Because Parkinson's disease is a progressive brain disorder that leads to shaking and stiffness, eventually causing difficulty with walking, balance, and coordination, patients are at very high risk of fractures from multiple and sometimes severe falls that can lead to permanent disability and even death. Researchers are studying whether zoledronic acid, approved by the FDA to treat osteoporosis by increasing bone strength, will reduce fractures in people with Parkinson’s disease.
The Trial of Parkinson’s and Zoledronic acid (TOPAZ)1 is seeking to enroll 3,500 participants over the age of 60, making it the largest double-blind, placebo-controlled, randomized clinical trial ever attempted in people with parkinsonism.
Anecdotally, only a very small proportion of people with parkinsonism receive treatment to reduce fracture risk. Barriers to seeking or receiving treatment include:
TOPAZ was designed to overcome barriers to treatment by allowing people to enroll without the need for a doctor’s referral or BMD testing; treating participants with an intravenous infusion vs. an oral medication and, importantly, making the trial conveniently home-based.
The need to enroll such a large number of participants, many of whom have mobility and/or cognitive challenges, would make a traditional site-based study impossible. Even if the required number of prospective participants could be found living within a reasonable proximity to a clinical site, travel to and from the site would be very difficult if not impossible for many participants. It could also be time-consuming and expensive for the participant to get to the site and would put a burden not only on the patient, but also their caregivers.
The study recruitment began October 1, 2020 and is expected to be completed within three years.
Based on previous conversations with PCM Trials, researchers knew that a trial that would have been impossible to even imagine if it were site-based would actually be feasible using mobile research nurses. By involving PCM Trials in planning from the very beginning, they were able to design a study that could recruit a large number of participants from across a wide geography, and develop a multi-step protocol that could be done entirely from participants’ homes.
PCM Trials manages the study drug, including storage, blinding, randomization, and delivery to its Certified Mobile Research Nurses who have been trained on the study protocol. Participants receive a supply of vitamin D supplements and are instructed to take the medication for a period of time in advance of the nurse’s home visit to prevent the very low risk of hypocalcemia after the infusion. At the home visit, the participants are given one dose of the study drug intravenously. This treatment has been shown to prevent fractures in people with osteoporosis, with the preventive effects persisting for two years.
During the home visit, the nurse:
In terms of communicating with the investigators, the PCM mobile research nurses:
Because TOPAZ is a home-based trial, researchers are able to meet their goals of recruiting an unusually large number of participants from across the U.S., without the geographic constraints that would come with a site-based trial. Being able to recruit from a broad geographic area is enabling the study to include participants who are more representative of “real world” patients.And the fact that the study is patient-centric and convenient, which is especially important to a population of older patients with limited mobility, is also making it easier to recruit participants. The trial is ahead of its recruitment goals.
In addition, researchers at site-based trials sometimes conduct additional tests simply because the patient is at the clinic. Having a home-based study forces researchers to engage only in those activities that are necessary for the study. This, along with the fact that there is no overhead or staff costs of a clinical site, have resulted in an estimated cost savings of 80% per participant compared with a similar trial conducted in a clinical site.
This case study is based on a presentation delivered at OTC East2 by Steven R. Cummings, MD, The San Francisco Coordinating Center. The San Francisco Coordinating Center is a non-profit academic research organization with more than 20 years of experience conducting multicenter studies and clinical trials. Watch the presentation, “Clinical Trials from Home, The Role of Research Nurses” here.