, is key in NCE development.

Challenges & Considerations

 

Strategies for PD Biomarker Quantitation

Quantifying Pharmacodynamic (PD) biomarkers in bioanalysis involves careful planning and execution to ensure accurate and reliable measurement of the biological responses to a drug. Here are the strategies concerning requirements and rationale for PD biomarker quantitation in bioanalysis.

 

Veeda’s Capabilities & Approach for Novel Drug Development Program

Bioanalysis is a vital part of drug development, focusing on accurately measuring drugs and their by-products in biological samples. A successful bioanalysis strategy involves method development, validation, and application in clinical studies.

• At Veeda, method development involves extensive research, considering various factors like drug properties, dose, linearity range, extraction protocols, chromatography, and equipment. Method validation includes experiments ensuring compliance with regulations, such as selectivity, accuracy, precision, sensitivity, matrix effects, and stability studies. In clinical sample analysis, it’s crucial for determining drug levels in biological samples. Incurred sample reanalysis validates reported sample analyte concentrations, ensuring reliability
• Employing emerging technologies like LC-MS/MS machines, ICP-OES, LIMS, and BSL-2 labs enhances our capabilities. Quality management systems (QMS) established protocols ensuring consistent quality standards, customer satisfaction, and regulatory compliance
• Data analysis and statistical approaches at Veeda derive meaningful insights from experimental results, ensuring their reliability and validity
• Regulatory compliance involves adherence to industry-specific laws, guidelines, and standards
• Cross-validation with clinical endpoints ensures alignment between laboratory analyses and clinical outcomes, establishing correlations between measured biomarkers/drug concentrations and therapeutic effects/safety outcomes

Our Expertise in PD Biomarker Method Development & Validation

Conclusion

Bioanalysis is pivotal in identifying, measuring, and characterizing Pharmacodynamic (PD) markers, which indicate a drug’s biological effects in an organism. Its role involves:

• Identification: Using techniques like mass spectrometry, immunoassays, and chromatography to screen and identify potential PD markers
• Quantification: Developing precise methods to measure PD markers accurately
• PK/PD Modelling: Integrating bioanalytical data into models for predictive insights on drug concentration and PD marker levels
• Dose-Response Assessment: Analyzing concentration-response relationships to establish dose-response curves
• Early Phase Development: Using bioanalytical data to guide decisions about dosing, further development, and safety concerns
• Safety Assessment: Identifying and measuring biomarkers that signal potential safety issues during drug development

Reference:

1. Abbas M, Alossaimi MA, Altamimi AS, Alajaji M, Watson DG, Shah SI, Shah Y, Anwar MS. Determination of α1-acid glycoprotein (AGP) concentration by HPLC in patients following local infiltration analgesia for primary total hip arthroplasty and its relation to ropivacaine (total and unbound). Frontiers in Pharmacology. 2023;14
2. Kandoussi H, Zeng J, Shah K, Paterson P, Santockyte R, Kadiyala P, Shen H, Shipkova P, Langish R, Burrrell R, Easter J. UHPLC–MS/MS bioanalysis of human plasma coproporphyrins as potential biomarkers for organic anion-transporting polypeptide-mediated drug interactions. Bioanalysis. 2018 May;10(9):633-44
3. Shin S, Fung SM, Mohan S, Fung HL. Simultaneous bioanalysis of l-arginine, l-citrulline, and dimethylarginines by LC–MS/MS. Journal of Chromatography B. 2011 Mar 1;879(7-8):467-74
4. Yin F, Ling Y, Martin J, Narayanaswamy R, McIntosh L, Li F, Liu G. Quantitation of uridine and L-dihydroorotic acid in human plasma by LC–MS/MS using a surrogate matrix approach. Journal of Pharmaceutical and Biomedical Analysis. 2021 Jan 5;192:113669
5. US Food and Drug Administration; U.S. Department of Health and HumanServices; Food and Drug Administration; Center for Drug Evaluation and Research (CDER); Center for Veterinary Medicine (CVM). Bioanalytical Method Validation: Guidance for Industry; U.S. Department of Health and Human Services, Food and Drug Administration: Silver Spring, MD, 2018

Introduction

Chronic Obstructive Pulmonary Disease (COPD) and Asthma are significant respiratory conditions that affect millions worldwide. In 2019, COPD accounted for 3.3 million deaths and 74.4 million disability-adjusted life years (DALYs), with a global prevalence of 212.3 million cases. Meanwhile, the prevalence of Asthma has been rising due to increased life expectancy and changing demographics. Additionally, the overlap of Asthma and COPD cases has become more frequent, presenting unique challenges in diagnosis and treatment.

