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Cyclic Vomiting Syndrome Phase 2 Continuous Endpoint NCT04645953

Staccato Granisetron® (AZ 010) for the Treatment of Cyclic Vomiting Syndrome: Complete Statistical Analysis

This analysis concerns a randomized, placebo-controlled Phase 2 study of Staccato Granisetron (AZ-010) for acute treatment of moderate to severe cyclic vomiting syndrome. The registry record describes the design and outcome measures, but does not report the primary outcome results.

Trial start: 2021-02-05  ·  Enrollment: 150  ·  Sponsor: Alexza Pharmaceuticals, Inc.
Scope of this record

This page provides an independent statistical analysis and educational interpretation of publicly reported results. ClinicalTrials.gov provides the official trial registry record. Numerical trial results on this page are restricted to the results posted in the ClinicalTrials.gov record; calculations added by Clinical Biostats are labelled as such.

1. Trial at a Glance

This page covers the registry results for Staccato Granisetron® (AZ 010) for the Treatment of Cyclic Vomiting Syndrome (NCT04645953), a randomized phase 2 study. The primary outcome is The Number of Vomiting/Retching Events Reported by Study Participants Following Treatment/Dosing During the Home Treament Period..

150
Enrollment
Phase 2
n/a
Arms
In the primary outcome
n/a
Effect
No re-analysis shown
n/a
95% CI
See limitations
FeatureRegistry value
ClinicalTrials.gov identifierNCT04645953
PhasePhase 2
ConditionCyclic Vomiting Syndrome
AllocationRandomized
Design modelParallel
MaskingTriple
Enrollment150
Arms in the primary outcomen/a
Lead sponsorAlexza Pharmaceuticals, Inc.
Results postedYes

2. Clinical Question

Population

Adults diagnosed with cyclic vomiting syndrome (CVS) who experienced recurring, stereotypical vomiting episodes. The primary efficacy population is described as per protocol: CVS patients between 18 and 60 years of age who experienced at least 3 episodes of recurrent vomiting in the last 12 months and 2 episodes in the last 6 months. The study description identifies adult outpatients.

Intervention

A single orally-inhaled dose of AZ-010, at either 1mg or 3mg. The registry lists these as combination products and describes the study as evaluating safety and efficacy for acute treatment.

Comparator

A single orally-inhaled dose of Staccato Placebo. The study is described as placebo-controlled, randomized, double-blind, and parallel group.

Primary question

How many vomiting or retching events did participants report during the two hours after initial treatment, and how did that endpoint vary across the randomized treatment groups? The registry specifies observations at 30, 60, 90 and 120 minutes post-dose. The primary outcome results and a treatment-effect estimate are not reported in the registry record.

3. Trial Design

NCT04645953 is a completed Phase 2 randomized study sponsored by Alexza Pharmaceuticals, Inc. The registry gives a recorded enrollment of 150. The study began on 2021-02-05, and primary completion is recorded as 2022-07-26. Its status is COMPLETED. Those administrative details do not themselves provide evidence about the primary outcome.

The design is described as multicenter, double-blind, parallel group, and placebo-controlled. Masking is listed as triple. The registry describes the study as evaluating the safety and efficacy of Staccato Granisetron (AZ-010) for acute treatment of moderate to severe CVS. Participants were adult outpatients diagnosed with CVS and experiencing recurring episodes of stereotypical vomiting.

The listed interventions are 1mg AZ010, 3mg AZ-010, and Staccato Placebo. Each arm description specifies a single orally-inhaled dose. The primary outcome is the reported number of vomiting/retching events during the home treatment period, with observations specified at 30, 60, 90 and 120 minutes post-dose. The primary population is described as per protocol, with age and episode-history eligibility criteria stated in the registry.

Additional listed outcomes cover anxiety or panic, prior episodes, rescue medication use, health care provider visits, nausea and vomiting symptoms, abdominal pain, and attack intensity. The record also describes safety assessment through adverse events, vital signs, 12-lead ECG, clinical laboratory results, and physical examination. Specific details of the randomization procedure, masking implementation, and treatment allocation are not reported in the registry record.

