1
|
Sauer L, Sato A, Davies HD. Therapeutics Pipeline. Pediatr Clin North Am 2024; 71:481-498. [PMID: 38754937 DOI: 10.1016/j.pcl.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Children have unique physiologic, developmental, and psychosocial needs and unique vulnerabilities, making them a challenging population for which to develop therapeutics. This is particularly apparent in the urgent and chaotic environment of a pandemic or outbreak. Advances in the development of medical countermeasures (MCMs) for pediatric populations have grown substantially over the last decade, and the coronavirus disease 2019 pandemic forced advancements in how we approach pediatric MCM development. Consequently, a MCMs pipeline targeting the pediatric population is essential. This article addresses the challenges inherent in these differences that must be taken into account.
Collapse
Affiliation(s)
- Lauren Sauer
- GCHS, Special Pathogen Research Network, Department of Environmental, Agricultural and Occupational Health, UNMC College of Public Health, 984355 Nebraska Medical Center, Omaha, NE, USA
| | - Alice Sato
- Department of Pediatrics, Division of Pediatric Infectious Disease, University of Nebraska Medical Center, 987810, Nebraska Medical Center, Omaha, NE 68198-7810, USA
| | - Herbert Dele Davies
- Department of Pediatrics, Division of Pediatric Infectious Disease, University of Nebraska Medical Center, 987810, Nebraska Medical Center, Omaha, NE 68198-7810, USA; Academic Affairs, University of Nebraska Medical Center, 987810 Nebraska Medical Center, Omaha, NE 68198-7810, USA.
| |
Collapse
|
2
|
Erceg D, Jakirović M, Prgomet L, Madunić M, Turkalj M. Conducting Drug Treatment Trials in Children: Opportunities and Challenges. Pharmaceut Med 2024; 38:179-204. [PMID: 38730200 DOI: 10.1007/s40290-024-00523-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 05/12/2024]
Abstract
Children were often referred to as "therapeutic orphans" in the past due to different reasons such as ethical, regulatory, economic, scientific, etc., ones. They were exposed to avoidable risks while missing out on therapeutic advances. Pediatric patients have suffered from a lack of scientific and regulatory standards (e.g., proper drug testing, authorization of medicines for their use, etc.), although the pharmaceutical legislative framework, which ensures the high standards of safety, quality, and efficacy of medicinal products for use in adults, was developed primarily in response to past "drug disasters," mainly involving children. The adoption of pediatric regulatory initiatives first in the USA and then in Europe and other countries and regions has significantly changed the worldwide frameworks and permanently changed pediatric drug research and development. This article tries to give various perspectives with historical context, a review of the different challenges and opportunities as well as important stakeholders in pediatric drug development. The pediatric trial networks are probably the most important stakeholder that enables efficient patient recruitment, access to better resource utilization, and global collaboration of different stakeholders necessary for performing quality and well-designed clinical trials.
Collapse
Affiliation(s)
- Damir Erceg
- "Srebrnjak" Children's Hospital, Clinical Trials Unit, 10000, Zagreb, Croatia.
- School of Medicine, Catholic University of Croatia, 10000, Zagreb, Croatia.
- Faculty of Dental Medicine and Health, University of Osijek, "Josip Juraj Strossmayer", 31000, Osijek, Croatia.
- Medical School, University of Osijek "Josip Juraj Strossmayer", 31000, Osijek, Croatia.
| | - Marina Jakirović
- "Srebrnjak" Children's Hospital, Clinical Trials Unit, 10000, Zagreb, Croatia
| | - Luka Prgomet
- Institute of Emergency Medicine of Zagreb County, 10410, Velika Gorica, Croatia
| | - Marina Madunić
- Emergency Department, General Hospital Zabok, 49210, Zabok, Croatia
| | - Mirjana Turkalj
- "Srebrnjak" Children's Hospital, Clinical Trials Unit, 10000, Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, 10000, Zagreb, Croatia
- Medical School, University of Osijek "Josip Juraj Strossmayer", 31000, Osijek, Croatia
| |
Collapse
|
3
|
Eisenstein EL, Hill KD, Wood N, Kirchner JL, Anstrom KJ, Granger CB, Rao SV, Baldwin HS, Jacobs JP, Jacobs ML, Kannankeril PJ, Graham EM, O'Brien SM, Li JS. Evaluating registry-based trial economics: Results from the STRESS clinical trial. Contemp Clin Trials Commun 2024; 38:101257. [PMID: 38298917 PMCID: PMC10826145 DOI: 10.1016/j.conctc.2024.101257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/18/2023] [Accepted: 01/08/2024] [Indexed: 02/02/2024] Open
Abstract
Background Registry-based trials have the potential to reduce randomized clinical trial (RCT) costs. However, observed cost differences also may be achieved through pragmatic trial designs. A systematic comparison of trial costs across different designs has not been previously performed. Methods We conducted a study to compare the current Steroids to Reduce Systemic inflammation after infant heart surgery (STRESS) registry-based RCT vs. two established designs: pragmatic RCT and explanatory RCT. The primary outcome was total RCT design costs. Secondary outcomes included: RCT duration and personnel hours. Costs were estimated using the Duke Clinical Research Institute's pricing model. Results The Registry-Based RCT estimated duration was 31.9 weeks greater than the other designs (259.5 vs. 227.6 weeks). This delay was caused by the Registry-Based design's periodic data harvesting that delayed site closing and statistical reporting. Total personnel hours were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design (52,488 vs 29,763 vs. 24,480 h, respectively). Total costs were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design ($10,140,263 vs. $4,164,863 vs. $3,268,504, respectively). Thus, Registry-Based total costs were 32 % of the Explanatory and 78 % of the Pragmatic design. Conclusion Total costs for the STRESS RCT with a registry-based design were less than those for a pragmatic design and much less than an explanatory design. Cost savings reflect design elements and leveraging of registry resources to improve cost efficiency, but delays to trial completion should be considered.
Collapse
Affiliation(s)
| | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, NC, USA
- Duke Pediatric and Congenital Heart Center, Durham, NC, USA
| | - Nancy Wood
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Kevin J. Anstrom
- Collaborative Studies Coordinating Center, Chapel Hill, NC, USA
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - H. Scott Baldwin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | - Eric M. Graham
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Jennifer S. Li
- Duke Clinical Research Institute, Durham, NC, USA
- Duke Pediatric and Congenital Heart Center, Durham, NC, USA
| |
Collapse
|
4
|
Alexander KP. Meaningful Evidence for Anticoagulation in the Gray (Elder) Zone. JAMA Cardiol 2022; 7:581-582. [PMID: 35416911 DOI: 10.1001/jamacardio.2022.0477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Karen P Alexander
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| |
Collapse
|
5
|
Rose K, Ettienne EB, Grant-Kels JM, Striano P, Neubauer D, Tanjinatus O. Neurology's vital role in preventing unnecessary and potentially harmful pediatric studies. Expert Rev Neurother 2022; 22:209-219. [PMID: 35213279 DOI: 10.1080/14737175.2022.2045953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Regulatory authorities recognize two human populations: adults and children defined as <18 years. For drug approval, they demand separate studies. But humans mature slowly during puberty. The 18th birthday is an administrative limit that does not correspond to a physiological change. Separate drug approval before/after the 18th birthday reflects the children-are-therapeutic-orphans concept that emerged after 1962. The Food and Drug Administration (FDA) has backed away from this concept for antiepileptic drugs, but sticks to it in other areas. In contrast, the European Medicines Agency (EMA) is continuously expanding its demand for "pediatric" studies. Parents hesitate increasingly to let their children participate in questionable studies. AREAS COVERED Neurologists challenge the children-are-therapeutic-orphans mantra. Young patients do not need separate proof of efficacy & safety, but appropriate dosing recommendations. Minors should be treated as human beings, instead of being abused in questionable studies. EXPERT OPINION Young patients with multiple sclerosis and other neurological diseases deserve studies with therapeutic intentions. "Pediatric" careers have emerged in academia, regulatory authorities, and pharmaceutical companies. Institutional Review Boards/ Ethics Committees should suspend questionable "pediatric" studies and reject newly submitted ones. The medical professions should distance themselves from questionable "pediatric" research that reflects massive conflicts of interest.
Collapse
Affiliation(s)
- Klaus Rose
- Klausrose Consulting, Riehen, Switzerland
| | | | - Jane M Grant-Kels
- Dermatology Department, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, "G. Gaslini" Institute, Genova, Italy
| | - David Neubauer
- Department of Child, Adolescent & Developmental Neurology, University Children's Hospital, Ljubljana, Slovenia
| | | |
Collapse
|
6
|
Harris KC, Mackie AS, Dallaire F, Khoury M, Singer J, Mahle WT, Klassen TP, McCrindle BW. Unique Challenges of Randomised Controlled Trials in Pediatric Cardiology. Can J Cardiol 2021; 37:1394-1403. [PMID: 34186112 DOI: 10.1016/j.cjca.2021.06.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 02/07/2023] Open
Abstract
Pediatric cardiology has evolved over time with reductions in childhood mortality due to congenital heart disease. Surgical innovation drove early changes in care. Increasingly, the need for more robust evidence provided by randomised controlled trials (RCTs) has been recognised. Although the number of RCTs has increased, there remains a relative paucity of truly impactful trials in the field. However, those trials that have changed practice have demonstrated the potential and importance of this work. Examples include the PRIMACORP trial, which established the safety and efficacy of milrinone after cardiac surgery, and the Single Ventricle Reconstruction trial, which was the first multicentre pediatric cardiac surgical RCT. The successful conduct and important findings emanating from these trials serve as beacons as clinicians strive to improve the evidence base in this field. The establishment of national and international networks such as the Pediatric Heart Network and the Canadian Pediatric Cardiology Research Network provide a strong foundation for future collaborative work. Despite this progress, there remain important challenges to designing and executing RCTs in pediatric cardiology. These include issues of greater disease and patient heterogeneity and increased costs. The use of innovative study designs and analytic methods and the establishment of core outcome measures have the potential to overcome some of the issues related to the smaller patient numbers compared with adult disciplines. As pediatric cardiologists look to the future, it is imperative that we work together to derive the maximum benefit from the considerable efforts directed toward conducting impactful clinical trials in pediatric cardiology.