Current Treatment Landscape

1. Bronchodilators: The use of both short-acting inhaled bronchodilators (albuterol and ipratropium) as rescue therapy and long-acting bronchodilators (LABAs and LAMAs) has become common. Several new bronchodilators are in development, showing promise for future therapies.
2. Muscarinic Antagonist–β2-Agonists (MABAs): MABAs are under clinical trials, though challenges exist in balancing their LABA and LAMA activity.
3. New Corticosteroids: Fluticasone furoate, a once-daily inhaled corticosteroid (ICS) in combination with vilanterol, offers a new option. However, safety concerns related to corticosteroids remain.
4. Phosphodiesterase Inhibitors: Roflumilast is currently marketed as an anti- inflammatory treatment in COPD, but its narrow therapeutic window limits its use.
5. Kinase Inhibitors: Some kinase inhibitors have shown promise in COPD and Asthma models, but challenges in specificity and side effects require further research.
6. Mediator Antagonists: CRTh2 antagonists, cytokine inhibitors, and protease inhibitors have been widely used in Asthma treatment, but their efficacy varies.
7. Antioxidants: While antioxidants like N-acetylcysteine and sulforaphane have been explored, their efficacy remains limited.

Challenges and Suggested Approaches

Researchers face challenges in developing novel drugs for Asthma and COPD, including limited investment by pharmaceutical companies, lack of funding for basic research, and a scarcity of helpful biomarkers. To overcome these hurdles, identifying new therapeutic targets and biomarkers is crucial for better patient selection and long-term therapy monitoring.

New approaches in COPD and Asthma treatment include:

• Reversing Corticosteroid Resistance: Finding solutions to the challenge of corticosteroid resistance in patients.
• Resolving Inflammation and Aberrant Repair: Addressing inflammation and tissue repair dysregulation.
• Decelerating Aging: Focusing on strategies to mitigate the impact of aging on disease progression.

Biomarker-Driven Trial Designs

Biomarker-driven trial designs are transforming the landscape of COPD and Asthma treatments, offering a more precise and personalized approach to patient care. These innovative trial designs focus on specific biomarkers that play a crucial role in understanding the underlying mechanisms of these respiratory conditions and predicting treatment responses.

In COPD, eosinophilic inflammation is a key biomarker that helps identify patients who are more likely to respond favorably to inhaled corticosteroids (ICS) and certain biologic therapies targeting type 2 inflammation. Conversely, in non-type 2 inflammation, neutrophilia becomes a significant biomarker, guiding clinicians to explore alternative treatment strategies due to a reduced response to ICS.

For Asthma, fractional exhaled nitric oxide (FeNO) levels serve as a valuable biomarker for type 2 inflammation. Elevated FeNO levels are associated with a higher likelihood of responding well to ICS and specific biologic agents like anti-IgE and anti-IL-4R treatments. Additionally, IgE levels can indicate atopy and predict better responses to ICS and anti-IgE treatments.

Periostin emerges as a promising biomarker in both COPD and Asthma. It is associated with type 2 inflammation and airway remodeling, making it a potential indicator of treatment response to anti-IL-13 therapies in Asthmatic individuals with high periostin levels.

Summary of Clinical Trial Findings

Biomarkers are essential tools in guiding treatment decisions and assessing therapy response for Asthma and COPD. These biomarkers help in patient stratification, identifying subgroups likely to respond to specific therapies, and reducing the risk of adverse effects.

Contract Research Organizations (CROs) play a crucial role in advancing biomarker-driven research. They possess specialized expertise in biomarker discovery, validation, and analysis, accelerating the translation of research findings into clinical applications

Conclusion

In conclusion, COPD and Asthma present significant global health challenges, affecting millions of people and causing substantial morbidity and mortality. The current treatment landscape has seen advancements, but unmet needs persist. Biomarkers offer promising opportunities fo personalized treatments, while CROs play a crucial role in advancing research and developmen efforts. To address the challenges, increased investment in respiratory medicine research is essential. By fostering collaboration and innovation among stakeholders, we can strive toward better management and improved outcomes for patients living with COPD and Asthma ultimately enhancing their quality of life.

