Sibeprenlimab, which neutralizes A PRoliferation Inducing Ligand (APRIL), as a new approach to treating IgA nephropathy.

INTRODUCTION: Immunoglobulin A (IgA) nephropathy is a common immune-mediated kidney disease leading to high blood pressure and may progress to kidney failure. None of the present treatments are disease-modifying or prolong life. The levels of A PRoliferation Inducing Ligand (APRIL) are raised in subjects with IgA nephropathy. Sibeprenlimab is a humanized IgG2 monoclonal antibody that binds to, and neutralizes, APRIL. AREAS COVERED: A phase 2 clinical trial of intravenous sibeprenlimab (VIS649) in IgA nephropathy: NCT04287985. The primary efficacy endpoint was the change from baseline in 24-h protein-to-creatinine ratio at 12 months, and this was reduced by sibeprenlimab. Sibeprenlimab also caused clinical remission in some subjects, stabilized estimated glomerular filtration rate (eGFR), and reduced galactose deficient IgA1, IgA, IgM, and IgG levels without causing any infections or other adverse events. EXPERT OPINION: Sibeprenlimab is a promising new approach to treating IgA nephropathy. The pharmaceutical company behind sibeprenlimab is also developing it for subcutaneous use, which would have advantages over intravenous use. As IgA nephropathy is a long-term progressive disease, key questions that need to be answered, over a long-time course, with sibeprenlimab are (i) whether its safety is maintained, and (ii) whether it improves clinical outcomes.

More failure with solanezumab - this time in preclinical Alzheimer's disease.

INTRODUCTION: There is no cure for Alzheimer's disease, which is the sixth leading cause of death in the USA. Lecanemab is anti-Aß monoclonal antibody approved for the treatment of early Alzheimer's disease but is only marginally effective. Other antibodies are being developed including solanezumab. AREAS COVERED: A phase 3 clinical trial of solanezumab in preclinical Alzheimer's disease. In the A4 study, solanezumab did not reduce the decline in cognition or function and had no effect on brain amyloid burden. EXPERT OPINION: After the poor results in the EXPEDITION series of trials, the development of solanezumab should have been terminated. The rationale for undertaking the A4 trial was questionable, and the lack of benefit was probable. The controversial approval of two anti-Aß monoclonal antibodies (aducanumab and lecanemab) for the treatment of Alzheimer's disease by the US Food and Drug Administration (FDA), despite a high incidence of amyloid-related imagining abnormalities (ARIA), may be fueling this continuation of clinical development of agents such as solanezumab. The lesson from the A4 trial is that more careful/realistic consideration needs to be given before embarking on further phase 3 trials with anti-Aß monoclonal antibodies.

Retatrutide showing promise in obesity (and type 2 diabetes).

INTRODUCTION: Obesity is a major risk factor for cardiovascular disease, diabetes, osteoarthritis, and some cancers. Retatrutide stimulates Glucagon-like peptide 1 (GLP-1), Glucose-dependent insulinotropic polypeptide (GIP) receptors, and glucagon receptors, and is being developed for the treatment of obesity and type 2 diabetes. AREAS COVERED: A phase 2 clinical trial of retatrutide (LY3437943) in the treatment of obesity. The primary end point was percentage change in weight from baseline to 24 weeks, which ranged from -7.2% to -~18% as the dose of retatrutide increased from 1 mg to 12 mg. The most frequent adverse events were gastrointestinal (nausea, diarrhea, vomiting). EXPERT OPINION: The results for retatrutide in phase 2 for obesity (and diabetes) are mostly encouraging. Consistent with being a GLP-1 receptor agonist, heart rate was increased by up to 6.7 beats/min by retatrutide, which may be detrimental and offset some of the benefits of weight loss. Presumably, retatrutide is being developed as a challenger to the recently developed weight loss medicines; semaglutide and/or tirzepatide. Thus, comparator studies are needed between retatrutide and these drugs, but none are ongoing and, in my opinion, this lack is a major omission in the development of retatrutide.

Continuous subcutaneous levodopa-carbidopa for the treatment of advanced Parkinson's disease: is it an improvement on other delivery?