Collapse
Affiliation(s)
- Kevin C Harris
- Children's Heart Centre, British Columbia Children's Hospital &-University of British Columbia, Vancouver, British Columbia, Canada.
| | - Andrew S Mackie
- Division of Pediatric Cardiology, Department of Pediatrics Stollery Children's Hospital. University of Alberta, Edmonton, Alberta, Canada
| | - Frederic Dallaire
- Division of Pediatric Cardiology, Department of Pediatrics, Sherbrooke University, Sherbrooke, Québec, Canada
| | - Michael Khoury
- Division of Pediatric Cardiology, Department of Pediatrics Stollery Children's Hospital. University of Alberta, Edmonton, Alberta, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - William T Mahle
- Division of Pediatric Cardiology, Emory University, Atlanta, Georgia, USA
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba and Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Rome BN, Kesselheim AS. Transferrable Market Exclusivity Extensions to Promote Antibiotic Development: An Economic Analysis. Clin Infect Dis 2021; 71:1671-1675. [PMID: 31630159 DOI: 10.1093/cid/ciz1039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/15/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To address the growing threat of multidrug-resistant organisms, policymakers are seeking ideas to promote development of novel antibiotics. In 2018, the REVAMP Act was proposed in Congress to reward manufacturers of certain novel antibiotics with transferrable market exclusivity vouchers. METHODS We estimated the economic impact of this proposal by identifying antimicrobial drugs approved by the FDA from 2007-2016 that would likely have qualified for an exclusivity voucher and matching each drug to the highest-revenue fast-track drug facing generic entry within 4 years after the antibiotic was approved. Assuming a spending decrease of 75% after generic entry, we calculated the per-drug and total societal costs of these transferrable market exclusivity extensions over a decade. RESULTS We identified 10 antimicrobials that would have qualified for an exclusivity voucher, each of which was matched with 1 of 17 fast-track drugs facing generic entry through July 2019. These 10 drugs had a median annual revenue before generic entry of $249 million (range, $26 million-$2.7 billion). Accounting for a 75% spending reduction after generic entry, the median excess spending associated with 12 months of extended exclusivity was $187 million, for a total of $4.5 billion over 10 years. CONCLUSIONS While market exclusivity extensions are a politically appealing mechanism to encourage novel antibiotic development, this approach would cost public and private payers billions of dollars over the next decade.
Collapse
Affiliation(s)
- Benjamin N Rome
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
8
|
Rose K, Tanjinatus O, Grant-Kels JM, Ettienne EB, Striano P, Neubauer D. Minors and a Dawning Paradigm Shift in "Pediatric" Drug Development. J Clin Pharmacol 2021; 61:736-739. [PMID: 33368372 DOI: 10.1002/jcph.1806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/19/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Klaus Rose
- klausrose Consulting, Riehen, Switzerland
| | | | | | | | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, "G. Gaslini" Institute, Genova, Italy
| | - David Neubauer
- Department of Child, Adolescent & Developmental Neurology, University Childrens' Hospital, Ljubljana, Slovenia
| |
Collapse
|
9
|
Olson MK, Yin N. New clinical information and physician prescribing: How do pediatric labeling changes affect prescribing to children? HEALTH ECONOMICS 2021; 30:144-164. [PMID: 33137242 DOI: 10.1002/hec.4182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 09/22/2020] [Accepted: 10/05/2020] [Indexed: 06/11/2023]
Abstract
Our study examines how physician prescribing responds to new scientific information added to drug labels. We focus on a series of label changes with new information about the effects of drugs in children. The information arose in response to a 1997 policy, pediatric exclusivity, which gave drug sponsors a 6-month exclusivity extension for conducting additional pediatric studies of already marketed drugs. The information from these studies was expected to improve pediatric prescribing by promoting appropriate use and by reducing inappropriate off-label prescribing. However, there has been little study about the actual effects of these labeling changes on physician prescribing behavior. We use a difference-in-differences strategy to examine how pediatric prescriptions respond to different types of labeling changes. Our results show that most label changes lead to reductions in prescribing to children. We find that the largest drop in prescribing occurs when the label indicates a drug is not effective for children. The evidence suggests that the labeling changes alleviated physician uncertainty about prescribing drugs to children and reduced some inappropriate off-label use.
Collapse
Affiliation(s)
- Mary K Olson
- Department of Economics, The Murphy Institute, Tulane University, New Orleans, Louisiana, USA
| | - Nina Yin
- Center for Human Capital and Labor Market Research, Central University of Finance and Economics, Beijing, China
| |
Collapse
|
10
|
Zupancic JAF. Cost-effectiveness and pricing of caffeine. Semin Fetal Neonatal Med 2020; 25:101179. [PMID: 33277220 DOI: 10.1016/j.siny.2020.101179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In a formal economic evaluation ancillary to the Caffeine for Apnea of Prematurity trial, caffeine was shown to reduce costs while simultaneously improving clinical outcomes. Although these results still apply, the current price of caffeine is substantially higher than when it was introduced. Such pharmaceutical price growth contributes appreciably to medical costs and inflation. In this review, the examples of caffeine and surfactant show how prices are determined for the neonatology formulary. Drivers include small market size, government-imposed barriers to competition designed to encourage innovation, high willingness-to-pay, failure of government buyers to exercise their market power, and asymmetries in knowledge about costs and effects between producers and patients. Many of these factors are exercised at the national policy or market levels. However, by conducting rigorous clinical trials and economic evaluations, neonatologists can still ensure that the drugs they prescribe are both efficacious and represent good use of societal resources.
Collapse
Affiliation(s)
- John A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Rose Building Room 333, Boston, MA, USA; Division of Newborn Medicine, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
11
|
Horavova L, Nebeska K, Souckova L, Demlova R, Babula P. The Current Status of European and National Financial Sources for Clinical Research and Their Impact on Paediatric Non-commercial Clinical Trials: A Case Study of the Czech Republic. Ther Innov Regul Sci 2020; 54:1461-1472. [PMID: 32504401 PMCID: PMC7704485 DOI: 10.1007/s43441-020-00173-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/28/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Paediatric non-commercial interventional clinical trials (NICTs) are crucial for healthcare provision. In spite of the fact that current regulations and initiatives try to enhance the quantity and quality of paediatric NICTs, there are still shortcomings that need to be addressed in order to accelerate the conduct of relevant clinical trials in children. To improve the current landscape of paediatric clinical research, it is necessary to identify and analyse the main trends and shortcomings, along with their impact on national performance in paediatric NICTs and this is the aim of this work. METHOD A retrospective systematic search of paediatric NICTs was performed on four international clinical trials registries. Entries were filtered by date from 01/01/2004 to 31/12/2017. Each identified paediatric NICT was screened and analysed for sponsors, funders, type of intervention, therapeutic area, design characteristics and associated publications. RESULTS The search identified 439 unique NICTs. When stratifying the trials by enrolment ages, 86 trials were found involving the paediatric population. Most trials investigated the use of medicinal products and were focused on cancer or cardiovascular diseases. The most common sources of the funding were non-profit organizations. Furthermore, from the total number of completed trials, only half of them already published their results. CONCLUSION The main shortcomings-specifically, ethical, methodological and, in particular, economic obstacles were identified. There is a continual need for greater support and collaboration between all major stakeholders including health policymakers, grant agencies, research institutions, pharmaceutical industries and healthcare providers at the national and international level.
Collapse
Affiliation(s)
- L Horavova
- Department of Applied Pharmacy, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic.
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00, Brno, Czech Republic.
| | - K Nebeska
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00, Brno, Czech Republic
| | - L Souckova
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00, Brno, Czech Republic
- University Hospital St. Anne's Brno - International Clinical Research Center, Brno, Czech Republic
| | - R Demlova
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00, Brno, Czech Republic
- University Hospital St. Anne's Brno - International Clinical Research Center, Brno, Czech Republic
- Department of Clinical Trials, Masaryk Memorial Cancer Institute Brno, Brno, Czech Republic
| | - P Babula
- Department of Applied Pharmacy, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
- Department of Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| |
Collapse
|
12
|
Rose K, Neubauer D, Grant-Kels JM. Ethical Issues in Pediatric Regulatory Studies Involving Placebo Treatment. JOURNAL OF PEDIATRIC EPILEPSY 2020. [DOI: 10.1055/s-0040-1712147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AbstractSeparate pediatric studies for antiepileptic drugs (AEDs) emerged with general separate drug approval in children and were defined by the U.S. Food and Drug Administration (FDA) as <17 years and by the European Union (EU) as <18 years. These administrative age limits are necessary in pediatrics, but they correspond variably with the physiological maturity of young patients and are not helpful for therapeutic decisions or as study inclusion criteria. AEDs are often effective for partial onset seizures (POS) in 2 to 17-year-olds as well as in ≥18-year-olds, if dosed correctly. Separate pediatric AED studies assume no difference between the legal and the physiological meaning of the word “child.” While the FDA now accepts efficacy of AEDs in POS in children ≥2 years, the EU still requires separate “pediatric” studies. For retigabine it waived all pediatric studies after having required 20 such studies over several years. We feel the current regulation creates a situation where many studies in children are done unnecessarily; we question the ethics of such an approach, which in our view, is morally wrong. Critical publications contributed to the FDA's shift of opinion for AEDs in POS but did not address the blur of different meanings of the word “child.”
