ID

24804

Beschrijving

Study ID: 101468/228 Clinical Study ID: 101468/228 Study Title:A two year Phase IIIb randomised, multicenter, double-blind, SINEMET controlled, parallel group, flexible dose study, to assess the effectiveness of controlled release ropinirole add-on therapy to L-dopa at increasing the time to onset of dyskinesia in Parkinson's disease subjects. Patient Level Data: Study Listed on ClinicalStudyDataRequest.com Clinicaltrials.gov Identifier: NCT00363727 Sponsor: GlaxoSmithKline Collaborators: N/A Phase: phase 3 Study Recruitment Status: Completed Generic Name: ropinirole Trade Name: Zygara,ZIPEREVE,ZEPREVE,Requip Depot,REQUIP,REPREVE,Modutab,ADARTREL Study Indication : Dyskinesias; Parkinson Disease; Parkinson's Disease Study part: Serious adverse events

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Versies (3)
  1. 18-08-17 18-08-17 -
  2. 08-09-17 08-09-17 -
  3. 20-09-21 20-09-21 -
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GlaxoSmithKline

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18 augustus 2017

DOI

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Creative Commons BY-NC 3.0
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Serious adverse events GSK study Dyskinesia in Parkinson's disease NCT00363727

Engels

Serious adverse events GSK study Dyskinesia in Parkinson's disease NCT00363727

1 Formulieren  
General information
Beschrijving

General information

Protocol indentifier
Beschrijving

Protocol indentifier

Datatype

text

Subject Identifier
Beschrijving

Subject Identifier

Datatype

text

Alias
UMLS CUI [1]
C2348585
Centre
Beschrijving

Centre

Datatype

date

Randomization number
Beschrijving

Randomization number

Datatype

text

Serious adverse events
Beschrijving

Serious adverse events

Did the subject experience a serious adverse event during the study?
Beschrijving

If Yes, record details below.

Datatype

boolean

Section 1
Beschrijving

Section 1

Event
Beschrijving

Record one SAE diagnosis per line, or a sign/symptom if the diagnosis is not available. If a diagnosis subsequently becomes available, this then should be entered and the sign/symptom crossed out, initialled and dated by the investigator. A separate form should be used for each SAE however if multiple SAEs which are temporally or clinically related are apparent at the time of initial reporting then these may be reported on the same page.

Datatype

text

Start date
Beschrijving

Record the start date of the first occurrence of the SAE.

Datatype

date

Outcome
Beschrijving

All SAEs must be followed until the events are resolved, the condition stabilises, the events are otherwise explained, or the subject is lost to follow-up. Indicate if the event was ’Recovered/Resolved’ or ’Recovered/Resolved with sequelae’. If the SAE is ongoing at the time the subject completes the study or becomes lost to follow-up, the outcome must be recorded as ’Not recovered/Not resolved’ or ’Recovering/Resolving’. Also enter ’Not recovered/Not resolved’ if the SAE was ongoing at the time of death, but was not the cause of death, enter fatal for the SAE which was the direct cause of death.

Datatype

integer

End Date
Beschrijving

Record the end date. This is the date the SAE Recovered/Resolved, or if the outcome was fatal, record the date the subject died. If the event Recovered/ Resolved with sequelae, enter the date the subject’s medical condition resolved or stabilised. Leave blank if the SAE is ’Not recovered/Not resolved’ or ’Recovering/Resolving’.

Datatype

date

Maximum Intensity
Beschrijving

Record the maximum intensity that occurred over the duration of the event. Amend the intensity if it increases. Mild = An event that is easily tolerated by the subject, causing minimal discomfort and not interfering with everyday activities. Moderate = An event that is sufficiently discomforting to interfere with everyday activities. Severe = An event that prevents normal everyday activities. Not applicable = Those event(s) where intensity is meaningless or impossible to determine (i.e., blindness and coma).

Datatype

text

Action Taken with Investigational Product(s) as a Result of the SAE
Beschrijving

Investigational product(s) withdrawn = Administration of investigational product(s) was permanently discontinued. Dose reduced =Dose is reduced for one or more investigational product(s). Dose increased =Dose increased for one or more investigational product(s). Dose not changed=Investigational product(s) continues even though an adverse event has occurred. Dose interrupted=Administration of one or more investigational product(s) was temporarily interrupted but then restarted. Not applicable=Subject was not receiving investigational product(s) when the event occurred (e.g., pre-or post-dosing) or the subject died and there was no prior decision to discontinue IP(s).