References:

• https://www.bmj.com/content/378/bmj-2021-069679
• https://erj.ersjournals.com/content/58/5/2004656

Disease Overview :

Global Scenario :

In developed nations, the prevalence of Chronic Myeloid Leukaemia (CML) is primarily concentrated among the elderly population, typically aged 60 and above. In contrast, in developing nations, the diagnosis of the disease occurs approximately ten years earlier, impacting individuals in their 50. It is the most common type of blood cancer.

Indian Scenario :

Chronic Myeloid Leukaemia (CML) is a clonal myeloproliferative disorder of a pluripotent stem cell. CML is the commonest adult leukaemia in India and the annual incidence ranges from 0.8– 2.2/100,000 population in males and 0.6– 1.6/100,000 population in females in India.

Out of the 250 CML Trials in active stage, 123 CML Trials worldwide are Phase II trials. 38 CML Trials are exclusively industry funded or are in collaboration with academia and small biopharmaceutical companies.

Why there is need to conduct CML Trials?

CML is the world’s first cancer with specific genotype knowledge, which led to a rationally therapeutic schedule. Imatinib, a tyrosine kinase inhibitor (TKI), was approved by the FDA to treat CML in 2001. The discovery of the TKI-based treatment, changed the CML disease status from a lethal disease to a chronic disease, especially for patients in the chronic phase. There has been an apparent improvement in the survival of CML patients in high-income countries like the United States, France, and Japan. The disease burden of CML distinctly varies in different countries due to diverse opportunities for early-stage screening, novel drugs and medical resources.

Prevailing trends in CML Clinical Trials

Targeted Therapies :

The development of targeted therapies, such as tyrosine kinase inhibitors (TKIs), has been a significant trend in CML clinical trials. TKIs, such as Imatinib, Dasatinib, and Nilotinib, have revolutionized the treatment of CML by specifically targeting the abnormal BCR-ABL protein responsible for the disease.

Treatment-Free Remission (TFR) :

TFR is a growing area of interest in CML clinical trials. It focuses on the possibility of discontinuing TKI treatment in patients who achieve deep molecular responses, aiming to maintain disease control without the need for ongoing therapy.

Combination Therapies :

Investigating the effectiveness of combining different TKIs or combining TKIs with other agents is an ongoing trend in CML clinical trials. Combinations may enhance treatment response, overcome drug resistance, and improve long-term outcomes for patients.

History of Targeted Therapy for CML Trials

Key Challenges and Considerations: Operational & Clinical

The challenges in CML clinical trials are based on the four phases as mentioned below:

• Chronic Phase
• Accelerated Phase
• Accelerated Phase with Patients with NO prior treatment
• Accelerated Phase with Patients with prior treatment

CML clinical trials across different phases present obstacles for CROs in their operational and clinical activities. These challenges include communication and coordination with sponsors, complex protocols, site monitoring difficulties, patient population identification, geriatric research, study cost management, staff training, and utilization of technology-enabled platforms.

*Below is the chart that shows the impact of these above mentioned challenges with respect to CML Phases for a CRO:

*3/4 of the graph is blue: classified as a major impact, 1/4 of the graph is blue: classified as minor impact, 1/2 of the graph is blue: classified as neutral

Veeda Oncology

In conclusion, CML clinical trials have witnessed significant progress, aided by the expertise of Indian CROs. With our proficiency in managing protocol complexities, addressing the unique requirements of the geriatric population, and optimizing costs, Veeda stands ready to accelerate your upcoming CML trial. We remain dedicated to offering exceptional support to sponsors engaged in CML research. By leveraging our extensive knowledge, sponsors can expect a seamless trial experience, adherence to regulatory requirements, and the generation of robust data. Contact us today to know more about Veeda’s CML trial services.

