ID

25640

Beschrijving

Study part: Serious Adverse Events (SAE). A Single Blind, Parallel Group, Up-titration, Phase 1 Study in Healthy Volunteers to Determine a Starting Dose and Select an Up-titration Regimen for a new Formulation of Ropinirole. Patient Level Data: Study Listed on ClinicalStudyDataRequest.com. Phase: phase 1. Study Recruitment Status: Completed Generic Name: ropinirole. Trade Name: Modutab, ZIPEREVE, ZEPREVE, REPREVE, ADARTREL, REQUIP, Zygara; Zygara, ZIPEREVE, ZEPREVE, Requip Depot, REQUIP, REPREVE, Modutab, ADARTREL. Study Indication : Restless Legs Syndrome. Study ID: 101468/201. Clinical Study ID: 101468/201

Trefwoorden

Versies (2)
  1. 08-09-17 08-09-17 -
  2. 10-05-19 10-05-19 -
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GlaxoSmithKline

Geüploaded op

8 september 2017

DOI

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Creative Commons BY-NC 3.0
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Serious Adverse Events (SAE) Ropinirole Restless Legs Syndrome 101468/201

Engels

Serious Adverse Experiences (SAE)

1 Formulieren  
SERIOUS ADVERSE EVENT (SAE)
Beschrijving

SERIOUS ADVERSE EVENT (SAE)

Alias
UMLS CUI-1
C1519255
Subject number
Beschrijving

Subject number

Datatype

integer

Alias
UMLS CUI [1]
C2348585
Person Reporting SAE
Beschrijving

Person Reporting SAE

Datatype

text

Alias
UMLS CUI [1]
C0008961
AEGIS Number
Beschrijving

AEGIS Number

Datatype

integer

Alias
UMLS CUI [1,1]
C0237753
UMLS CUI [1,2]
C0600091
Serious Adverse Event
Beschrijving

Serious Adverse Experience

Datatype

text

Alias
UMLS CUI [1]
C1519255
Specify reason(s) for considering this a serious AE. Mark all that apply- Results in death
Beschrijving

reason death

Datatype

boolean

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C0011065
Specify reason(s) for considering this a serious AE. Mark all that apply- life threatening
Beschrijving

reason life threatening

Datatype

boolean

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C2826244
Specify reason(s) for considering this a serious AE. Mark all that apply- results in hospitalisation or prolongation of existing hospitalisation
Beschrijving

reason hospitalization

Datatype

boolean

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C0019993
Specify reason(s) for considering this a serious AE. Mark all that apply- results in disability/incapacity
Beschrijving

reason disability

Datatype

boolean

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C0231170
Specify reason(s) for considering this a serious AE. Mark all that apply- congenital abnormality/birth defect
Beschrijving

reason congenital abnormality

Datatype

boolean

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C0000768
Specify reason(s) for considering this a serious AE. Mark all that apply- other (Please specify)
Beschrijving

reason other

Datatype

text

Alias
UMLS CUI [1,1]
C0392360
UMLS CUI [1,2]
C0205394
Onset Date and Time
Beschrijving

Onset Date and Time

Datatype

datetime

Alias
UMLS CUI [1]
C2826806
End Date and Time
Beschrijving

End Date and Time

Datatype

datetime

Alias
UMLS CUI [1]
C2826793
Outcome
Beschrijving

Outcome

Datatype

integer

Alias
UMLS CUI [1]
C1705586
Event course
Beschrijving

Experience Course

Datatype

integer

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0750729
No. of episodes
Beschrijving

Number of episodes

Datatype

integer

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C4086638
Intensity (maximum)
Beschrijving

Intensity

Datatype

integer

Alias
UMLS CUI [1]
C1710066
Action Taken with Respect to Investigational Drug
Beschrijving

Action Taken with Respect to Investigational Drug

Datatype

integer

Alias
UMLS CUI [1]
C2826626
Did the SAE abate?
Beschrijving

SAE abate

Datatype

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C3853704
If study medication was interrupted, stopped or dose reduced: Was study medication reintroduced (or dose increased)?
Beschrijving

dosage change

Datatype

boolean

Alias
UMLS CUI [1]
C0420247
If yes, did SAE recur?
Beschrijving

Serious Adverse Experiences recurrence

Datatype

boolean

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0034897
Relationship to Investigational Drug
Beschrijving