Collapse
Affiliation(s)
- Klaus Rose
- Klausrose Consulting, Riehen, Switzerland
| | - David Neubauer
- Department of Child, Adolescent and Developmental Neurology, University Childrens' Hospital, Ljubljana, Slovenia
| | - Jane M. Grant-Kels
- Department of Dermatology, UConn Health, Farmington, Connecticut, United States
| |
Collapse
|
13
|
McLaughlin M. Safe and effective medication utilization in pediatric patients requiring rehabilitation services during the Coronavirus pandemic of 2019. J Pediatr Rehabil Med 2020; 13:221-223. [PMID: 33185613 DOI: 10.3233/prm-200026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The role of pediatric rehabilitation providers during the Coronavirus Disease 2019 (COVID) pandemic of 2020 highlighted the need for improved knowledge about medications utilized in pediatric patients. Pediatric patients with cerebral palsy who were previously receiving botulinum toxin injections on a regular basis went prolonged periods of time between injections, and patients who have intrathecal baclofen pumps were called in to get refills with different intervals. The medically complex patients treated by rehabilitation providers were limited in the type and scope of care they received, and some may have developed adverse outcomes related to this delay in care. As a Pediatric Physiatrist who has advanced training and significant research experience within the realm of Clinical Pharmacology, I have seen this pandemic demonstrate the Sisyphean challenge of continuing appropriate tone management in patients with cerebral palsy while ensuring those patients with neuromuscular conditions maintain their highest level of function. Both of these clinical problems received significant attention within this issue, which I hope allows providers taking care of these populations a reference point to take to the bedside.
Collapse
|
14
|
Ody C, Schmitt M. Who cares about a label? The effect of pediatric labeling changes on prescription drug utilization. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2019; 19:419-447. [PMID: 30887158 DOI: 10.1007/s10754-019-09265-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 03/06/2019] [Indexed: 06/09/2023]
Abstract
Off-label drug use is common, particularly in pediatric populations. In response, legislation requires and/or provides financial incentives for drug manufacturers to perform pediatric clinical trials. Using New Hampshire's all-payer claims database, we examine the impact of subsequent changes to drug labeling on pediatric drug utilization. To separate changes in utilization induced by labeling changes from other temporal factors, we estimate difference-in-differences models that compare utilization trends for pediatric patients to those of adults. We estimate that establishing safety and efficacy increases a drug's market share by (a statistically significant) 2.8 percentage points, whereas failure to do so decreases a drug's market share by (a statistically insignificant) 0.9 percentage points. We then interpret these estimates within the context of public and market incentives to conduct pediatric clinical trials.
Collapse
|
15
|
Rose K, Grant-Kels JM. The Meanings of "Pediatric Drug Development". Ther Innov Regul Sci 2019; 53:767-774. [PMID: 30526039 DOI: 10.1177/2168479018812060] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 10/18/2018] [Indexed: 07/09/2024]
Abstract
Pediatric drug development (PDD) became an industry goal when the Food and Drug Administration (FDA) granted patent extensions. This was later expanded to obligations for pediatric studies and to the European Medicines Agency's (EMA's) strict pediatric investigation plans (PIPs). Industry now sponsors many often international studies in young patients that are difficult or impossible to recruit. PDD's intellectual foundations characterize children as "therapeutic orphans," allegedly discriminated in drug treatment and development. While toxicities occured in newborns, demanding separate efficacy and safety (E&S) studies in all age groups is wasteful and reflects hidden conflicts of interest. The American Academy of Pediatrics (AAP) successfully procured pediatric research funds; the FDA dislikes pediatric off-label use and envisions labels as instructions for physicians. Pediatricians have continuously improved child health care by careful use of available drugs. Instead of physiologically defining children vis-à-vis drug treatment, the FDA defines children as ≤16 years old, offering convincing pretense for the need for mostly senseless "pediatric" studies in young adults, adolescents, and children. Although these studies may help advance pediatric academic careers, they do not improve pediatric health care. The EMA defines children as <18 years old and demands even more senseless and potentially harmful "pediatric" studies. Young patients need pharmacokinetic/pharmacodynamic and dose finding, but not separate E&S, studies. Institutional review boards and ethics committees should suspend or reject questionable FDA/EMA-demanded "pediatric" studies. Industry and science need repositioning towards "PDD"; US/EU pediatric laws need revision. We hope this will not take decades.
Collapse
Affiliation(s)
- Klaus Rose
- klausrose Consulting, Riehen, BS, Switzerland
| | | |
Collapse
|
16
|
Rose K, Neubauer D, Grant-Kels JM. Too Many Avoidable Suicides Occur Worldwide in Young Patients. Rambam Maimonides Med J 2019; 10:RMMJ.10374. [PMID: 31545703 PMCID: PMC6824826 DOI: 10.5041/rmmj.10374] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
United States (US) and European Union (EU) laws attempt to counterbalance the presumed discrimination of children in drug treatment and drug development. The US Food and Drug Administration (FDA)-rewarded pediatric studies with antidepressants triggered in 2004 an FDA black-box warning of suicidality in young patients. Fewer antidepressants were prescribed, and the number of completed suicides of young persons increased. The dilemma between this warning and the need to adequately treat young depressed patients remains unsolved. We analyzed the history of drug development, the evolving view of diseases in young patients, US/EU pediatric laws, and pediatric studies triggered by FDA/European Medicines Agency (EMA) in depression and other diseases on the background of developmental pharmacology; financial, institutional, and other interests; and the literature. The FDA/EMA define children administratively, not physiologically, as <17 (FDA)/<18 years old (EMA). But young persons mature physiologically well before their 17th/18th birthday. Depression occurs in young persons, has special characteristics, but is not fundamentally different from adult depression. Young persons are not another species. Regulatory requirements for "pediatric" studies focus on "pediatric" labels. Many "pediatric" studies, including those in depression, lacked and lack medical sense and harm patients by placebo treatment although effective drugs exist. The FDA has partially abandoned separate "pediatric" efficacy studies, but not in psychiatry. Clinicians, parents, institutional review boards, and ethics committees should become aware of questionable "pediatric" studies, should re-evaluate ongoing ones, consider to suspend them, and to reject new ones. The concept of separate "pediatric" drug approval needs to be abandoned.
Collapse
Affiliation(s)
- Klaus Rose
- klausrose Consulting, Pediatric Drug Development & More, Riehen, Switzerland
- To whom correspondence should be addressed: E-mail:
| | - David Neubauer
- Department of Child, Adolescent and Developmental Neurology, University Children’s Hospital, Ljubljana, Slovenia
| | | |
Collapse
|
17
|
Rose K, Neubauer D, Grant-Kels JM. Rational Use of Medicine in Children-The Conflict of Interests Story. A Review. Rambam Maimonides Med J 2019; 10:RMMJ.10371. [PMID: 31335307 PMCID: PMC6649781 DOI: 10.5041/rmmj.10371] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND United States (US) and European Union (EU) legislation attempts to counterbalance the presumed discrimination in pediatric drug treatment and development. METHODS We analyzed the history of drug development, US/EU pediatric laws, and pediatric studies required by US/EU regulatory authorities and reviewed relevant literature. RESULTS The US and EU definitions of a child are defined administratively (rather than physiologically) as being aged <17 years and <18 years, respectively. However, children mature physiologically well before their seventeenth or eighteenth birthdays. The semantic blur for these differing definitions may indicate certain conflicts of interest. CONCLUSIONS Pediatric healthcare today is better than ever. Regulatory-related requirements for "pediatric" studies focus on labeling. Most of these studies lack medical usefulness and may even harm "pediatric" patients through administration of placebo and/or substandard treatment, despite the resultant publications, networking, patent extensions, and strengthened regulatory standing. Clinicians, parents, and ethics committees should be aware of these issues. New rules are needed to determine new pharmaceutical dose estimates in prepubescent patients, and when/how to clinically confirm them. Internet-based structures to divulge this information should be established between drug developers, clinicians, and regulatory authorities. A prerequisite for the rational use of pharmaceuticals in children would be to correct the flawed concept that children are discriminated against in drug treatment and development, and to abandon separate "pediatric" drug approval processes.
Collapse
Affiliation(s)
- Klaus Rose
- klausrose Consulting, Pediatric Drug Development & More, Riehen, Switzerland
| | - David Neubauer
- Department of Child, Adolescent and Developmental Neurology, University Children’s Hospital, Ljubljana, Slovenia
| | | |
Collapse
|
18
|
Baum VC, Bax R, Heon D, Yang Z, Sakiyama M. Pediatric drug regulation: International perspectives. Paediatr Anaesth 2019; 29:572-582. [PMID: 30924233 DOI: 10.1111/pan.13638] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/21/2019] [Accepted: 03/21/2019] [Indexed: 11/29/2022]
Abstract
There was a time when the predominant approach to exposing children to new drugs was to protect children from research. This has evolved over the past several decades into protecting children through research. To encourage pediatric studies and approval of pediatric medicines, governments have provided financial incentives as well as obligations/requirements for pharmaceutical companies to carry out pediatric studies in certain circumstances. The unique considerations for children have been acknowledged by the various governments and drug regulatory agencies through international dialogue and cooperation among patient and patient care representatives, regulatory agencies, and academic, clinical and manufacturing stakeholders. We describe pediatric drug regulation in five of the largest international drug regulatory agencies and additionally discuss efforts at international cooperation and discussion in pediatric drug regulation.
