ID
36391
Description
Study ID: 101468/201 Clinical Study ID: 101468/201 Study Title: 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 Clinicaltrials.gov Identifier: Sponsor: GlaxoSmithKline Collaborators: N/A 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 The Study consists of 21 Visits(Days): Screening (at least 21 days before dosing) Week 1: including Day 1-7 Week 2: including Day 8-14 Week 3: including Day 15-19 Follow-up Visit (7-14 days after last dose) This document contains the SAE form. It has to be filled in if the subject experiences SAE during the study.
Keywords
Versions (2)
- 9/8/17 9/8/17 -
- 5/10/19 5/10/19 -
Copyright Holder
GlaxoSmithKline
Uploaded on
May 10, 2019
DOI
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License
Creative Commons BY-NC 3.0
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Determination of starting dose and up-titration regimen for a new formulation of Ropinirole in healthy adults, 101468/201
Serious Adverse Experiences (SAE)
- StudyEvent: ODM
Description
SERIOUS ADVERSE EVENT (SAE)
Alias
- UMLS CUI-1
- C1519255
Description
Person Reporting SAE
Data type
text
Alias
- UMLS CUI [1]
- C0008961
Description
AEGIS Number
Data type
integer
Alias
- UMLS CUI [1,1]
- C0237753
- UMLS CUI [1,2]
- C0600091
Description
Serious Adverse Experience
Data type
text
Alias
- UMLS CUI [1]
- C1519255
Description
Specify reason(s) for considering this a serious AE. Mark all that apply
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0566251
- UMLS CUI [1,2]
- C0011065
Description
Specify reason(s) for considering this a serious AE. Mark all that apply. NOTE: The term ‘life-threatening’ in the definition of ‘serious’ refers to an event in which the subject was at risk of death at the time of the event. It does not refer to an event, which hypothetically might have caused death, if it were more severe.
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0566251
- UMLS CUI [1,2]
- C2826244
Description
Specify reason(s) for considering this a serious AE. Mark all that apply. NOTE: In general, hospitalisation signifies that the subject has been detained (usually involving at least an overnight stay) at the hospital or emergency ward for observation and/or treatment that would not have been appropriate in the physician’s office or out-patient setting. Complications that occur during hospitalisation are AEs. If a complication prolongs hospitalisation or fulfils any other serious criteria, the event is serious. When in doubt as to whether “hospitalisation” occurred or was necessary, the AE should be considered serious. Hospitalisation for elective treatment of a preexisting condition that did not worsen from baseline is not considered an AE.
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0566251
- UMLS CUI [1,2]
- C0019993
Description
Specify reason(s) for considering this a serious AE. Mark all that apply. NOTE: The term disability means a substantial disruption of a person’s ability to conduct normal life functions. This definition is not intended to include experiences of relatively minor medical significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, and accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday life functions but do not constitute a substantial disruption.
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0566251
- UMLS CUI [1,2]
- C0231170
Description
Specify reason(s) for considering this a serious AE. Mark all that apply
Data type
boolean
Alias
- UMLS CUI [1,1]
- C0566251
- UMLS CUI [1,2]
- C0000768
Description
Specify reason(s) for considering this a serious AE. Mark all that apply. Medical or scientific judgement should be exercised in deciding whether reporting is appropriate in other situations, such as important medical events that may not be immediately life-threatening or result in death or hospitalisation but may jeopardize the subject or may require medical or surgical intervention to prevent one of the other outcomes listed in the above definition. These should also be considered serious. Examples of such events are invasive or malignant cancers, intensive treatment in an emergency room or at home for allergic bronchospasm, blood dyscrasias or convulsions that do not result in hospitalisation, or development of drug dependency or drug abuse.
Data type
text
Alias
- UMLS CUI [1]
- C3840932
Description
day month year
Data type
date
Alias
- UMLS CUI [1,1]
- C0574845
- UMLS CUI [1,2]
- C1519255
Description
00:00-23:59
Data type
time
Alias
- UMLS CUI [1,1]
- C0449244
- UMLS CUI [1,2]
- C1519255
Description
day month year
Data type
date
Alias
- UMLS CUI [1,1]
- C0806020
- UMLS CUI [1,2]
- C1519255
Description
00:00-23:59
Data type
time
Alias
- UMLS CUI [1,1]
- C1522314
- UMLS CUI [1,2]
- C1519255
Description
NOTE: If subject died, please inform GSK within 24 hours and complete form D
Data type
integer
Alias
- UMLS CUI [1,1]
- C1519255
- UMLS CUI [1,2]
- C1705586
Description
Experience Course
Data type
integer
Alias
- UMLS CUI [1,1]
- C0877248
- UMLS CUI [1,2]
- C0750729
Description
Number of episodes
Data type
integer
Alias
- UMLS CUI [1,1]
- C0877248
- UMLS CUI [1,2]
- C4086638
Description
INTENSITY (Maximum) Definition: MILD: Adverse Event which is easily tolerated. MODERATE: Adverse Event sufficiently discomforting to interfere with daily activity. SEVERE: Adverse Event which prevents normal everyday activities.