Datatype

text

Did the subject withdraw from study as a result of this SAE?
Beschrijving

Indicate ’Yes’ if the event(s) were directly responsible for the subject’s withdrawal as indicated on the Study Conclusion page, otherwise indicate ’No’.

Datatype

boolean

Is there a reasonable possibility that the SAE may have been caused by the investigational product?
Beschrijving

It is a regulatory requirement for investigators to assess relationship to investigational product(s) based on information available. The assessment should be reviewed on receipt of any new information and amended if necessary. ’A reasonable possibility’ is meant to convey that there are facts/evidence or arguments to suggest a causal relationship. Facts/evidence or arguments that may support ’a reasonable possibility’ include, e.g., a temporal relationship, a pharmacologically-predicted event, or positive dechallenge or rechallenge. Confounding factors, such as concomitant medication, a concurrent illness, or relevant medical history, should also be considered.

Datatype

boolean

If fatal, was a post-mortem/autopsy performed?
Beschrijving

If Yes, summarise findings in Section 11 Narrative Remarks of this SAE form.

Datatype

boolean

Section 2: Seriousness
Beschrijving

Section 2: Seriousness

[A] Results in death
Beschrijving

SAE results in death

Datatype

boolean

[B] Is life-threatening
Beschrijving

SAE is life-threatening

Datatype

boolean

[C] Requires hospitalisation or prolongation of existing hospitalisation
Beschrijving

SAE requires hospitalisation

Datatype

boolean

[D] Results in disability/incapacity
Beschrijving

SAE results in disability/incapacity

Datatype

boolean

[E] Congenital anomaly/birth defect
Beschrijving

Congenital anomaly/birth defect

Datatype

boolean

[F] Other
Beschrijving

Óther SAE

Datatype

boolean

Other, specify
Beschrijving

Other SAE specificationn

Datatype

text

Section 3: Demography data
Beschrijving

Section 3: Demography data

Date of birth
Beschrijving

Date of birth

Datatype

date

Sex
Beschrijving

Sex

Datatype

text

Weight
Beschrijving

Weight

Datatype

float

Maateenheden
  • kg
kg
Section 4
Beschrijving

Section 4

If Investigational Product(s) was Stopped, Did the Reported Event(s) Recur After Further Investigational Product(s) were Administered?
Beschrijving

If deliberate or inadvertant administration of further dose(s) of investigational product(s) to the subject occurred, did the reported adverse event recur?

Datatype

text

Section 5: Possible Causes of SAE Other Than Investigational Product(s)
Beschrijving

Section 5: Possible Causes of SAE Other Than Investigational Product(s)

Disease under study
Beschrijving

Disease under study

Datatype

boolean

Medical condition(s) (record in Section 6)
Beschrijving

Medical condition

Datatype

boolean

Lack of efficacy
Beschrijving

Lack of efficacy

Datatype

boolean

Withdrawal of investigational product(s)
Beschrijving

Withdrawal of investigational product

Datatype

boolean

Concomitant medication (record in Section 8)
Beschrijving

Concomitant medication

Datatype

boolean

Activity related to study participation (e.g., procedures)
Beschrijving

Activity related to study participation

Datatype

boolean

Other
Beschrijving

Other cause of SAE

Datatype

boolean

Other, specify
Beschrijving

Other cause of SAE specification

Datatype

text

Section 6: Relevant medical conditions
Beschrijving

Section 6: Relevant medical conditions

Specify any RELEVANT past or current medical disorders, allergies, surgeries, etc. that can help explain the SAE
Beschrijving

Medical conditions relevant to SAE

Datatype

text

Date of onset
Beschrijving

Date of onset

Datatype

date

Condition Present at Time of the SAE?
Beschrijving

Condition Present at time of SAE

Datatype

boolean

If No, Date of Last Occurrence
Beschrijving

Date of Last Occurrence

Datatype

date

Section 7
Beschrijving

Section 7

Other RELEVANT Risk Factors (provide any family or social history (e.g., smoking, alcohol, diet, drug abuse, occupational hazard) relevant to the SAE)
Beschrijving