Collapse
Affiliation(s)
- Victor C Baum
- Departments of Anesthesiology & Critical Care Medicine and Pediatrics, George Washington University, Washington, District of Columbia
| | - Ralph Bax
- Paediatric Medicines Office, Product Development Scientific Support Department, European Medicines Agency, London, UK
| | - Dominique Heon
- Bureau of Medical Sciences, Health Canada, Ottawa, Ontario, Canada
| | - Zhimin Yang
- Office of Clinical Evaluation 1, Center for Drug Evaluation, Chinese National Drug Administration, Beijing, China
| | - Michiyo Sakiyama
- Pediatric Drugs Working Group/Office of Vaccines and Blood Products, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| |
Collapse
|
19
|
Rose K, Grant-Kels JM. Pediatric melanoma-The whole (conflicts of interest) story. Int J Womens Dermatol 2019; 5:110-115. [PMID: 30997384 PMCID: PMC6451736 DOI: 10.1016/j.ijwd.2018.10.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/25/2018] [Accepted: 10/09/2018] [Indexed: 01/13/2023] Open
Affiliation(s)
- Klaus Rose
- klausrose Consulting, Riehen, Switzerland
| | | |
Collapse
|
20
|
Rose K. The Challenges of Pediatric Drug Development. CURRENT THERAPEUTIC RESEARCH 2019; 90:128-134. [PMID: 31388368 PMCID: PMC6677568 DOI: 10.1016/j.curtheres.2019.01.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 01/18/2019] [Accepted: 01/18/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND BACKGROUND "Pediatric Drug Development" is being used to describe not the development of drugs for children, but rather the planning & conducting separate efficacy and safety (E&S) studies requested/demanded by regulatory authorities designed to produce pediatric labels. Pediatric studies required for drug approval enroll "children"; defined as <17 years of age (US Food and Drug Administration [FDA])/ <18 years (European Union [EU]). The medical rationale for study designs was examined. MATERIAL & METHODS International industry-sponsored pediatric E&S studies registered in www.clinicaltrials.gov were analysed along with the history of US/EU laws, published literature, internet-retrieved regulatory documents, and regulatory/ American Academy of Pediatrics (AAP) justifications for doing separate pediatric E&S studies. RESULTS US/EU regulators utilize an official, but non-physiological definition of childhood based on an age limit of 17/18 years. This definition, which blurs the interface between medicine and law, emerged after clinical studies became required for drug approval in 1962 prompting drug manufacturers to insert pediatric warnings into product information. Intended largely as legal protection against liability, they were interpreted medically. Absorption, distribution, metabolism, excretion mature rapidly. Drug toxicities seen in newborns during the first months of life were cited by AAP/FDA in warnings of dangers of drugs in all "children" including in adolescents who are physiologically no longer children. Warnings were/are exaggerated, exploit/ed parents' protective instincts and fears, and increase/d pediatric clinical trial activity. Conflicts of interest created by this increased activity involve research funding, career status & advancement, commercial profits. DISCUSSION FDA/EMA-requested/demanded "pediatric" studies were identified which lack medical sense at best, others actually harm young patients by impeding use of superior, effective treatments. Separate labels for different indications make medical sense; separate approval in persons above/below 17/18 years of age does not. CONCLUSIONS Pediatric medical research should be restricted to studies which meet important medical needs of all recruited young patients, which generate information that cannot be obtained by other study designs, and do not limit access to superior alternative therapies. Clinical centers, investigators, and IRBs/ECs should more carefully examine studies for unjustified regulatory demands, prevention of subjects' access to superior treatments, and undeclared COI's. Questionable studies should not be approved and ongoing ones should be suspended.
Collapse
|
21
|
Sinha MS, Najafzadeh M, Rajasingh EK, Love J, Kesselheim AS. Labeling Changes and Costs for Clinical Trials Performed Under the US Food and Drug Administration Pediatric Exclusivity Extension, 2007 to 2012. JAMA Intern Med 2018; 178:1458-1466. [PMID: 30264138 PMCID: PMC6248195 DOI: 10.1001/jamainternmed.2018.3933] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/22/2018] [Indexed: 12/19/2022]
Abstract
Importance Pharmaceutical manufacturers can receive 6 additional months of market exclusivity for performing pediatric clinical trials of brand-name drugs widely used in adults. Congress created this incentive in 1997 because these drugs were being used off-label in children without such trials. Objective To review updates to drug labeling and the cost to consumers of extending market exclusivity related to the pediatric exclusivity program. Design From government records, we identified 54 drugs that earned the pediatric exclusivity incentive between 2007 and 2012. We evaluated labeling changes from the pediatric studies. We then extracted trial details from clinical review documents and used industry estimates of trial costs on a per-patient basis to estimate cost of investment for trials (with a 10% cost of capital). To calculate the net return and cost to consumers during the 6-month exclusivity period, we estimated additional revenue for the 48 drugs with available information. Main Outcomes and Measures For each drug, we evaluated labeling changes and costs associated with pediatric trials under the Best Pharmaceuticals for Children Act and the cost to consumers of 6-month market exclusivity extensions. Results The 141 trials in our sample enrolled 20 240 children (interquartile range [IQR], 2-3 trials and 127-556 patients per drug). These trials led to 29 extended indications and 3 new indications, as well as new safety information for 16 drugs. Median cost of investment for trials was $36.4 million (IQR, $16.6 to $100.6 million). Among 48 drugs with available financial information, median net return was $176.0 million (IQR, $47.0 million to $404.1 million), with a median ratio of net return to cost of investment of 680% (IQR, 80% to 1270%). Conclusions and Relevance Clinical trials conducted under the US Food and Drug Administration's pediatric exclusivity program have provided important information about the effectiveness and safety of drugs used in children. The costs to consumers have been high, exceeding the estimated costs of investment for conducting the trials. As an alternative, policymakers should consider direct funding of such studies.
Collapse
Affiliation(s)
- Michael S. Sinha
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mehdi Najafzadeh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - James Love
- Knowledge Ecology International (KEI), Washington, DC
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
22
|
Sarpatwari A, Beall RF, Abdurrob A, He M, Kesselheim AS. Evaluating The Impact Of The Orphan Drug Act’s Seven-Year Market Exclusivity Period. Health Aff (Millwood) 2018; 37:732-737. [DOI: 10.1377/hlthaff.2017.1179] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ameet Sarpatwari
- Ameet Sarpatwari is an instructor of medicine at Harvard Medical School and assistant director of the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital, both in Boston, Massachusetts
| | - Reed F. Beall
- Reed F. Beall is a postdoctoral fellow in the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital and a research fellow at Harvard Medical School
| | | | - Mengdong He
- Mengdong He is a research scientist at Brigham and Women’s Hospital
| | - Aaron S. Kesselheim
- Aaron S. Kesselheim is an associate professor of medicine at Harvard Medical School and director of the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital
| |
Collapse
|
23
|
Torok RD, Li JS, Kannankeril PJ, Atz AM, Bishai R, Bolotin E, Breitenstein S, Chen C, Diacovo T, Feltes T, Furlong P, Hanna M, Graham EM, Hsu D, Ivy DD, Murphy D, Kammerman LA, Kearns G, Lawrence J, Lebeaut B, Li D, Male C, McCrindle B, Mugnier P, Newburger JW, Pearson GD, Peiris V, Percival L, Pina M, Portman R, Shaddy R, Stockbridge NL, Temple R, Hill KD. Recommendations to Enhance Pediatric Cardiovascular Drug Development: Report of a Multi-Stakeholder Think Tank. J Am Heart Assoc 2018; 7:JAHA.117.007283. [PMID: 29440007 PMCID: PMC5850184 DOI: 10.1161/jaha.117.007283] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Rachel D Torok
- Duke University and the Duke Clinical Research Institute, Durham, NC
| | - Jennifer S Li
- Duke University and the Duke Clinical Research Institute, Durham, NC
| | | | - Andrew M Atz
- Medical University of South Carolina, Charleston, SC
| | | | | | | | | | | | | | | | | | - Eric M Graham
- Medical University of South Carolina, Charleston, SC
| | - Daphne Hsu
- Albert Einstein College of Medicine, New York, NY
| | | | | | | | | | | | | | | | | | | | | | | | - Gail D Pearson
- US National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Vasum Peiris
- US Food and Drug Administration , Silver Spring, MD
| | | | | | | | | | | | | | - Kevin D Hill
- Duke University and the Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
24
|
Ward RM, Benjamin DK, Davis JM, Gorman RL, Kauffman R, Kearns GL, Murphy MD, Sherwin CMT. The Need for Pediatric Drug Development. J Pediatr 2018; 192:13-21. [PMID: 28942898 PMCID: PMC7942021 DOI: 10.1016/j.jpeds.2017.08.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/29/2017] [Accepted: 08/04/2017] [Indexed: 12/19/2022]
Affiliation(s)
| | | | - Jonathan M. Davis
- Tufts University School of Medicine, Neonatal Advisory Committee in the Office of the FDA Commissioner
| | - Richard L. Gorman
- Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Research Institute
| | - Ralph Kauffman
- Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Research Institute
| | - Gregory L. Kearns
- Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Research Institute
| | | | | |
Collapse
|
25
|
Speich B, von Niederhäusern B, Schur N, Hemkens LG, Fürst T, Bhatnagar N, Alturki R, Agarwal A, Kasenda B, Pauli-Magnus C, Schwenkglenks M, Briel M. Systematic review on costs and resource use of randomized clinical trials shows a lack of transparent and comprehensive data. J Clin Epidemiol 2017; 96:1-11. [PMID: 29288136 DOI: 10.1016/j.jclinepi.2017.12.018] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 12/05/2017] [Accepted: 12/20/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Randomized clinical trials (RCTs) are costly. We aimed to provide a systematic overview of the available evidence on resource use and costs for RCTs to support budget planning. STUDY DESIGN AND SETTING We systematically searched MEDLINE, EMBASE, and HealthSTAR from inception until November 30, 2016 without language restrictions. We included any publication reporting empirical data on resource use and costs of RCTs and categorized them depending on whether they reported (i) resource and costs of all aspects at all study stages of an RCT (including conception, planning, preparation, conduct, and all tasks after the last patient has completed the RCT); (ii) on several aspects, (iii) on a single aspect (e.g., recruitment); or (iv) on overall costs for RCTs. Median costs of different recruitment strategies were calculated. Other results (e.g., overall costs) were listed descriptively. All cost data were converted into USD 2017. RESULTS A total of 56 articles that reported on cost or resource use of RCTs were included. None of the articles provided empirical resource use and cost data for all aspects of an entire RCT. Eight articles presented resource use and cost data on several aspects (e.g., aggregated cost data of different drug development phases, site-specific costs, selected cost components). Thirty-five articles assessed costs of one specific aspect of an RCT (i.e., 30 on recruitment; five others). The median costs per recruited patient were USD 409 (range: USD 41-6,990). Overall costs of an RCT, as provided in 16 articles, ranged from USD 43-103,254 per patient, and USD 0.2-611.5 Mio per RCT but the methodology of gathering these overall estimates remained unclear in 12 out of 16 articles (75%). CONCLUSION The usefulness of the available empirical evidence on resource use and costs of RCTs is limited. Transparent and comprehensive resource use and cost data are urgently needed to support budget planning for RCTs and help improve sustainability.
