1. Expedited Adverse Event Reporting Requirements

2. Protocol References Section Title 7.2 Safety-Related Data Collection
7.3
Expedited Adverse Event Reporting

3. Other References and Resources
Manual for Expedited Reporting of Adverse Events to DAIDS (Version 2.0)
DAIDS Table for Grading the Severity of Adult and Pediatric Adverse Events, Corrected Version 2.1, dated July 2017
Study drug package inserts
DAERS user and reference guides
DAIDS safety training resources

4. Overview of Presentation
Terms and definitions
Protocol specifications for expedited adverse event reporting
Relationship assessment
Case examples

5. Adverse Event Protocol Section 7.2
The definition of the term adverse event provided in Version 2.0 of the DAIDS EAE Manual will be used in this study

6. The definition of adverse event provided in Version 2
The definition of adverse event provided in Version 2.0 of the DAIDS EAE Manual will be used in this study.
Adverse event = any untoward medical occurrence in a patient or clinical investigation subject administered a study agent which does not necessarily have a causal relationship with this treatment. An adverse event can therefore by any unfavorable and unintended sign (including an abnormal laboratory finding, symptom, or disease) temporally associated with the use of a medicinal (investigational) agent, whether or not related to the medicinal (investigational) agent. (ICH E2A)

7. Adverse Event The same definition applies to all participants
Beginning at the time of enrollment
Regardless of the ARVs the mother takes or does not take
So for each mother-infant pair,
we start identifying adverse events
immediately after they are randomized
in the Subject Enrollment System

8. Pre-Existing Condition
Pre-existing condition = untoward medical occurrence identified in a study participant prior to enrollment. Pre-existing conditions are not adverse events. However, if a pre-existing condition worsens in severity or frequency after enrollment, the worsened condition is an adverse event.

9. Pre-Existing Conditions
Protocol Section 7.2.1
All pre-existing conditions identified among mothers during the 28 days prior to study entry will be entered into maternal medical history eCRFs

10. Expedited Adverse Events
The following types of adverse events must be reported in an expedited manner in IMPAACT 2010:
Serious adverse events (SAEs)
Suspected unexpected serious adverse reactions (SUSARs)
Pregnancy complications that result in medically indicated and/or elective termination of pregnancy
Spontaneous abortions and fetal deaths
Hepatic toxicities that result in discontinuation of DTG or EFV
Serious ABC hypersensitivity reactions in mothers switching from TDF or TAF to ABC
Protocol Section 7.3.2

11. Serious Adverse Event
Serious adverse event = an adverse event that ...
Results in death
Is life-threatening*
Requires inpatient hospitalization* or prolongation of existing hospitalization
Results in persistent or significant disability/incapacity
In a congenital anomaly/birth defect*
Is an important medical event that may not be immediately life- threatening or result in death or hospitalization but may jeopardize the participant or may require intervention to prevent one of the other outcomes listed above
*See helpful clarifications of these terms in the DAIDS EAE Manual

12. Congenital anomaly/birth defect

13. Do you have any questions about the definition of SAE for this study?

14. SUSAR
Suspected = Related to use of study drug Unexpected = Nature or severity is not consistent with the study drug’s current package insert Serious adverse reaction = SAE

15. Related or Not Related
Related = There is a reasonable possibility that the event may be related to study drug. Not related = There is not a reasonable possibility that the event may be related to study drug.

16. Reasonable Possibility
Reasonable possibility is intended to convey that there are facts, evidence, or arguments to suggest a causal relationship between the event and study drug

17. Facts, Evidence, or Arguments to Suggest a Causal Relationship
A temporal relationship between the event and use of study drug
A plausible biologic mechanism for study drug to cause the event
Previous reports of similar events associated with study drug (or drugs of the same class)
Resolution of the event after de-challenge (hold/discontinuation of study drug)
Recurrence of the event after re-challenge (resumption of study drug after a hold)

18. Related or Not Related
In addition to considering the possibility of a causal relationship with study drug, consider other potential causes of the event, e.g.,
Past medical history
Concurrent illness
Concomitant medications
For events assessed as not related, document an alternative etiology, diagnosis, or explanation in study records
Also mention the known epidemiology or typical frequency of the event occurring outside of the study – how common would this event be seen among pregnant/postpartum infants who are not receiving study drug?