References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142563/
2. https://www.cancer.net/cancer-types/leukemia-chronic-myeloid-cml/types-treatment
3. https://ehoonline.biomedcentral.com/articles/10.1186/s40164-020-00185-z

Bioassays are involved in each stage of drug discovery, starting from Target Identification until discovering the Lead compound. Bioassays provide valuable information which displays the therapeutic potency of a drug under investigation.

The data generated during bioassay also plays a vital role in drug development and quality control of finished biological products. Properly designed Bioassays help in assessing the biological effect, activity, signal transduction process, and receptor binding ability of drug product or biologic on a biological target (proteins) when compared to a reference or standard over a suitable biological system.

The pharmaceutical and biotech companies involved in drug discovery and development are continuously challenged with developing biologically relevant assays for the analysis of multiple potential mechanisms.

The process involves the use of quality critical reagents, use of specific cell lines, and purified test drug and reference drug products which at times may become a constraint. Most of these activities require sufficient time, which may become a limiting factor to biopharma manufacturers.

It is worth outsourcing activities to reputed CRO service providers to save time in developmental efforts and also to have an unbiased opinion on the functional activities of the drug product.

Veeda Group has qualified and experienced scientists to design, develop, execute, and validate the Bioassays for companies and provides premier bioassay services (in vitro and in vivo) that generate meaningful data to support pharmaceutical and biotech companies in their drug discovery and development journey.

Veeda Group’s Experience in Development and Execution of Bioassays include:

• Plaque Reduction Neutralization Test (PRNT assay)
• In Vitro Skin Sensitization Human Cell Line Activation test (h-CLAT assay)
• Nab Assay
• Assay Development (Pharmacodynamics, Pharmacokinetics, Immunogenicity, and Biomarker Assessment)
• In Vivo Bioassays for drug molecules like Luteinizing Hormone, Epoetin, HCG, Recombinant FSH, β-HCG, and Insulin.
• ADCC assay for biosimilars and different other assays like Ex Vivo assay, Cell-based assay, Receptor Binding Assay, Cytokine Release Assay, and ADA assay.

Veeda Group provides Integrated Discovery, Development & Regulatory Services with its multiple technology platforms:

• Exploratory toxicology studies
• Regulatory toxicology studies
• In vitro Bioassays
• Ex vivo Bioassays

The group also has the experience to handle a diverse range of Biotherapeutics like Therapeutic Monoclonal Antibodies, Insulin & Insulin Analogues, Cytokines, Low Molecular Weight Heparins, Biosimilars, Hormones & Biomarkers.

Veeda group has demonstrated capabilities to develop recombinant proteins such as non-glycosylated proteins and glycoproteins derived from either bacterial or mammalian host expression systems.

Bioassays in Preclinical Drug Development

Biological assays or bioassays are essential tools in preclinical drug development. Preclinical bioassays can be in vivo, ex vivo, and in vitro.

In vivo bioassays provide a more realistic and predictive measure of the functional effects of tests with reference drug products or standard material of defined potency, along with the application of statistical tools, study-specific lab techniques, and adherence to the well-designed study protocol.

These assays capture the complexity of target engagement, metabolism, and pharmacokinetics of novel drugs better than in vitro bioassays.

The most commonly used experimental mammals in in vivo efficacy assays are mice and rats. Occasionally other species may be used depending on the sensitivity & suitability of the assays.

Development and Validation of Bioassays

Bioassays are used as a screening method to identify the signals that indicate desired biological activity from a set of compounds. In general, two different types of signals can be generated by a bioassay, a linear dose-response and a sigmoidal (S-shaped) dose-response.

Since one solution does not fit all bioassays, it is good to evaluate and analyze the data to develop a precise approach to carry out each bioassay.

The life cycle stages of a bioassay are divided into:

Stage 1: Method design, development, and optimization

Stage 2: Procedure performance qualification

Stage 3: Procedure performance verification (fit for purpose)

Developing a bioassay that meets regulatory requirements and gets a drug product registered is a very complex process.

Developing a bioassay includes many strategies and tactical designs like selecting the correct in vivo platform, proper method or plate design, data analysis, system/ sample sustainability strategy, method implementation, method performance, and monitoring.

There are several steps to be followed for the development and validation of bioassays, such as dose-response and curve-fitting selection, development of reference, calculation of potency, bioassay characterization, design of bioassay calculator, standardization and automation of bioassay, and finally, evaluation.