Relationship to Investigational Drug

Datatype

integer

Alias
UMLS CUI [1,1]
C1518404
UMLS CUI [1,2]
C0013230
UMLS CUI [1,3]
C0439849
The SAE is probably associated with:
Beschrijving

Relationship to Investigational Drug

Datatype

text

Alias
UMLS CUI [1,1]
C1519255
UMLS CUI [1,2]
C0013230
UMLS CUI [1,3]
C0439849
Please specify
Beschrijving

specify

Datatype

text

Alias
UMLS CUI [1]
C1521902
Corrective Therapy
Beschrijving

y If ‘Yes’, record details in the Concomitant Medication section and/ or Healthcare Resource Utilisation form if appropriate

Datatype

boolean

Alias
UMLS CUI [1,1]
C0877248
UMLS CUI [1,2]
C0087111
Was patient withdrawn due to this specific AE?
Beschrijving

patient withdrawn due to this specific AE

Datatype

boolean

Alias
UMLS CUI [1,1]
C0422727
UMLS CUI [1,2]
C1518404
RELEVANT LABORATORY DATA
Beschrijving

RELEVANT LABORATORY DATA

Alias
UMLS CUI-1
C0022877
Test
Beschrijving

Test

Datatype

text

Alias
UMLS CUI [1,1]
C0022885
UMLS CUI [1,2]
C0332307
Date
Beschrijving

Date

Datatype

text

Alias
UMLS CUI [1]
C0011008
Value
Beschrijving

Value

Datatype

text

Alias
UMLS CUI [1]
C1522609
Units
Beschrijving

Units

Datatype

text

Alias
UMLS CUI [1]
C1519795
Normal Range
Beschrijving

Normal Range

Datatype

text

Alias
UMLS CUI [1]
C0086715
Remarks
Beschrijving

Remarks

Datatype

text

Alias
UMLS CUI [1]
C0947611
If applicable, was randomisation code broken at investigational site?
Beschrijving

randomisation code broken

Datatype

boolean

Alias
UMLS CUI [1,1]
C3897778
UMLS CUI [1,2]
C1272691
Randomisation/Study medication number:
Beschrijving

Randomisation Number

Datatype

integer

Alias
UMLS CUI [1,1]
C0034656
UMLS CUI [1,2]
C0237753
Investigator’s Signature:
Beschrijving

Investigators Signature

Datatype

text

Alias
UMLS CUI [1]
C2346576
Date
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
Please PRINT Name
Beschrijving

name

Datatype

text

Alias
UMLS CUI [1]
C0027365
SB Medical Monitor’s Signature:
Beschrijving

Medical Monitor’s Signature

Datatype

text

Alias
UMLS CUI [1]
C2346576
Please PRINT Name
Beschrijving

Name

Datatype

text

Alias
UMLS CUI [1]
C0027365
Date
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
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Similar models

Serious Adverse Experiences (SAE)