Collapse
Affiliation(s)
- Benjamin Speich
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Switzerland
| | - Belinda von Niederhäusern
- Clinical Trial Unit, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Nadine Schur
- Institute of Pharmaceutical Medicine, University of Basel, Basel, Switzerland
| | - Lars G Hemkens
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Switzerland
| | - Thomas Fürst
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland; School of Public Health, Imperial College London, London, United Kingdom
| | - Neera Bhatnagar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Reem Alturki
- Multi Organ Transplant Center, King Fahad Specialist Hospital Dammam, P.O. Box 15215, Dammam 31444, Saudi Arabia
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Kasenda
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Switzerland; Department of Medical Oncology, University of Basel and University Hospital Basel, Switzerland
| | - Christiane Pauli-Magnus
- Clinical Trial Unit, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Matthias Schwenkglenks
- Institute of Pharmaceutical Medicine, University of Basel, Basel, Switzerland; Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zürich, Switzerland
| | - Matthias Briel
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University of Basel and University Hospital Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
26
|
Desselas E, Pansieri C, Leroux S, Bonati M, Jacqz-Aigrain E. Drug versus placebo randomized controlled trials in neonates: A review of ClinicalTrials.gov registry. PLoS One 2017; 12:e0171760. [PMID: 28192509 PMCID: PMC5305102 DOI: 10.1371/journal.pone.0171760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 01/25/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Despite specific initiatives and identified needs, most neonatal drugs are still used off-label, with variable dosage administrations and schedules. In high risk preterm and term neonates, drug evaluation is challenging and randomized controlled trials (RCT) are difficult to conduct and even more is the use of a placebo, required in the absence of a reference validated drug to be used as comparator. METHODS We analyzed the complete ClinicalTrials.gov registry 1) to describe neonatal RCT involving a placebo, 2) to report on the medical context and ethical aspects of placebo use. RESULTS Placebo versus drug RCT (n = 146), either prevention trials (n = 57, 39%) or therapeutic interventions (n = 89, 61%), represent more than a third of neonatal trials registered in the National Institute of Health clinical trial database (USA) since 1999. They mainly concerned preterm infants, evaluating complications of prematurity. Most trials were conducted in the USA, were single centered, and funded by non-profit organizations. For the three top drug trials evaluating steroids (n = 13, 9.6%), erythropoietin (EPO, n = 10, 6.8%) and nitric oxide (NO, n = 9, 6.2%), the objectives of the trial and follow-up were analyzed in more details. CONCLUSION Although a matter of debate, the use of placebo should be promoted in neonates to evaluate a potential new treatment, in the absence of reference drug. Analysis of the trials evaluating steroids showed that long-term follow-up of exposed patients, although required by international guidelines, is frequently missing and should be planned to collect additional information and optimize drug evaluation in these high-risk patients.
Collapse
Affiliation(s)
- Emilie Desselas
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
| | - Claudia Pansieri
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Stephanie Leroux
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
| | - Maurizio Bonati
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
- Université Paris 7 Diderot, Paris, France
| |
Collapse
|
27
|
Kesselheim AS, Rome BN, Sarpatwari A, Avorn J. Six-Month Market Exclusivity Extensions To Promote Research Offer Substantial Returns For Many Drug Makers. Health Aff (Millwood) 2017; 36:362-370. [PMID: 28100464 DOI: 10.1377/hlthaff.2016.1340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To incentivize pharmaceutical manufacturers to invest in areas of unmet medical need, policy makers frequently propose extending the market exclusivity period of desired drugs. Some such proposals are modeled after the pediatric exclusivity patent extension program, which since 1997 has provided six additional months of market exclusivity for drugs studied in children. The most recent proposal would encourage rare disease research by providing six months of extended exclusivity for any existing drug that is granted subsequent FDA approval for a new rare disease indication. Yet the economic impact of such proposals is rarely addressed. We found that for the thirteen FDA-approved drugs that gained supplemental approval for a rare disease indication from 2005 through 2010, the median projected cost of clinical trials leading to approval was $29.8 million. If the exclusivity extension had been in place, the median discounted financial gain to manufacturers would have been $94.6 million. Median net returns would have been $82.4 million, with higher returns for drugs with higher annual sales. Extending market exclusivity would provide substantial compensation to many manufacturers, particularly for top-selling products, far in excess of the cost of conducting these trials. Alternative strategies to incentivize the study of approved drugs for rare diseases may offer similar benefits at a lower cost.
Collapse
Affiliation(s)
- Aaron S Kesselheim
- Aaron S. Kesselheim is an associate professor of medicine at Harvard Medical School and director of the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital, both in Boston, Massachusetts
| | - Benjamin N Rome
- Benjamin N. Rome is a resident physician at Brigham and Women's Hospital
| | - Ameet Sarpatwari
- Ameet Sarpatwari is an instructor in medicine at Harvard Medical School and assistant director of the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital
| | - Jerry Avorn
- Jerry Avorn is a professor of medicine at Harvard Medical School and chief of the Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital
| |
Collapse
|
28
|
Grabowski HG, DiMasi JA, Long G. The roles of patents and research and development incentives in biopharmaceutical innovation. Health Aff (Millwood) 2016; 34:302-10. [PMID: 25646111 DOI: 10.1377/hlthaff.2014.1047] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patents and other forms of intellectual property protection play essential roles in encouraging innovation in biopharmaceuticals. As part of the "21st Century Cures" initiative, Congress is reviewing the policy mechanisms designed to accelerate the discovery, development, and delivery of new treatments. Debate continues about how best to balance patent and intellectual property incentives to encourage innovation, on the one hand, and generic utilization and price competition, on the other hand. We review the current framework for accomplishing these dual objectives and the important role of patents and regulatory exclusivity (together, the patent-based system), given the lengthy, costly, and risky biopharmaceutical research and development process. We summarize existing targeted incentives, such as for orphan drugs and neglected diseases, and we consider the pros and cons of proposed voluntary or mandatory alternatives to the patent-based system, such as prizes and government research and development contracting. We conclude that patents and regulatory exclusivity provisions are likely to remain the core approach to providing incentives for biopharmaceutical research and development. However, prizes and other voluntary supplements could play a useful role in addressing unmet needs and gaps in specific circumstances.