INTRODUCTION: Parkinson's disease (PD) is the second most common neurodegenerative disease and is growing in prevalence and disability. The standard treatment for PD is oral levo-dopa (LD) with carbidopa (CD). As PD progresses, despite higher doses of LD/CD, plasma levels of LD fluctuate, and may be associated with motor fluctuations and dyskinesia. AREAS COVERED: The development of two new subcutaneous preparations of LD/CD (ND0612 and ABBV-951) for the treatment of motor fluctuations in PD is described in detail. Both reduce motor fluctuations and dyskinesia with minor infusion site adverse events. A third subcutaneous preparation, DIZ102, is in early-stage development. EXPERT OPINION: The premise for using continuous release LD in advanced PD is that steady state levels of LD will prevent motor fluctuations/dyskinesia, but this is not the whole story, and will limit the benefits of subcutaneous continuous release LD. With its present pump system ND0612 cannot be used as monotherapy, whereas ABBV-951 can be. Having to combine with oral LD/CD will complicate the use of ND0612. Both ND0612 and ABBV-951 only cause modest reductions in OFF time. It is not clear whether these subcutaneous preparations will have more benefits than the intestinal gel, which also reduces OFF time and dyskinesia.

Bempedoic acid as treatment for subjects at cardiovascular risk who are statin-intolerant.

INTRODUCTION: Atherosclerotic cardiovascular disease is the leading cause of death globally. LDL cholesterol is a key risk factor for cardiovascular disease.  The most common group of medicines for lowering LDL cholesterol are the statins, as they reduce the risk of cardiovascular events.  However, some subjects are statin-intolerant and remain at high risk. AREAS COVERED: CLEAR Outcomes; a phase 3 clinical trial of bempedoic acid, an ATP citrate lyase (ACL) inhibitor, in subjects who do not tolerate statins or are unable to take the recommended dose. It enrolled subjects with prior cardiovascular events (secondary prevention) and at high risk (primary prevention). The primary endpoint was a composite of major adverse cardiovascular events, and this occurred in less subjects in the bempedoic acid than the placebo group. EXPERT OPINION: Bempedoic acid is suitable for use as monotherapy in the prevention of cardiovascular events in statin intolerant subjects, and it has a good safety profile in most subjects.However, the effects of bempedoic acid in lowering LDL cholesterol and cardiovascular events are modest.  This suggests that more benefits may ensue ifbempedoic acid was used in combination with other lipid lowering agents to cause larger decreases in LDL cholesterol.

Is sotatercept, which traps activins and growth differentiation factors, a new dawn in treating pulmonary arterial hypertension (PAH)?

INTRODUCTION: Although the prevalence of pulmonary arterial hypertension (PAH) is low, mortality is high. In PAH, there is a down-regulation of the bone morphogenetic protein receptor type 2 pathway, leading to a prominence of the upregulation pathway that is mediated by activins and growth differentiation factors acting at the receptor type IIA (ActRIIA). Sotatercept is an ActRIIA fusion protein. STELLAR was a phase 3 study of sotatercept for the treatment of PAH. AREAS COVERED: STELLAR. The primary endpoint of STELLAR was change from baseline at 24 weeks in the 6-minute walking distance, which was increased by 34.4 m by sotatercept compared to 1 m in the placebo group. Epistaxis/nosebleed, telangiectasia, and dizziness were more common with sotatercept than placebo. EXPERT OPINION: By targeting the remodeling in PAH, sotatercept is providing a new approach to the treatment of PAH and has the potential to slow or reverse cardiovascular remodeling in other conditions, e.g. left heart failure. However, the development of sotatercept for the treatment of PAH still requires a consideration of the appropriate dose and a longer-term assessment of the benefits and safety. If sotatercept becomes available for self-administration, it will be of interest to assess whether this affects adherence and benefits.

Differences between students in various programs in a biochemistry course in lecture attendance, engagement, and academic outcomes.

The positive relationship between lecture attendance and academic outcomes may be changing in the era of lecturing recordings. The objective of the study was to test this and to determine whether it varied between student cohorts. Consenting students in biochemistry from pharmacy, biomedical science, medical laboratory science, and nutrition programs, which had access to lecture recordings, signed in when attending lectures. Attendance was related to academic outcomes by regression analysis. Average attendance was low (≤19%) and declined significantly between years for most weeks. The students who attended ≥50% of lectures (≤17%) had higher marks than those that attended <50%. Overall regression analysis showed there were positive associations between most academic outcomes and lecture attendance or engagement (attendance and lecture recording access). However, these associations were weak or moderate for students in the pharmacy and biomedical science programs and were not apparent for students in the medical laboratory science and nutrition programs. In a separate survey, the most common reason for attending lectures was "I think I learn more by attending" and for not attending, was "Work commitments made it difficult to get to lectures." The main conclusion is that students of biochemistry should be encouraged to attend lectures, as the limited evidence suggests that attendance may still be associated with better academic outcomes and that some students find them beneficial.