Both method development and validation of bioassays include three fundamental areas:

1. Pre-study (Identification and Design Phase) validation
2. In-study (Development and Production Phase) validation
3. Cross validation or method-transfer validation

During method development, assay conditions and procedures are selected that minimize the impact of potential sources of invalidity. Coming to the statistical validation for an in vivo assay, it involves four major components:

1. Adequate study design and data analysis method
2. Proper randomization of animals
3. Appropriate statistical power and sample size
4. Adequate reproducibility across assay runs.

Parallel group design, randomized block design, repeated measures design, and crossover design are the basic types of experimental designs used in in vivo assay.

The following are the key factors that should be kept in mind while designing an in vivo assay:

• All meaningful biological effects (pharmacologically) should be statistically significant.
• If biologically relevant assays are not present, then a range of plausible effects can be considered.
• The key endpoints should be well-defined before the beginning of the assay.
• Animals should be allocated randomly in an appropriate manner to the treatment groups.
• The dose levels should be selected appropriately. Dose and curve-fitting selection is among the most critical aspects of bioassay development. The dose is determined depending on the type of model used in the signal to fit the data. For Sigmoidal designs, a four- or five-parameter logistics (4PL or 5PL) model fits the data, whereas, for linear design, a parallel line analysis (PLA) model fits the data.

For a 4PL model, nine doses are recommended:

1. Three doses in the lower asymptote
2. Three doses in the upper asymptote
3. Three doses in the linear range

In contrast, for a PLA model, a minimum of four doses is recommended. A minimum of three consecutive doses is required to plot the dose curve.

• The selection of control groups and time points to collect samples should be optimal.
• The design strategies should minimize variability and maximize information.

To understand the design, developments, and statistical validation of in vivo bioassay in more detail, reach out to us at https://www.veedacr.com. One can also read the guidelines mentioned by NIH by visiting the link:

https://www.ncbi.nlm.nih.gov/books/NBK92013/pdf/Bookshelf_NBK92013.pdf

References

1. A. Little, “Essentials in Bioassay Development,” BioPharm International 32 (11) 2019
2. Padmalayam, Ph.D., Assay development in drug discovery
3. Zwierzyna M, Overington JP (2017) Classification and analysis of a large collection of in vivo bioassay descriptions. PLoS Comput Biol13(7): e1005641. https://doi.org/10.1371/journal.pcbi.1005641
4. White JR, Abodeely M, Ahmed S, Debauve G, Johnson E, Meyer DM, Mozier NM, Naumer M, Pepe A, Qahwash I, Rocnik E, Smith JG, Stokes ES, Talbot JJ, Wong PY. Best practices in bioassay development to support registration of biopharmaceuticals. Biotechniques. 2019 Sep;67(3):126-137. doi: 10.2144/btn-2019-0031. Epub 2019 Aug 5. PMID: 31379198.
5. F Chana and Hursh D, Bioassays through the Product lifecycle: Perspectives of CDER and CBER reviews.
6. Haas J, Manro J, Shannon H, et al. In Vivo Assay Guidelines. 2012 May 1 [Updated 2012 Oct 1]. In: Markossian S, Grossman A, Brimacombe K, et al., editors. Assay Guidance Manual [Internet]. Bethesda (MD): Eli Lilly & Company and the National Center for Advancing Translational Sciences; 2004-. Bookshelf URL: https://www.ncbi.nlm.nih.gov/books/

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Introduction

Cancer is a deadly disease leading to the death of many individuals across the globe. Biotech and Pharmaceutical researchers are carrying out extensive studies to develop drugs to treat cancer. However, the current medications used in cancer treatment have many loopholes.

They are toxic, lack specificity, and have short half-lives. The difficulty in administering complex oncology molecules, along with the above hurdles, has led to side effects, non-compliance, and patient inconvenience of many current treatments for cancer.

Liposomes are Nano-sized drug delivery systems that have shown to be quite effective in improving the selectivity of cancer chemotherapeutic agents.