19. Reminder of Random Assignments

20. Related or Not Related For EAEs reported for participants in Arm 1
Relationship assessments are required for DTG, FTC, and TAF
For EAEs reported for participants in Arm 2
Relationship assessments are required for DTG, FTC, and TDF
For EAEs reported for in Arm 3
Relationship assessments are required for EFV, FTC, and TDF

21. Related or Not Related
For mothers, assess relationship to each ARV received (ingested)
For infants, assess relationship to each ARV received by the mother to which the infant may have been exposed in utero or through breastfeeding

22. EAE Reporting Requirements for Infants
Study Entry through Week 14 Postpartum
Week 14 Postpartum through Study Exit
Arm 1
SAEs
SUSARs
Arm 2
Arm 3

23. EAE Reporting Requirements for Mothers
Study Entry through Week 14 Postpartum
Week 14 Postpartum through Study Exit
Arm 1
SAEs
Arm 2
Arm 3
SUSARs
Note that, for participants assigned to Arms 1 and 2, the requirements for mothers differ from the requirements for infants. For infants in these arms, after Week 14, SUSARs are required to be reported, rather than SAEs.

24. Additional EAE Reporting Requirements for Mothers
Event
Arm 1
Arm 2
Arm 3
Spontaneous abortions and fetal deaths
Yes No
Pregnancy complications that result in medically indicated and/or elective termination of the pregnancy

25. Additional EAE Reporting Requirements for Mothers
Event
Arm 1
Arm 2
Arm 3
Hepatic toxicities that
result in discontinuation of DTG or EFV
Yes
Serious ABC hypersensitivity reactions in mothers switching from TDF or TAF to ABC

26. 26
A pregnant woman randomized to Arm 1 at 18 weeks gestation is hospitalized at 20 weeks gestation with a febrile illness.
Has a reportable EAE occurred?
Yes No
Maybe
For mothers in Arm 1, all SAEs must be reported as EAEs.

27. 27
A pregnant woman randomized to Arm 2 at 18 weeks gestation is hospitalized at 20 weeks gestation with a febrile illness.
Has a reportable EAE occurred?
Yes No
Maybe
For mothers in Arm 2, all SAEs must be reported as EAEs.

28. 28
A pregnant woman randomized to Arm 3 at 18 weeks gestation is hospitalized at 20 weeks gestation with a febrile illness.
Has a reportable EAE occurred?
Yes No
Maybe
Th event is serious, but for mothers in Arm 3, EAE reportability depends on the site’s assessment of relationship and expectedness.
REMINDER that regardless of EAE reportability, the event must be entered into eCRFs so that data are complete for comparisons across arms.

29. A pregnant woman randomized to Arm 1 at 22 weeks gestation experiences a still birth at 28 weeks gestation.
Has a reportable EAE occurred?
Yes No
Maybe
For mothers in Arm 1, all fetal deaths must be reported as EAEs.

30. A pregnant woman randomized to Arm 2 at 22 weeks gestation experiences a still birth at 28 weeks gestation.
Has a reportable EAE occurred?
Yes No
Maybe
For mothers in Arm 2, all fetal deaths must be reported as EAEs.

31. A pregnant woman randomized to Arm 3 at 22 weeks gestation experiences a still birth at 28 weeks gestation.
Has a reportable EAE occurred?
Yes No
Maybe
For mothers in Arm 3, fetal deaths are not required to be reported as EAEs.
REMINDER that the pregnancy outcome must still be entered into pregnancy outcome eCRFs.
In addition, all still births are considered grade 3 events per the DAIDS tox table so an adverse event eCRFs should also be completed.
See next slide.

33. 33
An enrolled pregnant woman reports to the clinic for her antepartum Week 4 visit complaining of severe fatigue, nausea, vomiting, and abdominal pain. Lab testing provides grade 4 ALT and AST results.
Has a reportable EAE occurred?
Yes No
Maybe
The intent of this description is to highlight the requirement to report “hepatic toxicities that result in discontinuation of DTG or EFV” in all three arms. The correct answer to the question will depend on how the woman’s symptoms are managed, and specifically whether DTG or EFV is discontinued (as well as whether the event is serious). Note that per protocol Appendix Table II.4, Management of Maternal Clinical Hepatitis, for mothers with signs or symptoms of clinical hepatitis, DTG or EFV should be permanently discontinued; per protocol Section 7.3.2, this event would then need to be reported as an EAE for mothers in all arms.

34. What are your questions about EAE reporting?
Should we take these out for JHB?