Follow-up descriptive study of how proportioning marks between coursework and examination affects the performance of students in nursing.

BACKGROUND: There has been little attention to how the allocation of marks affects the academic performance of students in courses. Our previous study showed that students in nursing had much lower marks in exams than coursework (tutorials and case study) in a pharmacology course. It is not known whether this applies to nursing students in other courses and/or with different types of coursework. The purpose of this study was to analyse how the allocation of marks to examination and different coursework affected the performance of students in nursing in a bioscience course. METHODS: For the 379 completing students in a nursing degree undertaking a first-year first semester bioscience course, a descriptive study was undertaken of (i) the marks for the exam and two coursework components (individually undertaken laboratory skills, and a team/group project on health communication), with the marks being compared by Students t-test, (ii) any association between these marks was determined by regression line analysis, and (iii) modelling was undertaken to determine the effects of changing the allocation of marks on passing and failing rates. RESULTS: Students in nursing who completed a bioscience course had much lower marks in the exam than the coursework. Regression line analysis of the marks in the exam versus combined coursework showed (a) a poor line fit and (b) the correlation coefficient was moderate (r = 0.51), for the individual laboratory skills vs. exam was moderate (r = 0.49), but only weak for the group project on health communication vs. exam (r = 0.25). A high percentage of students passed the course (97%). Modelling showed that increasing the marks for the exam decreased the number of students passing the course to as few as 57%. CONCLUSIONS: The allocation of marks determines the percentage of students in nursing who pass courses, regardless of the type of coursework. The students in nursing in the bioscience course, who pass the course based on marks from coursework, but not the examination component, may not have the necessary knowledge to continue their program of study. Thus, requiring students in nursing to pass exams should be given further consideration.

Is retatrutide (LY3437943), a GLP-1, GIP, and glucagon receptor agonist a step forward in the treatment of diabetes and obesity?

INTRODUCTION: Despite there being a wide range of medicines available for the treatment of type 2 diabetes, the high rate of mortality suggests treatment needs to be improved. Only a few medicines have shown long-term effectiveness in obesity, and new medicines are urgently needed. AREAS COVERED: A multiple-ascending dose phase 1b clinical trial of a new drug retatrutide (LY3437943), which in addition to stimulating Glucagon-like peptide 1 (GLP-1) and Glucose-dependent insulinotropic polypeptide (GIP) receptors, stimulates glucagon receptors, in subjects with type 2 diabetes. Retatrutide was relatively safe and pharmacokinetics support once-weekly dosing. EXPERT OPINION: The role of stimulating glucagon receptors in the treatment of type 2 diabetes and/or obesity is poorly defined and needs to be clarified. Although retatrutide may be superior to the GLP-1 receptor agonist dulaglutide in reducing plasma glucose and body weight, this is not a meaningful comparison, as another GLP-1 receptor agonist (semaglutide) is more potent than dulaglutide at this and may have similar efficacy to retatrutide. Retatrutide also needs to be compared to another Eli Lilly and Company drug, the combined GLP-1 and GIP receptor agonist, tirzepatide. The safety of retatrutide needs to be determined in larger and longer trials.

A new role for an old drug: acetazolamide in decompensated heart failure.

INTRODUCTION: Mortality from heart failure remains high. Many subjects who have been hospitalized with acute decompensated heart failure leave hospital with residual congestion, despite treatment with loop diuretics. In an attempt to improve this, the Acetazolamide in Decompensated heart failure with Volume OveRload (ADVOR) trial was undertaken, where acetazolamide was added to the loop diuretic bumetanide. AREAS COVERED: This article discusses ADVOR. The primary endpoint of ADVOR was the reversal of congestion, which was increased by adding acetazolamide to bumetanide. However, acetazolamide did not shorten hospital stay or the composite of rehospitalisation and death after three months. EXPERT OPINION: The limitations of ADVOR include that acetazolamide did not improve quality of life and that the testing was in white subjects only. During the hospital stay for decompensation, medicines that inhibit the angiotensin and mineralocorticoid systems were increased, which suggests that the treatment for heart failure was not ideal on hospitalization. As the death rates in ADVOR were lower than in previous studies, this suggests that the overall treatment of decompensated/heart failure is improving. However, in the author's opinion, although the addition of acetazolamide is a small improvement in the treatment of acute decompensated heart failure with volume overload, more options need to be considered.

The ULTIMATE trials: are there advantages of ublituximab over teriflunomide in relapsing multiple sclerosis?