Other risk factors relevant to SAE

Datatype

text

Section 8: RELEVANT Concomitant Medications (include details of any concomitant medication(s) which may have contributed to the event)
Beschrijving

Section 8: RELEVANT Concomitant Medications (include details of any concomitant medication(s) which may have contributed to the event)

Drug name
Beschrijving

(Trade Name preferred)

Datatype

text

Dose
Beschrijving

Dose

Datatype

float

Unit
Beschrijving

Unit

Datatype

text

Frequency
Beschrijving

Frequency

Datatype

text

Route
Beschrijving

Route

Datatype

text

Taken prior to study?
Beschrijving

medication taken prior to study

Datatype

boolean

Alias
UMLS CUI [1]
C2826667
Start date
Beschrijving

Start date

Datatype

date

Stop Date
Beschrijving

Stop Date

Datatype

date

Ongoing Medication?
Beschrijving

Ongoing Medication

Datatype

boolean

Reason for Medication
Beschrijving

Reason for Medication

Datatype

text

Section 9: Details of Investigational Product(s)
Beschrijving

Section 9: Details of Investigational Product(s)

Dose level (randomization)
Beschrijving

Dose level randomization

Datatype

text

Start date (randomization)
Beschrijving

Start date randomization

Datatype

date

Stop date (randomization)
Beschrijving

Stop date randomization

Datatype

date

Continuing (randomization)
Beschrijving

Continuation randomization

Datatype

boolean

Dose level (At time of SAE)
Beschrijving

Dose level At time of SAE

Datatype

text

Start date (At time of SAE)
Beschrijving

Start date At time of SAE

Datatype

date

Stop date (At time of SAE)
Beschrijving

Stop date At time of SAE

Datatype

date

Continuing (At time of SAE)
Beschrijving

Continuation At time of SAE

Datatype

boolean

Was randomisation code broken at investigational site?
Beschrijving

randomisation code broken

Datatype

text

Section 10
Beschrijving

Section 10

Details of RELEVANT Assessments (provide details of any other tests/procedures which were carried out to diagnose or confirm the SAE e.g., laboratory data with units and normal range)
Beschrijving

Details of relevant assessments

Datatype

text

Section 11
Beschrijving

Section 11

Narrative Remarks (provide a brief narrative description of the SAE and details of treatment given)
Beschrijving