Collapse
Affiliation(s)
- Henry G Grabowski
- Henry G. Grabowski is a professor of economics at Duke University, in Durham, North Carolina
| | - Joseph A DiMasi
- Joseph A. DiMasi is director of economic analysis at the Tufts Center for the Study of Drug Development, Tufts University, in Boston, Massachusetts
| | - Genia Long
- Genia Long is a senior advisor at the Analysis Group, in Boston, Massachusetts
| |
Collapse
|
29
|
Hsu DT, Shaddy RE. Advantages, disadvantages and alternatives to using adult heart failure clinical trials to guide pediatric heart failure therapy. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
30
|
Thompson EM, Gururangan S, Grant G, Mitchell D, Sampson JH. The clinical and financial impact of a pediatric surgical neuro-oncology clinical trial. J Neurooncol 2016; 132:83-87. [DOI: 10.1007/s11060-016-2338-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 11/12/2016] [Indexed: 10/20/2022]
|
31
|
Meier-Girard D, Tibi A, Abdoul H, Prot-Labarthe S, Brion F, Bourdon O, Alberti C. Academic pediatric clinical research: factors associated with study implementation duration. BMC Med Res Methodol 2016; 16:36. [PMID: 27025840 PMCID: PMC4812626 DOI: 10.1186/s12874-016-0138-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 03/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ethical, methodological, and technical aspects of pediatric research, often results in complications and delays in implementation. Our objective was to identify factors associated with the implementation duration of hospital-based pediatric studies. METHODS All hospital-based pediatric studies sponsored by AP-HP between 2002 and 2008 were retrospectively identified. Association of the funding mechanism and methodological factors with the implementation duration was assessed using a multivariable mixed linear model. Pharmaceutical factors were explored as part of a subgroup analysis restricted to the studies involving drug therapy. Given that we took an exploratory approach, factors associated with implementation duration with p < 0.10 were kept in the final models. RESULTS A total of 139 studies were evaluated. The median implementation duration was 17.1 months (range: 0.9-55.3 months), and tended to increase over time (from 14.9 [25(th) percentile-75(th) percentile: 11.5-19.9] months in 2002 to 23.7 [15.2-31.0] months in 2008, p = 0.01). External (coefficient [95 % confidence interval]: -7.7 [-11.9;-3.5] months, p < 0.001) and internal funding (-5.3 95 % CI [-9.8;-0.8], p = 0.02) compared to governmental funding and number of centers (-0.1 95 % CI[-0.2;0.02] months for 1 center increase, p = 0.07) were associated with reduced duration, whereas interventional study (either involving drug therapy (6.0 95 % CI[0.7;11.3] months, p = 0.03 or not (3.5 95 % CI[-0.3;7.3] months, p = 0.06) was associated with increased duration compared to observational study. Regarding the 35 studies involving drug therapy, external funding decreased duration (-6.7 95 % CI[-13.2;-0.2] months, p = 0.05), whereas studies involving solely a pediatric population (7.8 95 % CI[1.1;14.5] months, p = 0.01) (compared to mixed adult-pediatric population), a placebo-controlled design (6.6 95 % CI[0.9;12.3] months, p = 0.01), and inappropriate drug formulation for at least one drug used in the study (6.9 95 % CI[-0.2;14.0] months, p = 0.06) were associated with increased duration. CONCLUSION Implementation of hospital-based pediatric studies primarily faced delays when they were interventional and, in particular, when they involved drug therapy. Regarding the latter, difficulties that resulted in delayed studies arose with respect to the supply of drugs and placebo in age-appropriate dosages and route of administration. Therefore, difficulties related to the use of pharmaceuticals need to be anticipated earlier in order to avoid implementation delays.
Collapse
Affiliation(s)
- Delphine Meier-Girard
- />Université Paris Diderot, Sorbonne Paris Cité, UMR-1123 ECEVE, F-75019 Paris, France
- />AP-HP, Hôpital Robert Debré, Unité d’Epidémiologie Clinique, F-75019 Paris, France
- />Inserm, U1123 and CICEC 1426, F-75019 Paris, France
- />University of Basel, University Children’s Hospital (UKBB), Basel, Switzerland
- />Department of Paediatric Pulmonology, University Children`s Hospital Basel (UKBB), Spitalstrasse 33, 4056 Basel, Switzerland
| | - Annick Tibi
- />Université Paris Descartes, Sorbonne Paris Cité, F-75270 Paris, France
- />Département d’Essais Cliniques, AP-HP, Agence Générale des Equipements et Produits de Santé, F-75013 Paris, France
| | - Hendy Abdoul
- />Université Paris Diderot, Sorbonne Paris Cité, UMR-1123 ECEVE, F-75019 Paris, France
- />AP-HP, Hôpital Robert Debré, Unité d’Epidémiologie Clinique, F-75019 Paris, France
- />Inserm, U1123 and CICEC 1426, F-75019 Paris, France
| | - Sonia Prot-Labarthe
- />Université Paris Diderot, Sorbonne Paris Cité, UMR-1123 ECEVE, F-75019 Paris, France
- />Inserm, U1123 and CICEC 1426, F-75019 Paris, France
- />AP-HP, Hôpital Robert Debré, Pharmacie à Usage Intérieur, F-75019 Paris, France
| | - Françoise Brion
- />Université Paris Descartes, Sorbonne Paris Cité, F-75270 Paris, France
- />AP-HP, Hôpital Robert Debré, Pharmacie à Usage Intérieur, F-75019 Paris, France
| | - Olivier Bourdon
- />Université Paris Descartes, Sorbonne Paris Cité, F-75270 Paris, France
- />AP-HP, Hôpital Robert Debré, Pharmacie à Usage Intérieur, F-75019 Paris, France
| | - Corinne Alberti
- />Université Paris Diderot, Sorbonne Paris Cité, UMR-1123 ECEVE, F-75019 Paris, France
- />AP-HP, Hôpital Robert Debré, Unité d’Epidémiologie Clinique, F-75019 Paris, France
- />Inserm, U1123 and CICEC 1426, F-75019 Paris, France
| |
Collapse
|
32
|
Dodgen AL, Hill KD. Safety and tolerability considerations in the use of sildenafil for children with pulmonary arterial hypertension. DRUG HEALTHCARE AND PATIENT SAFETY 2015; 7:175-83. [PMID: 26719728 PMCID: PMC4687613 DOI: 10.2147/dhps.s65571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Sildenafil is a phosphodiesterase type-5 inhibitor approved for treatment of pulmonary arterial hypertension (PAH) in adults. Data from pediatric trials demonstrate a similar acute safety profile to the adult population but have raised concerns regarding the safety of long-term use in children. Interpretation of these trials remains controversial with major regulatory agencies differing in their recommendations – the US Food and Drug Administration recommends against the use of sildenafil for treatment of PAH in children, while the European Medicines Agency supports its use at “low doses”. Here, we review the available pediatric data regarding dosing, acute, and long-term safety and efficacy of sildenafil for the treatment of PAH in children.
Collapse
Affiliation(s)
- Andrew L Dodgen
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Kevin D Hill
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA ; Duke Clinical Research Institute, Durham, NC, USA
| |
Collapse
|
33
|
Affiliation(s)
- Adam H. Skolnick
- From the Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York (A.H.S.); and Division of Cardiology, Duke University Medical Center, and Duke Clinical Research Institute, Durham, NC (K.P.A.)
| | - Karen P. Alexander
- From the Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York (A.H.S.); and Division of Cardiology, Duke University Medical Center, and Duke Clinical Research Institute, Durham, NC (K.P.A.)
| |
Collapse
|
34
|
Sarpatwari A, Kesselheim AS. The 21st century cures act: Opportunities and challenges. Clin Pharmacol Ther 2015; 98:575-7. [DOI: 10.1002/cpt.208] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- A Sarpatwari
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts USA
| | - AS Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts USA
| |
Collapse
|
35
|
Wang B, Kesselheim AS. Characteristics of efficacy evidence supporting approval of supplemental indications for prescription drugs in United States, 2005-14: systematic review. BMJ 2015; 351:h4679. [PMID: 26400844 PMCID: PMC4580725 DOI: 10.1136/bmj.h4679] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To characterize the types of comparators and endpoints used in efficacy trials for approvals of supplemental indications, compared with the data supporting these drugs' originally approved indications. DESIGN Systematic review. SETTING Publicly accessible data on supplemental indications approved by the US Food and Drug Administration from 2005 to 2014. MAIN OUTCOME MEASURES Types of comparators (active, placebo, historical, none) and endpoints (clinical outcomes, clinical scales, surrogate) in the efficacy trials for these drugs' supplemental and original indication approvals. RESULTS The cohort included 295 supplemental indications. Thirty per cent (41/136) of supplemental approvals for new indications were supported by efficacy trials with active comparators, compared with 51% (47/93) of modified use approvals and 11% (7/65) of approvals expanding the patient population (P<0.001), almost all of which related to pediatric patients (61/65; 94%). Trials using clinical outcome endpoints led to approval for 32% (44/137) of supplemental approvals for new indications, 30% (28/93) of modified indication approvals, and 22% (14/65) of expanded population approvals (P=0.29). Orphan drugs had supplemental approvals for 40 non-orphan indications, which were supported by similar proportions of trials using active comparators (28% (11/40) for non-orphan supplemental indications versus 24% (10/42) for original orphan indications; P=0.70) and clinical outcome endpoints (25% (10/40) versus 31% (13/42); P=0.55). CONCLUSIONS Wide variations were seen in the evidence supporting approval of supplemental indications, with the fewest active comparators and clinical outcome endpoints used in trials leading to supplemental approvals that expanded the patient population.