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
SERIOUS ADVERSE EVENT (SAE)
C1519255 (UMLS CUI-1)
Subject number
Item
Subject number
integer
C2348585 (UMLS CUI [1])
Person Reporting SAE
Item
Person Reporting SAE
text
C0008961 (UMLS CUI [1])
AEGIS Number
Item
AEGIS Number
integer
C0237753 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Serious Adverse Experience
Item
Serious Adverse Event
text
C1519255 (UMLS CUI [1])
reason death
Item
Specify reason(s) for considering this a serious AE. Mark all that apply- Results in death
boolean
C0392360 (UMLS CUI [1,1])
C0011065 (UMLS CUI [1,2])
reason life threatening
Item
Specify reason(s) for considering this a serious AE. Mark all that apply- life threatening
boolean
C0392360 (UMLS CUI [1,1])
C2826244 (UMLS CUI [1,2])
reason hospitalization
Item
Specify reason(s) for considering this a serious AE. Mark all that apply- results in hospitalisation or prolongation of existing hospitalisation
boolean
C0392360 (UMLS CUI [1,1])
C0019993 (UMLS CUI [1,2])
reason disability
Item
Specify reason(s) for considering this a serious AE. Mark all that apply- results in disability/incapacity
boolean
C0392360 (UMLS CUI [1,1])
C0231170 (UMLS CUI [1,2])
reason congenital abnormality
Item
Specify reason(s) for considering this a serious AE. Mark all that apply- congenital abnormality/birth defect
boolean
C0392360 (UMLS CUI [1,1])
C0000768 (UMLS CUI [1,2])
reason other
Item
Specify reason(s) for considering this a serious AE. Mark all that apply- other (Please specify)
text
C0392360 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Onset Date and Time
Item
Onset Date and Time
datetime
C2826806 (UMLS CUI [1])
End Date and Time
Item
End Date and Time
datetime
C2826793 (UMLS CUI [1])
Item
Outcome
integer
C1705586 (UMLS CUI [1])
Outcome
Code List
Outcome
CL Item
Resolved (1)
CL Item
Ongoing (2)
CL Item
Died (3)
Item
Event course
integer
C0877248 (UMLS CUI [1,1])
C0750729 (UMLS CUI [1,2])
Experience Course
Code List
Event course
CL Item
Intermittent (1)
CL Item
Constant (2)
Number of episodes
Item
No. of episodes
integer
C0877248 (UMLS CUI [1,1])
C4086638 (UMLS CUI [1,2])
Item
Intensity (maximum)
integer
C1710066 (UMLS CUI [1])
Intensity
Code List
Intensity (maximum)
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
Item
Action Taken with Respect to Investigational Drug
integer
C2826626 (UMLS CUI [1])
Action Taken with Respect to Investigational Drug
Code List
Action Taken with Respect to Investigational Drug
CL Item
None (1)
CL Item
Dose reduced (2)
CL Item
Dose increased (3)
CL Item
Drug interrupted/restarted (4)
CL Item
Drug stopped (5)
SAE abate
Item
Did the SAE abate?
boolean
C1519255 (UMLS CUI [1,1])
C3853704 (UMLS CUI [1,2])
dosage change
Item
If study medication was interrupted, stopped or dose reduced: Was study medication reintroduced (or dose increased)?
boolean
C0420247 (UMLS CUI [1])
Serious Adverse Experiences recurrence
Item
If yes, did SAE recur?
boolean
C1519255 (UMLS CUI [1,1])
C0034897 (UMLS CUI [1,2])
Item
Relationship to Investigational Drug
integer
C1518404 (UMLS CUI [1,1])
C0013230 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
Relationship to Investigational Drug
Code List
Relationship to Investigational Drug
CL Item
Not related (1)
CL Item
Dose reduced  (2)
CL Item
Dose increased  (3)
CL Item
Drug interrupted/restarted (4)
CL Item
Drug stopped  (5)
Item
The SAE is probably associated with:
text
C1519255 (UMLS CUI [1,1])
C0013230 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
undefined item
Code List
The SAE is probably associated with:
CL Item
Protocol design or procedures (Protocol design or procedures)
CL Item
Another condition (eg, condition under study, intercurrent illness) (Another condition (eg, condition under study, intercurrent illness))
CL Item
Another drug (Another drug)
specify
Item
Please specify
text
C1521902 (UMLS CUI [1])
Corrective Therapy
Item
Corrective Therapy
boolean
C0877248 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
patient withdrawn due to this specific AE
Item
Was patient withdrawn due to this specific AE?
boolean
C0422727 (UMLS CUI [1,1])
C1518404 (UMLS CUI [1,2])
Item Group
RELEVANT LABORATORY DATA
C0022877 (UMLS CUI-1)
Test
Item
Test
text
C0022885 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Date
Item
Date
text
C0011008 (UMLS CUI [1])
Value
Item
Value
text
C1522609 (UMLS CUI [1])
Units
Item
Units
text
C1519795 (UMLS CUI [1])
Normal Range
Item
Normal Range
text
C0086715 (UMLS CUI [1])
Remarks
Item
Remarks
text
C0947611 (UMLS CUI [1])
randomisation code broken
Item
If applicable, was randomisation code broken at investigational site?
boolean
C3897778 (UMLS CUI [1,1])
C1272691 (UMLS CUI [1,2])
Randomisation Number
Item
Randomisation/Study medication number:
integer
C0034656 (UMLS CUI [1,1])
C0237753 (UMLS CUI [1,2])
Investigators Signature
Item
Investigator’s Signature:
text
C2346576 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
name
Item
Please PRINT Name
text
C0027365 (UMLS CUI [1])
Medical Monitor’s Signature
Item
SB Medical Monitor’s Signature:
text
C2346576 (UMLS CUI [1])
Name
Item
Please PRINT Name
text
C0027365 (UMLS CUI [1])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
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