Narrative Remarks

Datatype

text

Investigator information
Beschrijving

Investigator information

Investigator’s signature
Beschrijving

confirming that the data on the SAE pages are accurate and complete

Datatype

text

Date
Beschrijving

Date

Datatype

date

Investigator’s name (print)
Beschrijving

Investigator’s name

Datatype

text

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Similar models

Serious adverse events GSK study Dyskinesia in Parkinson's disease NCT00363727

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
General information
Protocol indentifier
Item
Protocol indentifier
text
Subject Identifier
Item
Subject Identifier
text
C2348585 (UMLS CUI [1])
Centre
Item
Centre
date
Randomization number
Item
Randomization number
text
Item Group
Serious adverse events
serious adverse events
Item
Did the subject experience a serious adverse event during the study?
boolean
Event
Item
Event
text
Start date
Item
Start date
date
Item
Outcome
integer
Outcome
Code List
Outcome
CL Item
Recovered/Resolved (1)
CL Item
Recovering/Resolving (2)
CL Item
Not recovered/Not resolved (3)
CL Item
Recovered/Resolved with sequelae (4)
CL Item
Fatal (5)
End Date
Item
End Date
date
Item
Maximum Intensity
text
Maximum Intensity
Code List
Maximum Intensity
CL Item
Mild (1)
CL Item
Moderate (2)
CL Item
Severe (3)
CL Item
Not applicable (X)
Item
Action Taken with Investigational Product(s) as a Result of the SAE
text
Action Taken
Code List
Action Taken with Investigational Product(s) as a Result of the SAE
CL Item
Investigational product(s) withdrawn (1)
CL Item
Dose reduced (2)
CL Item
Dose increased (3)
CL Item
Dose not changed (4)
CL Item
Dose interrupted (5)
CL Item
Not applicable (X)
withdrawal
Item
Did the subject withdraw from study as a result of this SAE?
boolean
Relationship to Investigational Product
Item
Is there a reasonable possibility that the SAE may have been caused by the investigational product?
boolean
post-mortem/autopsy
Item
If fatal, was a post-mortem/autopsy performed?
boolean
Item Group
Section 2: Seriousness
SAE results in death
Item
[A] Results in death
boolean
SAE is life-threatening
Item
[B] Is life-threatening
boolean
SAE requires hospitalisation
Item
[C] Requires hospitalisation or prolongation of existing hospitalisation
boolean
SAE results in disability/incapacity
Item
[D] Results in disability/incapacity
boolean
Congenital anomaly/birth defect
Item
[E] Congenital anomaly/birth defect
boolean
Óther SAE
Item
[F] Other
boolean
Other SAE specificationn
Item
Other, specify
text
Item Group
Section 3: Demography data
Date of birth
Item
Date of birth
date
Item
Sex
text
Sex
Code List
Sex
CL Item
Male (Male)
CL Item
Female (Female)
Weight
Item
Weight
float
Item Group
Section 4
Item
If Investigational Product(s) was Stopped, Did the Reported Event(s) Recur After Further Investigational Product(s) were Administered?
text
Recurrence of SAE
Code List
If Investigational Product(s) was Stopped, Did the Reported Event(s) Recur After Further Investigational Product(s) were Administered?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown at this time (Unknown at this time)
CL Item
Not applicable (Not applicable)
Item Group
Section 5: Possible Causes of SAE Other Than Investigational Product(s)
Disease under study
Item
Disease under study
boolean
Medical condition
Item
Medical condition(s) (record in Section 6)
boolean
Lack of efficacy
Item
Lack of efficacy
boolean
Withdrawal of investigational product
Item
Withdrawal of investigational product(s)
boolean
Concomitant medication
Item
Concomitant medication (record in Section 8)
boolean
Activity related to study participation
Item
Activity related to study participation (e.g., procedures)
boolean
Other cause of SAE
Item
Other
boolean
Other cause of SAE specification
Item
Other, specify
text
Item Group
Section 6: Relevant medical conditions
Medical conditions relevant to SAE
Item
Specify any RELEVANT past or current medical disorders, allergies, surgeries, etc. that can help explain the SAE
text
Date of onset
Item
Date of onset
date
Condition Present at time of SAE
Item
Condition Present at Time of the SAE?
boolean
Date of Last Occurrence
Item
If No, Date of Last Occurrence
date
Item Group
Section 7
Other risk factors relevant to SAE
Item
Other RELEVANT Risk Factors (provide any family or social history (e.g., smoking, alcohol, diet, drug abuse, occupational hazard) relevant to the SAE)
text
Item Group
Section 8: RELEVANT Concomitant Medications (include details of any concomitant medication(s) which may have contributed to the event)
Drug name
Item
Drug name
text
Dose
Item
Dose
float
Unit
Item
Unit
text
Frequency
Item
Frequency
text
Route
Item
Route
text
medication taken prior to study
Item
Taken prior to study?
boolean
C2826667 (UMLS CUI [1])
Start date
Item
Start date
date
Stop Date
Item
Stop Date
date
Ongoing Medication
Item
Ongoing Medication?
boolean
Reason for Medication
Item
Reason for Medication
text
Item Group
Section 9: Details of Investigational Product(s)
Dose level randomization
Item
Dose level (randomization)
text
Start date randomization
Item
Start date (randomization)
date
Stop date randomization
Item
Stop date (randomization)
date
Continuation randomization
Item
Continuing (randomization)
boolean
Dose level At time of SAE
Item
Dose level (At time of SAE)
text
Start date At time of SAE
Item
Start date (At time of SAE)
date
Stop date At time of SAE
Item
Stop date (At time of SAE)
date
Continuation At time of SAE
Item
Continuing (At time of SAE)
boolean
Item
Was randomisation code broken at investigational site?
text
randomisation code broken
Code List
Was randomisation code broken at investigational site?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Not applicable (Not applicable)
Item Group
Section 10
Details of relevant assessments
Item
Details of RELEVANT Assessments (provide details of any other tests/procedures which were carried out to diagnose or confirm the SAE e.g., laboratory data with units and normal range)
text
Item Group
Section 11
Narrative Remarks
Item
Narrative Remarks (provide a brief narrative description of the SAE and details of treatment given)
text
Item Group
Investigator information
Investigator’s signature
Item
Investigator’s signature
text
Date
Item
Date
date
Investigator’s name
Item
Investigator’s name (print)
text
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