4. Participant Flow and Accounting

The registry reports how participants moved through each stage of the study. All counts below are exactly as posted; missing counts are not inferred from other stages.

Before assignment: Participant eligibility inclusion and exclusion criteria via the following assessments: Medical history (with particular reference to history of vomiting symptoms, CVS diagnosis, typical duration of CVS episode, average # of vomiting/retching events in typical CVS episode, frequency of CVS episodes per year, any triggers for CVS episode, conditions that may cause similar symptoms, treatment history, and current medications, medical history, COVID-19 screening.

Overall Study

Stage1mg AZ0103mg AZ010Placebo
STARTED505149
COMPLETED484846
NOT COMPLETED233

Reasons for not completing this period:

Reason1mg AZ0103mg AZ010Placebo
Lost to Follow-up211
Withdrawal by Subject010
Physician Decision010
Discontinued Prior to Dosing002

Analysis population for the primary outcome, as defined in the registry: Per protocol population (CVS patients between 18 and 60 years of age who experienced at least 3 episodes of recurrent vomiting in the last 12 months and 2 episodes in the last 6 months.

5. Baseline Characteristics

The table reproduces the baseline characteristics posted in the registry, which describe the participants analysed at baseline and help show whether the randomized groups were comparable.

CharacteristicUnit1mg AZ0103mg AZ010PlaceboTotal
Participants analysed505149150
Age, Continuousyears33.5 (SD 11.95)36.0 (SD 12.30)36.2 (SD 10.22)35.2 (SD 11.53)
Sex: Female, Male: FemaleParticipants343436104
Sex: Female, Male: MaleParticipants16171346
Ethnicity (NIH/OMB): Hispanic or LatinoParticipants85518
Ethnicity (NIH/OMB): Not Hispanic or LatinoParticipants414541127
Ethnicity (NIH/OMB): Unknown or Not ReportedParticipants1135
Race (NIH/OMB): American Indian or Alaska NativeParticipants1001
Race (NIH/OMB): AsianParticipants1113
Race (NIH/OMB): Native Hawaiian or Other Pacific IslanderParticipants0000
Race (NIH/OMB): Black or African AmericanParticipants74314
Race (NIH/OMB): WhiteParticipants414544130
Race (NIH/OMB): More than one raceParticipants0112
Race (NIH/OMB): Unknown or Not ReportedParticipants0000
Heightcm168.85 (SD 9.166)168.73 (SD 9.729)168.81 (SD 7.910)168.79 (SD 8.919)
Weightkg83.28 (SD 24.854)78.85 (SD 19.500)82.08 (SD 26.443)81.38 (SD 23.655)
Body Mass Index (kg/m2)kg/m^228.979 (SD 7.7236)27.529 (SD 6.0793)28.238 (SD 7.9544)28.244 (SD 7.2635)
Childbearing potential (Yes)Participants24292780
Childbearing potential (No)Participants26222270

6. Primary Endpoint

The registry lists the primary outcome as The Number of Vomiting/Retching Events Reported by Study Participants Following Treatment/Dosing During the Home Treament Period., measured over Within the following timepoints: 30, 60, 90 and 120-minutes post-dose..

ElementRegistry entry
Result typeMean
Measure of spreadStandard Deviation
Unitevent
Endpoint classificationContinuous Endpoint

The primary endpoint is the number of vomiting/retching events reported by participants after treatment during the home treatment period. The registry describes the endpoint as a mean with standard deviation and gives the unit as events. It defines the primary efficacy period as the two hours after initial treatment, with observations at 30, 60, 90 and 120 minutes post-dose. Participants recorded the number of vomiting and retching events they experienced.

Counting events captures the frequency of the symptom episode over a defined period. As a general statistical concept, a count endpoint differs from a binary endpoint: it retains distinctions between participants reporting different event counts rather than classifying everyone only as having or not having an event. Reporting the mean gives a measure of the average event count, while the standard deviation describes the spread of individual counts around that average.

The endpoint is clinically relevant to the study’s stated purpose of acute treatment, because it focuses on symptoms during the period immediately following dosing. However, the registry record does not report the treatment-group means, standard deviations, or a between-group effect estimate for this endpoint. It therefore does not allow the size or precision of any observed difference to be described.