INTRODUCTION: The involvement of B-cells in multiple sclerosis has only recently emerged. Ublituximab is a monoclonal antibody that binds to the B-cell antigen CD20 with enhanced B-cell targeting. AREAS COVERED: This evaluation is of the identical ULTIMATE (UbLiTuximab In Multiple Sclerosis Treatment Effects) I and II trials comparing ublituximab (TG-1101) and teriflunomide in relapsing multiple sclerosis. The primary efficacy end point was the annualized relapse rate and was lower in the ublituximab than the teriflunomide group. EXPERT OPINION: The continuation rates to oral teriflunomide in ULTIMATE were higher than in other trials, possibly because of the supervised double-dummy protocol used with intravenous ublituximab. This may have contributed to the higher efficacy with teriflunomide in this trial than previously reported. Nevertheless, ublituximab was more effective than teriflunomide at reducing the annualized relapse rates and MRI endpoints, but not for no evidence of disease activity (NEDA). Subsequently, a meta-analysis of the ULTIMATE trials did show that ublituximab was superior to teriflunomide in NEDA. Long-term studies of the adverse effects of ublituximab are required. Despite the positive results from ULTIMATE for ublituximab, it is still under the scrutiny of the Food and Drug Administration (FDA), and conclusions should await their findings.

Are there advantages of daprodustat over erythropoiesis-stimulating agents (ESAs) in treating anemia associated with chronic kidney disease (CKD)?

Anemia is common in CKD and increases the risk of developing heart disease. Although ESAs relieve the symptoms of anemia, they have adverse effects and do not reduce the adverse outcomes associated with anemia. This evaluation is of the phase 3 ASCEND clinical trials of the hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitor daprodustat versus ESAs in subjects with CKD undergoing dialysis or not. Daprodustat was non-inferior to ESAs in increasing hemoglobin, and in the incidence of cardiovascular events and adverse effects. Daprodustat is effective in subjects who are hyporesponsive to ESAs, and this is one circumstance when daprodustat may be preferred to ESAs. However, to become a widely used medicine in subjects with CKD responsive to ESAs, daprodustat needs to be well tolerated, used by a high percentage of subjects over a long time, and be superior to ESAs in improving clinical outcomes. As this may not be the case, there is not a strong basis for recommending daprodustat over ESAs. The other 'dustats' (roxadustat, vadadustat) have also not been shown to be superior to the ESAs, and none have been approved by the FDA to date.

Adding liraglutide to diet and exercise to maintain weight loss - is it worth it?

INTRODUCTION: Obesity is a major risk factor for cardiovascular disease, diabetes, osteoarthritis, and some cancers. Weight loss is an obvious management for this, but a major problem is that after weight loss, many people regain weight. AREAS COVERED: In the following evaluation of S-LITE (NCT04122716, Combined effects of GLP-1 analogue and exercise on maintenance of weight loss after very-low calorie diet), the author gives emphasis to the prevention of weight regain by liraglutide, not the effects of exercise. In S-LITE, liraglutide (with or without exercise) was effective in reducing weight regain in subjects with obesity. EXPERT OPINION: The subjects with obesity in S-LITE were limited by the enrollment criteria, and the findings of S-LITE cannot be generalized. The increased heart rate with liraglutide did not occur when liraglutide was combined with exercise, and this suggests that liraglutide should probably not be used alone, but only with exercise to maintain weight loss. As the only presently available medicine to have been shown to be effective against weight regain, liraglutide should probably be preferred to other weight-loss medicines in this circumstance. However, without clear evidence that liraglutide treatment for obesity prevents diabetes and/or reduces cardiovascular risk, it is difficult to justify using it.

Do we need bamlanivimab? Is etesevimab a key to treating Covid-19?

INTRODUCTION: Treatments for subjects with Covid-19 are required. One approach is neutralizing monoclonal antibodies. Bamlanivimab and etesevimab are monoclonal antibodies to SARS-CoV-2. AREAS COVERED: This evaluation is of the phase 3 BLAZE-1 clinical trial, which was of bamlanivimab plus etesevimab in adult ambulatory participants with a risk factor for, and mild to moderate, Covid-19 illness. The primary outcome was Covid 19 related hospitalization of ≥ 24 hours or death from any cause by day 29, and this occurred in 2.1% subjects in the bamlanivimab/etesevimab group, compared to 7.0% in the placebo group. EXPERT OPINION: In the pandemic, the attempts by the FDA to shorten approval processes for medicines and by journals to make information available in a timely manner are admirable. However, these shortened processes made negotiating the details of BLAZE-1 and producing accurate and critical appraisals difficult. It seems to me that if there are any benefits of bamlanivimab alone in Covid-19, they are not clear-cut. Bamlanivimab has limited effects against the beta and gamma variants and is not effective against the delta variant. Thus, the benefits of bamlanivimab/etesevimab in the phase 3 of the BLAZE-1 may be solely due to etesevimab, and this needs to be tested.