Collapse
Affiliation(s)
- Bo Wang
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA 02120, USA
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA 02120, USA
| |
Collapse
|
36
|
Tabor E. Food and Drug Administration Requirements for Clinical Studies in Pediatric Patients. Ther Innov Regul Sci 2015; 49:666-672. [PMID: 30227036 DOI: 10.1177/2168479015596021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many drugs approved by the US Food and Drug Administration (FDA) for use in adults lack adequate data on safety and efficacy in pediatric patients, a potential source of unintended harm to pediatric patients. Through a series of laws, regulations, and guidance documents, the US Congress and FDA have created a program both to encourage and mandate clinical studies in pediatric patients to develop evidence-based dosing, safety, and efficacy information. A "Pediatric Study Plan" (PSP) is required for every new drug. FDA provides incentives for the voluntary conduct of clinical trials in pediatric patients, including opportunities for added marketing exclusivity and for obtaining a "priority review voucher." FDA also mandates that clinical studies for new drugs be conducted in each pediatric age group (newborns, infants, children, and adolescents), except in circumstances where a waiver or a deferral of studies can be justified. Sometimes this mandate can be met by extrapolation from studies in adults, or from patients in one pediatric age group to another, for evidence of efficacy. However, separate studies of safety and dosing are usually required for each pediatric age group. The package insert for each new drug now must address the use in pediatric patients. In addition, the FDA website displays all changes in drug labeling related to pediatric patients (excerpted from the labels for easy access), summaries of all pediatric studies that have led to labeling changes, links to FDA medical reviews of pediatric studies, summaries of all pediatric safety issues presented to the FDA Pediatric Advisory Committee (with links to the meeting materials and transcripts), and details of deferred pediatric studies with their timelines and progress. These measures reflect the increasing attention by FDA and the medical community to the importance of clinical studies in pediatric patients.
Collapse
|
37
|
Paediatric cardiovascular clinical trials: an analysis of ClinicalTrials.gov and the Food and Drug Administration Pediatric Drug Labeling Database. Cardiol Young 2015; 25 Suppl 2:172-80. [PMID: 26377725 PMCID: PMC4591024 DOI: 10.1017/s1047951115000980] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent regulatory initiatives in the United States of America and Europe have transformed the paediatric clinical trials landscape by significantly increasing capital investment and paediatric trial volume. The purpose of this manuscript was to review the impact of these initiatives on the paediatric cardiovascular trials landscape when compared with other paediatric sub-specialties. We also evaluate factors that may have contributed to the success or failure of recent major paediatric cardiovascular trials so as to inform the optimal design and conduct of future trials in the field.
Collapse
|
38
|
Hsu DT. Challenges of designing multicenter trials in pediatric heart failure. PROGRESS IN PEDIATRIC CARDIOLOGY 2015. [DOI: 10.1016/j.ppedcard.2015.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
39
|
Affiliation(s)
- Alison Haywood
- School of Pharmacy; Griffith University, Gold Coast Campus
| | - Beverley Glass
- School of Pharmacy and Molecular Sciences; James Cook University; Townsville Queensland
| |
Collapse
|
40
|
Joseph PD, Craig JC, Caldwell PHY. Clinical trials in children. Br J Clin Pharmacol 2015; 79:357-69. [PMID: 24325152 PMCID: PMC4345947 DOI: 10.1111/bcp.12305] [Citation(s) in RCA: 203] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/28/2013] [Indexed: 12/31/2022] Open
Abstract
Safety and efficacy data on many medicines used in children are surprisingly scarce. As a result children are sometimes given ineffective medicines or medicines with unknown harmful side effects. Better and more relevant clinical trials in children are needed to increase our knowledge of the effects of medicines and to prevent the delayed or non-use of beneficial therapies. Clinical trials provide reliable evidence of treatment effects by rigorous controlled testing of interventions on human subjects. Paediatric trials are more challenging to conduct than trials in adults because of the paucity of funding, uniqueness of children and particular ethical concerns. Although current regulations and initiatives are improving the scope, quantity and quality of trials in children, there are still deficiencies that need to be addressed to accelerate radically equitable access to evidence-based therapies in children.
Collapse
Affiliation(s)
- Pathma D Joseph
- The Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
| | - Jonathan C Craig
- School of Public Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
| | - Patrina HY Caldwell
- The Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
| |
Collapse
|
41
|
Rose K. European Union pediatric legislation jeopardizes worldwide, timely future advances in the care of children with cancer. Clin Ther 2014; 36:163-77. [PMID: 24529288 DOI: 10.1016/j.clinthera.2014.01.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 01/15/2014] [Accepted: 01/15/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Diagnosis of childhood cancer is no longer an automatic death sentence, but it has not lost all of its horror. Drugs, surgery, radiation, and clinical trials have advanced our capacity to handle these cancers, but pediatric cancers still face challenges. Pediatric pharmaceutical legislation was introduced in the United States in 1997 and has triggered many clinical trials that have helped us better understand what drugs do to a child's body and vice versa. Following the US precedence, the European Union introduced its own legislation. The US legislation was designed to generate additional pediatric data and balances between mandatory requirements and voluntary incentives. The US legislation was designed to mandate full registration of all new drugs for children whenever there is any potential pediatric use. OBJECTIVE The purpose of this article is to discuss unintended negative consequences of the legislation of the European Medicines Agency (EMA). METHODS We analyzed the effects of the EU pediatric legislation with respect to the history of the emergence of modern drugs, pediatric clinical pharmacology, and the development of drugs for pediatric malignancies. RESULTS No new drug can be registered in the European Union without a detailed pediatric investigation plan (PIP) approved by the EMA's Pediatric Committee (PDCO). This has moved the discussion of the pediatric aspects of drug development to an earlier stage and has increased public awareness. It also has brought industry and pediatric oncologists closer together. However, in a review of >100 PDCO PIP decisions in childhood cancer, we found a lack of balance between the legitimate desire to include children in drug development and the common sense needed in the complex worlds of drug development and pediatric oncology. Many decisions appeared to have been based on both exaggerated assumptions about the frequency of childhood malignancies and the feasibility of the clinical trials proposed. CONCLUSIONS Pharmaceutical companies are being forced into long-term commitments to clinical trials before efficacy in adults has been demonstrated. Pediatric clinical oncology trials are being driven by regulatory "tunnel vision" and not by therapeutic benevolence, epidemiologic data, or feasibility. As a result, children with cancer are being monopolized for PDCO-triggered, often unfeasible trials that are not always in their best interests and seldom produce useful therapies. Because clinical trials are global, this affects children with cancer worldwide. Until now, carefully worded concerns about these negative consequences have been published in specialty journals. It is time to start a broader debate on how to move forward.
Collapse
Affiliation(s)
- Klaus Rose
- klausrose Consulting, Pediatric Drug Development & More, Riehen, Switzerland.
| |
Collapse
|
42
|
Wimmer S, Rascher W, McCarthy S, Neubert A. The EU paediatric regulation: still a large discrepancy between therapeutic needs and approved paediatric investigation plans. Paediatr Drugs 2014; 16:397-406. [PMID: 25056717 DOI: 10.1007/s40272-014-0082-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Prior to the implementation of the EU Paediatric Regulation, the European Medicines Agency (EMA) defined unmet paediatric needs for active substances already available on the market. Seven years after the Paediatric Regulation came into force, we investigated the extent to which previously identified needs have led to programmes for generating evidence necessary for the regulatory approval of medicines for managing childhood conditions. METHODS The websites of the EMA and the European Commission Community Research and Development Information Service (CORDIS) were systematically screened to identify active substances from the assessment of paediatric needs, off-patent priority list, agreed Paediatric Investigation Plans (PIP) and 7th Framework Programme (FP7) projects related to paediatric medicines. RESULTS A total of 357 active substances with paediatric needs were identified by June 2013. 511 PIPs were agreed by the Paediatric Committee at the EMA (PDCO), including 51 (14.3 %) PIPs for a previously identified need. Amongst those, 21 were off-patent at the time of the PIP approval, 15 of which received funding from the European Commission's FP7. According to the assessment of paediatric needs, evidence is particularly needed for active substances treating cardiovascular diseases (n = 61), cancer (n = 40) and in the field of anaesthesiology (n = 38). Whereas oncology drugs (n = 66) were frequently represented in PIPs, drugs for cardiovascular diseases (n = 39) and anaesthesiology (n = 3) rarely were. CONCLUSIONS Most PIPs are attributable to marketing authorisations of new active substances, whereas off-patent drugs which are commonly used off-label remain unstudied to a large extent. More effort including ongoing research funding is essential to further regularise and standardise paediatric pharmacotherapy.