7. Why No Re-analysis Is Shown

Reported as posted, not recalculated. Primary outcome has several categories or time points; not reduced to one comparison. A result is recalculated only when the posted data support a clean two-arm comparison, so no result is shown beyond what the sponsor posted.

8. Statistical Interpretation

Clinical Biostats interpretation

The registry record establishes the trial’s question and measurement plan, but the registry entries do not include results for the primary vomiting/retching endpoint. There are no group means, standard deviations, confidence intervals, or primary-outcome p-values reported in the registry record. Without those results, the direction, magnitude, and precision of the primary comparison cannot be characterized. Completion status and enrollment alone do not answer the efficacy question.

The endpoint was measured repeatedly after the dose, at 30, 60, 90 and 120 minutes. These are distinct timepoints within the stated two-hour period, not a single result that can be reconstructed from the study description. A treatment effect at one timepoint would not automatically describe the effect at another, and the registry record does not give the outcome values for any of them. It also does not report an aggregate endpoint across the timepoints.

The registry notes that each treatment group contained 47-49 patients, while only 22-35 patients per treatment group (approximately 45-70%) recorded vomiting/retching events at any given timepoint. This information indicates that the number of observations contributing event records at a timepoint was lower than the number of patients in the treatment groups. The reason for that difference and the analysis used to address it are not reported in the registry record. A count of recorded events should not be interpreted as proof that people without a recorded event had no symptoms or had no missing assessment.

The record lists adverse-event counts, which describe safety information separately from the primary efficacy endpoint. The serious adverse event figures are 3 participants affected in each listed group, with 0 deaths in each group. Other adverse events affected 28 participants in the 1mg AZ010 group, 40 in the 3mg AZ-010 group, and 44 in the placebo group. These descriptive figures do not provide a statistical comparison of safety between treatments, and do not substitute for the missing primary efficacy results.

Any planning illustrations based on an observed effect are not observed power and are not evidence that the trial detected a treatment effect. The registry record does not report the primary outcome results needed to interpret such illustrations against an actual effect estimate. Overall, the record supports a description of the design, endpoint, and selected safety counts, but not a conclusion about the primary efficacy comparison.

9. Statistical Methods Explained

The registry identifies the primary measure as a continuous outcome summarized by a mean and standard deviation. The underlying observation is a count of vomiting/retching events, but the registry’s stated parameter is the mean event count. As a general statistical concept, the mean describes the average across the observations included in an analysis. The standard deviation describes how dispersed those observations are around the mean; it is not the uncertainty of the estimated mean itself.

What would a treatment-effect estimate describe?

A treatment-effect estimate would quantify the difference or contrast in the primary endpoint between treatment groups, using a specified statistical model or comparison. Its interpretation depends on the precise estimand: for example, which participants and timepoints are included, and how incomplete observations are handled. The registry record does not report the model, contrast, or primary effect estimate. It is therefore not possible to identify the exact inferential procedure or interpret a numerical treatment effect from the record.

A confidence interval is a general way to express uncertainty around an estimated effect. A narrower interval indicates greater precision than a wider interval, while the interval’s position relative to a value representing no difference informs how compatible the data are with different effect sizes. No confidence interval for the primary outcome is reported in the registry record. A p-value, if reported, would address compatibility with a null hypothesis under specified assumptions; it would not by itself describe the size or clinical importance of an effect. The primary outcome p-value is also not reported in the registry record.

Why can repeated timepoints matter?

The endpoint is assessed at 30, 60, 90 and 120 minutes post-dose. Repeated measurements from the same participant are generally correlated rather than statistically independent. As a general statistical principle, an analysis of repeated observations may need to account for that within-person correlation. The registry record does not state whether the timepoints were analyzed separately, combined, or modeled jointly. It does not report the method for accounting for repeated measures or define a single treatment contrast across the timepoints.