Quantitative study of lecture attendance and the association between this attendance and academic outcomes for nursing and nonnursing students in an introductory pathophysiology course.

Since the availability of lecture recordings, there have been limited studies of any associations between face-to-face lecture attendance and academic outcomes. The aims of the study, in an introductory pathophysiology course, where lecture recordings were available, were 1) to quantify lecture attendance and any associations between academic outcomes and lecture attendance, and 2) to determine why students do or do not attend lectures. Data were analyzed for the whole cohort before separating the nursing (∼60%) and nonnursing students. Of 288 enrolled students, 205 consented to sign the attendance register, and 139 to undertake the online survey. Lecture attendance was higher (41%) before the midsemester exam than afterwards (24%), P < 0.001, due to higher attendance by the nursing than nonnursing students. Students who attended ≥50% of lectures consistently got higher academic outcomes than those that attended <50%, e.g., examinations, 11 percent points higher. Pearson's or Spearman's correlation coefficients for students from both the sign-in and survey showed that there were positive associations between lecture attendance and academic outcomes, which were mainly weak for nursing students (P ≤ 0.05), with no association for nonnursing students. From the survey, most students who attended lectures did so because they considered they learned more by attending lectures, whereas not liking the lecture time was the most common reason for not attending lectures. In conclusion, even though students have access to lecture recordings, lecture attendance is still a determinant of academic outcomes for some students of pathophysiology.

Still grasping at straws: donanemab in Alzheimer's disease.

INTRODUCTION: Alzheimer's disease is the leading cause of disability and poor health, takes a huge emotional and financial burden on family caregivers, and is costly. Donanemab (LY3002813) is a new monoclonal antibody that uniquely targets Aß(p3-42), a pyroglutamate form of Amyloid-ß (Aß) exclusively found in plaques. AREAS COVERED: The phase 2 trial of donanemab in participants with early symptomatic Alzheimer's disease, TRAILBLAZER-ALZ. Donanemab reduced cerebral plaque but not tau load and only marginally improved the primary outcome of cognition and activities of daily living (p = 0.04) without altering individual measures of these. EXPERT OPINION: In TRAILBLAZER-ALZ, anticholinesterase use was given at the beginning but not the end of the trial, and thus, it is not known whether changes in this or other medicines were involved in the outcome with donanemab. Tau load (measured with flortuacipir PET) may be a biomarker of cognition but was not altered by donanemab. As there is no clear evidence that removing cerebral amyloid plaques with Aß antibodies, such as donanemab, improves cognition and the activities of daily living in Alzheimer's disease, clinical trials with these agents should be abandoned, and more time and money should spend on further investigating the underlying cause of Alzheimer's disease.

Quantitative study showing how and why students access lecture recordings, and of the association between accessing and academic outcomes, in a biochemistry course.

Many factors predict academic performance at university but accessing lecture recordings has not been established as one. Our aims were to quantify how and why biochemistry students accessed lecture recordings and to determine any association between accessing lecture recordings and academic outcomes. Lecture recording access data was collected and related to academic outcomes. On average, students accessed 46% of lecture recordings and each recording was accessed 2.3 times, but not to completion. After lecture delivery, students were slow to access lecture recordings, and the number of accesses was still increasing prior to the examinations. For the entire cohort, there were weak positive associations between accessing lecture recordings and academic outcomes for the semester, and between the access to lecture recordings in weeks 1-5 and 6-11 with the mid-semester and final examination, respectively. For programs, the weak association for the semester was only apparent for the pharmacy and biomedical science students, and not for the medical laboratory or nutrition students. The most common reason for accessing lecture recording was to "Revise lecture concepts for assessment purposes." For students, who did not attend lectures, lecture recordings were accessed predominantly as "I prefer the flexibility of online recordings." Flexibility was also the theme of the positive additional feedback on accessing lecture recordings. In conclusion, consideration needs to be given on how to persuade students to access lecture recordings in a timelier way. As accessing lecture recordings is weakly associated with positive academic outcomes for some program cohorts, this supports their continued availability.