Collapse
Affiliation(s)
- Stefan Wimmer
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Loschgestraße 15, 91054, Erlangen, Germany
| | | | | | | |
Collapse
|
43
|
Burns KM, Byrne BJ, Gelb BD, Kühn B, Leinwand LA, Mital S, Pearson GD, Rodefeld M, Rossano JW, Stauffer BL, Taylor MD, Towbin JA, Redington AN. New mechanistic and therapeutic targets for pediatric heart failure: report from a National Heart, Lung, and Blood Institute working group. Circulation 2014; 130:79-86. [PMID: 24982119 DOI: 10.1161/circulationaha.113.007980] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Kristin M Burns
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.).
| | - Barry J Byrne
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| | - Bruce D Gelb
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| | - Bernhard Kühn
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| | - Leslie A Leinwand
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| | - Seema Mital
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| | - Gail D Pearson
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| | - Mark Rodefeld
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| | - Joseph W Rossano
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| | - Brian L Stauffer
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| | - Michael D Taylor
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| | - Jeffrey A Towbin
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| | - Andrew N Redington
- From the National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B., G.D.P.); University of Florida, Gainesville, FL (B.J.B.); Icahn School of Medicine at Mount Sinai, New York, NY (B.D.G.); Boston Children's Hospital and Harvard Medical School, Boston, MA (B.K.); Biofrontiers Institute, Boulder, CO (L.A.L.); Hospital for Sick Children, Toronto, ON, Canada (S.M., A.N.R.); Indiana University School of Medicine, Indianapolis, IN (M.R.); University of Pennsylvania School of Medicine, Philadelphia, PA (J.W.R.); University of Colorado School of Medicine, Aurora, CO (B.L.S.); and Cincinnati Children's Hospital Medical Center, Cincinnati, OH (M.D.T., J.A.T.)
| |
Collapse
|
44
|
Characteristics of pediatric cardiovascular clinical trials registered on ClinicalTrials.gov. Am Heart J 2014; 167:921-9.e2. [PMID: 24890544 DOI: 10.1016/j.ahj.2014.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 02/09/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND ClinicalTrials.gov is an National Institutes of Health-sponsored registry of federally and privately funded trials. We sought to determine fundamental characteristics of registered pediatric cardiovascular trials (PCVTs). METHODS A data set including 68,134 interventional clinical trials was downloaded from ClinicalTrials.gov and entered into a relational database. Aggregate data from PCVTs were compared with other trial specialties. Multivariable logistic regression was used to evaluate factors associated with improved trial quality metrics including blinding and randomization. RESULTS Between July 1, 2005, and September 27, 2010, 5035 (7%) registered trials targeted pediatric populations, including 213 PCVTs (4.2%), 1,176 pediatric infectious disease trials (23%), 664 pediatric mental health trials (13%), and 346 pediatric hematology/oncology trials (7%). Median (interquartile range) PCVT enrollment was 65 subjects (36-186) and median study duration was 2.3 years (1.3-3.7). The most common PCVTs targeted acquired diseases including hypertension (n = 41, 14%), obesity (n = 26, 9%), pulmonary hypertension (n = 25, 9%), and dyslipidemia (n = 19, 7%). Important factors associated with improved quality metrics included National Institutes of Health as opposed to industry funding (OR, 1.9; P < .0001); trial location (trials with both US and foreign enrollment vs trials with US only or foreign only enrollment, P = .02) and trials restricted to younger children as opposed to trials including adolescents (OR, 1.4; P < .0001). CONCLUSION PCVTs represent a small proportion of clinical trials relative to other pediatric subspecialties. Most PCVTs tend to parallel adult morbidities while there is a relative paucity of trials focused on congenital heart disease. These data may be useful to stakeholders in informing decisions regarding the conduct of PCVTs, and to provide insight into mechanisms to advance PCVT infrastructure.
Collapse
|
45
|
Turner MA, Catapano M, Hirschfeld S, Giaquinto C. Paediatric drug development: the impact of evolving regulations. Adv Drug Deliv Rev 2014; 73:2-13. [PMID: 24556465 DOI: 10.1016/j.addr.2014.02.003] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 01/20/2014] [Accepted: 02/11/2014] [Indexed: 01/07/2023]
Abstract
Children deserve medicines that are adapted to their needs. The need to include children in drug development has been recognised increasingly over the past few decades. Legal and regulatory frameworks are well established in the EU and US. The amount of work done to study medicines for children is significantly greater than it was 10 years go. Proof-of-concept has been demonstrated for all segments of the paediatric drug development pipeline. It is now time to examine how the practice of developing medicines for children has evolved within those frameworks and to determine how that work should be generalised. This review describes the development of medicines for children and critically appraises the work that has been done within those frameworks. Significant effort is needed to realize the potential provided by the current regulatory framework. Using the work programme of the Global Research in Paediatrics (GRiP) Network of Excellence as a template we outline current work and future growing points.
Collapse
Affiliation(s)
- M A Turner
- University of Liverpool, Department of Women's and Children's Health, Institute of Translational Medicine, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool L8 7SS, UK.
| | - M Catapano
- University of Pavia, Italian Group for the Study of Pharmacoeconomics (GISF), Via Luigi Porta 14, 27100 Pavia, Italy.
| | - S Hirschfeld
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), 31 Center Drive, Building 31, Room 2A32, Bethesda, MD 20892-2425, USA.
| | - C Giaquinto
- Azienda Ospedaliera di Padova (AOPD), Department of Paediatrics, Via Giustiniani 1, 35128 Padova, Italy.
| |
Collapse
|
46
|
Abstract
BACKGROUND Medical devices can be useful in a variety of diseases, but few devices have been specifically approved for use in children. The 2007 Pediatric Medical Device Safety and Improvement Act was passed to stimulate pediatric device development. The current state of trial evidence underpinning the approval of pediatric devices remains poorly described. METHODS We identified all high-risk (ie, class III) devices approved through the premarket approval or humanitarian device exemption pathways for therapeutic use in children between 2008 and 2011. We collected key information on clinical trial design (randomization, blinding, controls, and types of end points) as well as age distribution of trial participants. We also identified US Food and Drug Administration (FDA)-mandated postmarketing trials. RESULTS Twenty-two devices were approved for use in children via the premarket approval pathway and 3 via the humanitarian device exemption pathway. Twenty-two (88%) qualified as pediatric despite minimum approval ages of ≥18 years (the FDA Center for Devices and Radiologic Health considers patients 18-21 years old as pediatric). Most devices were approved on the basis of nonrandomized (59%), open-label (68%) studies with surrogate effectiveness end points (86%). Overall, 21 (84%) devices were not studied in any patients <18 years of age. Postmarketing studies were mandated by the FDA for 19 (76%) devices, although only 3 (18%) required enrollment of pediatric patients. CONCLUSIONS Most high-risk pediatric devices are approved on the basis of trials in patients ≥18 years old, with few pediatric patients exposed to the devices before market availability. Few postmarketing studies require additional study in pediatric patients.
Collapse
Affiliation(s)
- Thomas J. Hwang
- Faculty of Arts and Sciences, Harvard University, Cambridge, Massachusetts;,Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Florence T. Bourgeois
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts; and,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
47
|
Amann JP, Glauser T, Chiron C. Developing antiepileptic drugs in children: balancing protection and access. HANDBOOK OF CLINICAL NEUROLOGY 2014; 111:741-6. [PMID: 23622221 DOI: 10.1016/b978-0-444-52891-9.00076-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
This chapter addresses the issue of the balance between protection of children submitted to research and children's access to new treatments, focusing on the field of antiepileptic drugs. Due to the lack of interest pharmaceutical companies have for such an unrewarding market, ethical and legal problems, difficulties recruiting patients, and in Europe insufficient public resources, many infants and children with epilepsy are still exposed to off-label drugs. The incentives and regulations specifically directed toward research in children in the United States and EU provided the first step to change this condition. The challenge is to perform trials determined by the needs of children and to obtain benefits in the same order of magnitude as for adults but with reduced risks. In order to optimize the development of new AEDs in pediatrics, the new European guidelines (2010) recommend the identification of adult clinical trial results that can be extrapolated to the pediatric population (i.e., those in partial epilepsies) and the use of innovative strategies that help limit the number of pediatric patients enrolled in trials (i.e., those with epileptic encephalopathies). A key step will be to develop international networks of pediatric epilepsy centers with the shared purpose of optimizing development and execution of clinical trials.
Collapse
Affiliation(s)
- Jean-Paul Amann
- INSERM UMR663; Université Paris Descartes, Paris and CEA, France
| | | | | |
Collapse
|
48
|
Kern SE. Challenges in conducting clinical trials in children: approaches for improving performance. Expert Rev Clin Pharmacol 2014; 2:609-617. [PMID: 20228942 DOI: 10.1586/ecp.09.40] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Recent legislative changes in both Europe and the USA have increased the responsibility of drug developers to purposefully study the agents they market in children so that specific dosing recommendations can be made to assist clinicians in their use. Typically, clinicians use empiricalor experiential-based rationales for selecting the dose to use in children, generally in a manner that attempts to achieve the same dose-exposure or pharmacokinetic profile in children as in adults. However, whether this approach achieves the necessary dose exposure or exposure effect needed may not be systematically explored during off-label use. This creates the opportunity for under- or over-exposure in children, particularly in very young children (i.e., less than 2 years old) where a combination of factors during development can effect both pharmacokinetics and pharmacodynamics. The ethical, physiological and statistical differences of studying new therapeutic agents in children present economic challenges that may create unintended incentives - both positive and negative - for any individual developer who tries to meet the requirements of new legislation to study pharmaceutical agents in children. There should be a continued emphasis in academic clinical pharmacology programs towards creative methods and approaches to better understand these differences in children compared with adults. The ability to use information from knowledge obtained from adult studies, from preclinical studies, from studies of compounds with similar chemistry or pharmacology, or from known physiological differences between children and adults is essential to choosing a suitable dose for children and achieving these regulatory aims.
Collapse
Affiliation(s)
- Steven E Kern
- Associate Professor of Pharmaceutics and Pharmaceutical Chemistry, Adjunct Associate Professor of Pediatrics and Anesthesiology, Research Associate Professor of Bioengineering, University of Utah, Salt Lake City, UT, USA, Tel.: +1 801 585 5958, ,
| |
Collapse
|
49
|
Raymond AS. Regulatory aspects of drug development in children: change and resistance to change. Expert Rev Clin Pharmacol 2014; 3:593-5. [DOI: 10.1586/ecp.10.38] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
50
|
Marier JF, Mangum B, Reid B, Barrett JS. A Modeling and Simulations Framework to Support Global Regulatory Strategies for Pediatric Drug Development Programs. Ther Innov Regul Sci 2013; 47:550-556. [DOI: 10.1177/2168479013500289] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|