The primary outcome description says each treatment group contained 47-49 patients, but only 22-35 patients per treatment group (approximately 45-70%) recorded events at any given timepoint. This matters because estimates based on fewer observations may be less precise, and the observed participants may not represent all randomized participants if the availability of records is related to symptoms or other factors. These are general considerations, not claims about why records were absent in this study. The reason for the lower number of recorded observations and the missing-data method are not reported in the registry record.

How can count data behave?

Counts take nonnegative integer values and can have a distribution unlike a continuous measurement that is approximately symmetric. As a general explanation, a count model may be considered when the distribution is skewed or when many observations are at the lower end of the scale. Some count models assume that the variance is related to the mean. Over-dispersion occurs when the variability is greater than a model’s assumptions allow; if unaddressed, standard errors and inferential results may be unreliable. The registry record does not report a distributional assessment, a count model, or whether over-dispersion was evaluated. The fact that the outcome is reported as a mean and standard deviation does not establish which model was used.

The record states that safety and tolerability were assessed through adverse events, vital signs, 12-lead ECG, clinical laboratory results, and physical examination. It says clinically significant deteriorations in physical examination findings, in the investigator’s opinion, are captured and summarized as adverse events. The registry record does not provide the statistical methods for those assessments or a detailed definition of the serious adverse event summaries presented.

What do the planning assumptions represent?

The registry includes a sample-size planning illustration based on an observed effect, with a two-sided significance level of 0.05, equal allocation between two arms, and a normal approximation. The illustration considers detecting a stated fraction of the observed effect. These assumptions describe a planning exercise, not the trial’s own design justification; the trial’s sample-size justification is not reported in the registry record. Such illustrations are not observed power. Because the primary outcome effect estimate is not reported in the registry record, the planning illustration cannot be treated as an independent confirmation of an efficacy result.

Overall, the registry specifies the endpoint and measurement schedule but leaves the central inferential details unreported. The statistical analysis plan, treatment-effect model, handling of repeated measurements, missing-data strategy, and multiplicity procedure are not reported in the registry record. Without those details and the outcome estimates, the design can be described, but the primary analysis cannot be independently reconstructed from the record.

10. Multiplicity, Missing Data and Analysis Populations

The registry lists 8 outcome measures and 18 analyses. Secondary outcomes include Anxiety/Panic Visual Analog Scale (VAS) Score, Prior Episode Questionnaire, Rescue Medication Use Within 1 Day of Dose, health care provider visits, Rhodes Index of Nausea, Vomiting, and Retching (RINVR), abdominal pain VAS score, and intensity of vomiting/retching attack. The primary endpoint is also measured at 30, 60, 90 and 120 minutes post-dose.

When investigators test multiple outcomes, timepoints, or treatment contrasts, the chance of obtaining at least one apparently notable result can increase. As a general statistical principle, a multiplicity strategy may specify which outcome is primary, whether tests are adjusted, and how secondary or repeated-timepoint findings should be interpreted. The registry identifies a primary endpoint but does not report a multiplicity adjustment or the hierarchy for interpreting the listed analyses. Those details are not reported in the registry record.

For the primary endpoint, the record notes that only 22-35 patients per treatment group (approximately 45-70%) recorded vomiting/retching events at any given timepoint, despite 47-49 patients in each treatment group. This indicates fewer event records at each timepoint than patients in the groups, but does not establish whether records were missing, not applicable, or absent for another reason. The reason and missing-data handling are not reported in the registry record. No assumptions about the values for participants without recorded events should be made from these counts alone.

The primary population is described as per protocol, with the stated CVS, age, and episode-history criteria. The registry record does not specify how membership in the per-protocol population was determined, whether another population was used for efficacy analyses, or how deviations from protocol were handled. These analysis-population details, like the multiplicity and missing-data methods, are needed to understand exactly which observations informed any treatment-effect estimate.

11. Safety Results

The registry reports serious adverse events as affected participants divided by participants at risk.

ArmParticipants with serious adverse eventsParticipants at riskPercentage
1mg AZ0103506.0%
3mg AZ0103515.9%
Placebo3496.1%
Participants with at least one serious adverse event
Serious adverse events by arm1mg AZ0106.0%3mg AZ0105.9%Placebo6.1%% of participants with at least one serious adverse event

Deaths

ArmDeaths (participants affected of at risk)
1mg AZ0100 of 50
3mg AZ0100 of 51
Placebo0 of 49

Other (non-serious) adverse events

Participants with at least one non-serious event at or above the registry's 0% reporting threshold.