Finerenone - are we there yet with a non-steroidal mineralocorticoid receptor antagonist for the treatment of diabetic chronic kidney disease?

Introduction: Chronic kidney disease occurs in 40% of subjects with diabetes and increases the risk of cardiovascular death three-fold, compared to having diabetes alone. The non-steroidal mineralocorticoid receptor antagonist finerenone protects against chronic kidney disease in animal models.Areas covered: This evaluation is of a phase 3 trial of finerenone; Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD). In FIDELIO-DKD, finerenone reduced the primary composite outcome of kidney failure, a sustained decrease of at least 40% in eGFR over four weeks, or death from renal causes, from 21.1% to 17.8%, with a good safety profile.Expert opinion: Finerenone is an effective mineralocorticoid receptor antagonist for the treatment of diabetic chronic kidney disease. Recently, glucagon-like peptide 1 (GLP-1) receptor agonists and sodium-glucose cotransporters 2 (SGLT-2) inhibitors have been added to the list of medicines for use in subjects with this condition. Although finerenone has a different mechanism of action to these medicines, it will need to be tested and shown to be effective in presence of these medicines in diabetic kidney disease, prior to widespread use.

Will evinacumab become the standard treatment for homozygous familial hypercholesterolemia?

Introduction: Homozygous Familial Hypercholesterolemia (HoFH) is a very severe genetic form of hypercholesterolemia. Lacking LDL receptors in the liver, subjects with HoFH have raised plasma levels of LDL cholesterol, and up to 100 times higher risk of premature atherosclerotic cardiovascular disease than the general population.Areas covered: This evaluation is of a phase 3 trial of evinacumab; Evinacumab Lipid Studies in Patients with Homozygous Familial Hypercholesterolemia (ELIPSE HoFH). Evinacumab is a human monoclonal antibody inhibitor of angiopoietin-like protein 3 (ANGPTL3). In ELIPSE HoFH, evinacumab reduced LDL cholesterol by 47.1 ± 4.6%, HDL cholesterol by 30.4%, and triglycerides by 50.4 ± 7.7%.Expert opinion: Evinacumab is not the ideal treatment for HoFH as it does not reduce LDL cholesterol levels to treatment targets while increasing HDL cholesterol. Although the incidence of adverse effects with evinacumab was low in ELIPSE HoFH, further studies are necessary to clarify its effects on liver enzymes and clinical cardiovascular outcomes. Evinacumab is a candidate to become the standard treatment for HoFH, as it may be better tolerated and/or more efficacious than the presently available specific treatment (lomitapide). However, the widespread use of evinacumab to treat high triglycerides or LDL cholesterol is unlikely due to evinacumab decreasing HDL cholesterol.

Descriptive study of how proportioning marks determines the performance of nursing students in a pharmacology course.

BACKGROUND: In programs with higher proportions of marks allocated to ongoing assessment, the students have higher overall marks than those with a lower proportion allocated to assessment. Little or no attention has been made to how the allocation affects the academic success of students in individual courses. The purpose of this study was to determine how the allocation of marks to examinations, tutorials and an assignment affects the performance of nursing students in a pharmacology course. METHODS: For students who passed a pharmacology course (i) the marks for examinations and ongoing assessment (tutorials and/or an assignment) were compared, and (ii) regression line and correlation analysis was undertaken to determine any association between these marks. In addition, for completing students, modelling was undertaken to determine the effects of changing the allocation of marks on passing and failing rates. RESULTS: Nursing students who passed a pharmacology course obtained significantly lower marks in examinations than ongoing assessment, and for the ongoing assessment, lower marks in the assignment than tutorials. Regression line analysis showed that the marks in ongoing assessment (tutorials and/or the assignment) versus examination marks were a poor line-fit. The correlation coefficients between ongoing assessment and examinations were weak to moderate. A high percentage of students passed the course (> 90%) and, modelling for completing students, showed that decreasing the marks for examination would have led to slightly more students passing the pharmacology course with higher grades. In contrast, increasing the marks for examination would have dramatically decreased the number of students passing the course, and their grades. CONCLUSIONS: The allocation of marks can have a major effect on student performance. As ongoing assessment is only a weak or moderate indicator of performance in examination this has implications for students who rely on passing examinations for their advancement. For instance, nursing students in some countries (e.g. USA) are required to pass examinations prior to registration, whereas in others (e.g. Australia) they are not. Consideration needs to be given as to whether it is appropriate for nursing students who fail examinations to pass courses/programs.