However, clinical trial experts face many challenges when designing a Bioequivalence (BE) study for generic oncology drugs. It includes selecting the study population, selecting the individual dose for patients, selecting the required study design (cross-over vs. steady-state design), and processing samples at investigator sites due to sampling uncertainty, high patient dropout rates, and stringent regulatory guidelines.

A bioequivalence study is generally conducted in healthy volunteers if the drug has shown a safety profile in a healthy population and is not a narrow therapeutic index drug.

However, the same is not ethically and medically acceptable in most anticancer drugs because of cytotoxicity in a healthy population. Moreover, the regulatory requirements also vary from region to region.

How to Design a Study for a Generic Oncology Product on Liposome Injection Involving Cancer Patients?

Study Overview

Veeda Clinical Research completed an open-label, randomized, two-treatment, two-period, two-sequence, single-dose, multicentric, fasting, cross-over bioequivalence study of Doxorubicin Hydrochloride Liposome Injection 2 mg/mL in ovarian cancer patients for an Indian based Sponsor Company towards submission to USFDA.

The study was completed within the stipulated timeframe with meticulous project management. In both periods, the subjects received a 50mg/m2 Single dose (intravenous infusion) of Doxorubicin Hydrochloride Liposome Injection 2 mg/mL (either test or reference product), according to the randomization schedule created before the trial, on the first day of the chemotherapy cycle.

The washout period was at least 28 days between each consecutive dosing period. Each cycle began with the collection of serial blood samples; a total of 25 blood samples were collected, with the last blood sample collected at 360.00 hours in each period.

Blood samples starting from 72.00 hours till 360.00 hours were collected on an ambulatory basis in each period to determine free and liposomal encapsulated doxorubicin plasma concentrations for PK analysis.

Subjects Inclusion and Exclusion Criteria

The study involved female patients between the age of 18-65 years who had ovarian cancer (confirmed through cytological and histopathological tests) and who were already receiving or scheduled to start therapy with the reference listed drug (RLD) or the reference standard product.

The four major inclusion criteria in this study were:

• Subjects with Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2
• Subject with Left Ventricular Ejection Fraction ≥ 50%
• Subjects with a life expectancy of at least three months are determined by checking liver, kidney, and bone marrow function.
• Subjects who had recovered from minor (at least one week) and major (at least four weeks) surgery.

Women who were pregnant, lactating, or planning for a family were excluded from the study. A total of 18 parameters were judged under exclusion criteria.

Some of the major exclusion criteria were:

• Impaired cardiac function with the occurrence of unstable angina/arrhythmia/ myocardial infarction/ Qtc prolongation/ coronary artery bypass graft surgery/ heart failure/ symptomatic peripheral vascular disease within the last six months
• Known history of brain metastasis.
• Pre-existing motor or sensory neurotoxicity of a severity ≥ grade 2 according to NCI criteria
• Positive test results for hepatitis and HIV

Reporting and Handling of Adverse Events

The investigators reported six serious adverse events (SAE) during the entire study. Fever with diarrhea was reported in two subjects. Another two subjects were observed with Nausea, Vomiting, and weakness.

Fever due to hospitalization and Non-neutropenic fever with acute gastroenteritis were also found in one subject each. At the time of writing this article, all SAEs have been resolved after constant follow-ups with the patient.

During the study, hypersensitivity reaction due to Doxorubicin Hydrochloride Liposome Injection was avoided by administering Prophylactic Antiemetic and Dexamethasone Injection 8mg.

Conclusion

The study was successful as the test product showed bioequivalence with the reference product. The pharmacokinetic parameters like Cmax, AUC_0-t, and AUC_0-∞ were within the range of 80.00 to 125.00%.

Veeda Clinical Research provided end-to-end services in identifying and selecting the clinical trial sites, prepare and submit regulatory documents like protocol, ICF, CRF, and Clinical Study Report to drug regulatory authority on behalf of the sponsor company.

Trained and experienced nurses and investigators regularly monitored the oncology patients who participated in the study. The study was completed successfully with less patient dropouts, abiding by the principles of Good Clinical Practice.

Finally, the product was approved by USFDA. Experienced personnel, including the Principal and Clinical investigators team at different sites, the project management team, CRAs, phlebotomists, nurses, the medical writing team, and the bioanalytical team of Veeda Clinical Research, is responsible for successfully completing this clinical trial.