Data type
integer
Alias
- UMLS CUI [1,1]
- C1710066
- UMLS CUI [1,2]
- C1519255
Description
Action Taken with Respect to Investigational Drug
Data type
integer
Alias
- UMLS CUI [1]
- C2826626
Description
SAE abate
Data type
text
Alias
- UMLS CUI [1,1]
- C1519255
- UMLS CUI [1,2]
- C3853704
Description
dosage change of study medication
Data type
text
Alias
- UMLS CUI [1,1]
- C0420247
- UMLS CUI [1,2]
- C0304229
Description
Serious Adverse Experiences recurrence
Data type
text
Alias
- UMLS CUI [1,1]
- C1519255
- UMLS CUI [1,2]
- C0034897
Description
Definition: NOT RELATED: The adverse event is definitely not related to the test drug. UNLIKELY: There are more likely causes and the drug is not suspected as a cause. SUSPECTED (REASONABLE POSSIBILITY): A direct cause and effect relationship between the drug and the adverse event has not been demonstrated but there is a reasonable possibility that the event was caused by the drug. PROBABLE: There is probably a direct cause and effect relationship between the adverse event and the study drug.
Data type
integer
Alias
- UMLS CUI [1,1]
- C1518404
- UMLS CUI [1,2]
- C0013230
- UMLS CUI [1,3]
- C0439849
Description
Relationship to Investigational Drug, Assessment
Data type
integer
Alias
- UMLS CUI [1,1]
- C1519255
- UMLS CUI [1,2]
- C0013230
- UMLS CUI [1,3]
- C0439849
- UMLS CUI [1,4]
- C1516048
Description
Another contition: eg, condition under study, intercurrent illness
Data type
text
Alias
- UMLS CUI [1,1]
- C1519255
- UMLS CUI [1,2]
- C2348235
Description
If ‘Yes’, record details in the Concomitant Medication section and/or Healthcare Resource Utilisation form if appropriate
Data type
text
Alias
- UMLS CUI [1,1]
- C0877248
- UMLS CUI [1,2]
- C0087111
Description
Patient withdrawn due to this specific AE
Data type
text
Alias
- UMLS CUI [1,1]
- C0422727
- UMLS CUI [1,2]
- C1518404
Description
Relevant laboratory data
Alias
- UMLS CUI-1
- C0022877
- UMLS CUI-2
- C1519255
Description
Test
Data type
text
Alias
- UMLS CUI [1,1]
- C0022885
- UMLS CUI [1,2]
- C0332307
Description
day month year
Data type
text
Alias
- UMLS CUI [1]
- C2826247
Description
Value
Data type
text
Alias
- UMLS CUI [1]
- C1522609
Description
Units
Data type
text
Alias
- UMLS CUI [1]
- C1519795
Description
Normal Range
Data type
text
Alias
- UMLS CUI [1]
- C0086715
Description
Please provide a brief narrative description of the SAE, attaching extra pages eg. hospital discharge summary if necessary
Data type
text
Alias
- UMLS CUI [1]
- C0947611
Description
Randomisation code broken
Data type
text
Alias
- UMLS CUI [1,1]
- C3897778
- UMLS CUI [1,2]
- C1272691
Description
Randomisation Number
Data type
integer
Alias
- UMLS CUI [1,1]
- C0034656
- UMLS CUI [1,2]
- C0237753
Description
Confirming that the above data are accurate and complete
Data type
text
Alias
- UMLS CUI [1]
- C2346576
Description
day month year
Data type
date
Alias
- UMLS CUI [1,1]
- C2346576
- UMLS CUI [1,2]
- C0011008
Description
Please PRINT Name
Data type
text
Alias
- UMLS CUI [1]
- C2826892
Description
Medical Monitor’s Signature
Data type
text
Alias
- UMLS CUI [1]
- C2346576
Description
Please PRINT Name
Data type
text
Alias
- UMLS CUI [1,1]
- C0027365
- UMLS CUI [1,2]
- C1708968
Description
day month year
Data type
date
Alias
- UMLS CUI [1,1]
- C1708968
- UMLS CUI [1,2]
- C1519316
Similar models
Serious Adverse Experiences (SAE)
- StudyEvent: ODM
C0600091 (UMLS CUI [1,2])
C0011065 (UMLS CUI [1,2])
C2826244 (UMLS CUI [1,2])
C0019993 (UMLS CUI [1,2])
C0231170 (UMLS CUI [1,2])
C0000768 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,2])
C4086638 (UMLS CUI [1,2])
C1519255 (UMLS CUI [1,2])
C0304229 (UMLS CUI [1,2])
C0034897 (UMLS CUI [1,2])
C0013230 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
C0013230 (UMLS CUI [1,2])
C0439849 (UMLS CUI [1,3])
C1516048 (UMLS CUI [1,4])
C2348235 (UMLS CUI [1,2])
C1518404 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,2])
C1272691 (UMLS CUI [1,2])
C0237753 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,2])
C1708968 (UMLS CUI [1,2])
C1519316 (UMLS CUI [1,2])