ArmParticipants affected of at risk
1mg AZ01028 of 50
3mg AZ01040 of 51
Placebo44 of 49

Most frequent serious adverse event terms

Event termOrgan system1mg AZ0103mg AZ010Placebo
CVS, NauseaGastrointestinal disorders2 of 502 of 512 of 49
Surgical and medical proceduresSurgical and medical procedures1 of 500 of 510 of 49
Biliary dilatationHepatobiliary disorders0 of 501 of 510 of 49
HypertensionVascular disorders0 of 500 of 511 of 49

Most frequent non-serious adverse event terms

Event termOrgan system1mg AZ0103mg AZ010Placebo
VomitingGastrointestinal disorders3 of 507 of 512 of 49
HeadacheNervous system disorders3 of 500 of 514 of 49
NauseaGastrointestinal disorders2 of 501 of 513 of 49
Cyclic Vomiting SyndromeGastrointestinal disorders1 of 502 of 512 of 49
Stomach painGastrointestinal disorders0 of 503 of 511 of 49
COVID-19Infections and infestations1 of 501 of 512 of 49
HypokalemiaMetabolism and nutrition disorders1 of 501 of 512 of 49
ConstipationGastrointestinal disorders0 of 502 of 510 of 49
DehydrationMetabolism and nutrition disorders0 of 501 of 511 of 49
AnxietyPsychiatric disorders0 of 500 of 512 of 49

Serious events with the highest arm-level rate: cvs, nausea (4.1%), hypertension (2.0%), surgical and medical procedures (2.0%), biliary dilatation (2.0%).

Do not overextend the safety comparison. Serious-adverse-event counts are safety observations, not efficacy outcomes, and should not be combined with the primary result into a single benefit-risk number.

The registry reports serious adverse events and other adverse events separately for the 1mg AZ010, 3mg AZ-010, and placebo groups. The serious-event figures are 3 participants affected out of 50 at risk for 1mg AZ010, 3 out of 51 for 3mg AZ-010, and 3 out of 49 for placebo. Deaths are listed as 0 in each group. Other adverse events affected 28 out of 50, 40 out of 51, and 44 out of 49 participants, respectively.

These figures are descriptive counts of participants affected, not estimates of causal treatment effects. They do not show event timing, duration, severity beyond the serious-event classification, or whether an event was judged related to treatment. The registry record does not report those details in the registry record. Counts also do not establish whether the same participant experienced multiple events, or provide a statistical comparison between groups.

The registry lists serious-event terms and percentages including CVS, Nausea at 4.1%, Hypertension at 2.0%, Surgical and medical procedures at 2.0%, and Biliary dilatation at 2.0%. The listed terms should be read as registry-reported safety categories, not as a complete account of each participant’s clinical course. The safety assessment also included vital signs, 12-lead ECG, clinical laboratory results, and physical examination, but results for those assessments are not reported in the registry record.

12. What the Result Does, and Does Not, Mean

The record describes a randomized, double-blind, placebo-controlled study of single-dose AZ-010 for acute treatment of CVS. Its primary endpoint is the number of vomiting/retching events reported during the two hours after dosing, measured at 30, 60, 90 and 120 minutes. Those details establish what the trial was designed to examine and how the primary symptom outcome was scheduled for observation.

They do not establish what the trial found. Primary outcome values by group, a treatment-effect estimate, and its uncertainty are not reported in the registry record. Therefore, the direction and size of any difference between either AZ-010 dose and placebo cannot be stated, nor can the precision of that difference be assessed. The record’s completed status does not imply a particular efficacy result.

The counts of participants affected by adverse events provide descriptive safety information for the listed groups. They are not sufficient to establish whether differences between groups are due to treatment, chance, or other factors. The registry record does not report detailed event-level information or statistical comparisons for these counts. Similarly, the listed serious-event terms and percentages should not be read as a full safety profile.

As a general statistical principle, evidence about an average treatment effect does not show that every individual has the same experience. Interpretation also depends on the target population, endpoint definition, analysis population, completeness of measurements, and analysis methods. Here, the endpoint population is described as per protocol, and fewer participants recorded events at each timepoint than were in the treatment groups. The registry record does not explain this difference or how it was addressed analytically.

Any sample-size illustration based on an observed effect is a planning calculation, not observed power and not an independent trial result. The registry record does not report the primary result that would be needed to interpret such an illustration in context. The defensible conclusion from the available record is limited to the study’s design, prespecified outcome description, and selected adverse-event counts; efficacy conclusions are not supported by the information reported.

13. Why This Trial Matters Statistically

This study is statistically notable for using a repeated, participant-reported count outcome during a short home treatment period. Vomiting/retching events were recorded at 30, 60, 90 and 120 minutes post-dose, so interpretation may depend on how repeated observations and the timing of events were represented in the analysis. The registry record gives the measurement schedule but does not report whether timepoints were analyzed separately or jointly.

It also makes clear that the number of patients with recorded event data at a given timepoint was lower than the number in each treatment group: 22-35 patients per treatment group (approximately 45-70%) recorded events at any given timepoint, compared with 47-49 patients per treatment group. This difference is important for judging the amount of information available for the primary endpoint. Without an account of why fewer observations were available and how the analysis handled them, readers cannot determine whether the results would be sensitive to missing-data assumptions.

The study includes multiple secondary measures and analyses as well as several primary measurement timepoints. As a general statistical principle, interpretation across multiple tests needs a clear plan to distinguish confirmatory findings from exploratory ones and to address the possibility of chance findings. The registry record lists the measures and analyses but does not report a multiplicity strategy.

These features make reporting of the primary estimates, uncertainty, analysis population, and methods particularly important. The available record describes those questions but does not report the primary outcome results or the procedures used to analyze them. That limitation prevents a full statistical appraisal of whether the design yielded a precise estimate of the acute treatment effect.

14. Limitations

The central limitation is that the primary efficacy results are not reported in the registry record. There are no treatment-group event-count summaries or inferential estimates in the registry record, so a comparison of 1mg AZ010, 3mg AZ-010, and placebo cannot be interpreted. The primary endpoint description is informative about measurement, but not about the observed effect.

The registry notes that each treatment group contained 47-49 patients, while only 22-35 patients per treatment group (approximately 45-70%) recorded vomiting/retching events at any given timepoint. It does not explain why event records were available for fewer participants, whether this reflects missing assessment data or another circumstance, or how the analysis handled the differing numbers of observations. This uncertainty limits assessment of possible bias and precision.

The statistical analysis plan is not reported in the registry record. In particular, the record does not state the model used for the primary endpoint, how repeated timepoints were handled, which contrasts were estimated, or whether any adjustment for multiple analyses was used. The basis for defining the per-protocol analysis population and the handling of protocol deviations are also not reported.

The registry lists adverse-event counts and serious-event terms, but the registry entries described do not provide event-level details, relatedness assessments, or results for the other safety assessments. The record also includes planning illustrations, but the trial’s own sample-size justification is not reported. These limitations do not indicate that a particular result was favorable or unfavorable; they define what can and cannot be concluded from the registry information.

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18. Record Summary

NCT04645953 is a completed, randomized Phase 2, double-blind, parallel-group, placebo-controlled study sponsored by Alexza Pharmaceuticals, Inc., with a registry enrollment of 150. It evaluated single orally-inhaled doses of 1mg AZ010 and 3mg AZ-010 against Staccato Placebo for acute treatment of moderate to severe CVS.

The primary endpoint was the number of vomiting/retching events reported during the two hours after initial treatment, with observations at 30, 60, 90 and 120 minutes post-dose. The primary population is described as per protocol. The registry also lists secondary symptom, rescue-medication, and health care utilization outcomes, and reports selected adverse-event counts.

The primary outcome results and key statistical analysis details are not reported in the registry record. Accordingly, the trial’s design and measurement plan can be described, but the primary treatment effect and its precision cannot be assessed from the reported information.

Clinical Biostats