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Liu ITT, Kesselheim AS. Drug Repurposing Via the Best Pharmaceuticals for Children Act. JAMA Pediatr 2024:2821642. [PMID: 39073790 DOI: 10.1001/jamapediatrics.2024.2287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
This Viewpoint discusses the benefits and impediments of drug repurposing in the US and how the Best Pharmaceuticals for Children Act may serve as a successful legislative model to stimulate greater drug repurposing.
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Affiliation(s)
- Ian T T Liu
- 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
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2
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Miller KL, Lanthier M. Orphan Drug Label Expansions: Analysis Of Subsequent Rare And Common Indication Approvals. Health Aff (Millwood) 2024; 43:18-26. [PMID: 38190603 DOI: 10.1377/hlthaff.2023.00219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
The Orphan Drug Act of 1983 was enacted to provide financial incentives to stimulate drug development for rare diseases. In recent years, concerns have been raised regarding these orphan drugs, including how many are being approved for both rare and common diseases and the number of subsequent indication approvals. Policy makers have suggested modifications to the Orphan Drug Act's incentives to address these concerns. In this study we investigated the approval "family trees" of orphan drugs. We found that 491 novel orphan drugs were approved between 1990 and 2022. To date, 65 percent have been approved for a single rare disease, 15 percent have been approved for multiple rare diseases, and 20 percent have been approved for both rare and common diseases. Ten percent of orphan drugs received a subsequent indication approval for a pediatric population of an orphan disease. Revenue estimates from 2021 show that one-third of the drugs approved for both rare and common indications and 6 percent of rare-only drugs were among the 200 top-selling drugs worldwide. The results have implications for the possible externalities of modifying the incentives of the Orphan Drug Act, such as a potential decrease in the initiation of programs to develop pediatric rare disease drugs.
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Affiliation(s)
- Kathleen L Miller
- Kathleen L. Miller , Department of Health and Human Services, Washington, D.C
| | - Michael Lanthier
- Michael Lanthier, Food and Drug Administration, Silver Spring, Maryland
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MacArthur RB, Ashworth LD, Zhan K, Parrish RH. How Compounding Pharmacies Fill Critical Gaps in Pediatric Drug Development Processes: Suggested Regulatory Changes to Meet Future Challenges. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121885. [PMID: 36553327 PMCID: PMC9777176 DOI: 10.3390/children9121885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/04/2022]
Abstract
Drugs administered to children in the United States fall into two broad categories: (1) those that have followed the US Food and Drug Administration (US-FDA) pediatric drug approval process and are marketed as finished dosage forms with pediatric labeling; and (2) all others, many of which are used "off-label". The use of most drug products in pediatrics is still off label, often requiring special preparation, packaging, and, in some cases, compounding into preparations. The latter category includes compounded preparations that incorporate either a US-FDA approved finished dosage form (e.g., a sterile solution, sterile powder, nonsterile capsules, oral solution, crushed tablets, etc.), or rely on bulk active pharmaceutical ingredients (APIs). Compounded preparations are prepared for individual patients in 503A pharmacies, or on a larger scale and not just for specific patients, in licensed 503B establishments. Critical gaps in the current drug approval process for finished dosage forms have created a proverbial "Gordian knot" that needs to be untangled thoughtfully to facilitate increased production and approval of vitally needed medications for pediatric patients. This opinion will describe current regulatory processes pertaining to pediatrics-only drug approval in the United States. Additionally, discussed are steps required for a product to acquire pediatric labeling. Gaps in regulatory approval pathways for both manufactured and compounded pediatric drugs will be identified, especially those that complicate and slow development and availability to patients. Finally, suggestions for regulatory modifications that may enhance pediatric product development strategies for both manufacturers and compounders are suggested.
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Affiliation(s)
- Robert B. MacArthur
- Department of Pharmacy Services, Rockefeller University Hospital, New York, NY 10065, USA
- Correspondence: (R.B.M.); (R.H.P.II); Tel.: +1-(201)-694-2383 (R.B.M.); +1-(706)-223-5185 (R.H.P.II)
| | - Lisa D. Ashworth
- Department of Pharmacy Services, Children’s Health System of Texas, Dallas, TX 75235, USA
| | - Keming Zhan
- Department of Biostatistics, Columbia University, New York, NY 10027, USA
| | - Richard H. Parrish
- Department of Biomedical Sciences, Mercer University School of Medicine, Columbus, GA 31902, USA
- Correspondence: (R.B.M.); (R.H.P.II); Tel.: +1-(201)-694-2383 (R.B.M.); +1-(706)-223-5185 (R.H.P.II)
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4
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Veldman A, Richter E, Hacker C, Fischer D. The Use of Off-Label Medications in Newborn Infants Despite an Approved Alternative Being Available—Results of a National Survey. PHARMACY 2022; 10:pharmacy10010019. [PMID: 35202069 PMCID: PMC8877519 DOI: 10.3390/pharmacy10010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/17/2022] [Accepted: 01/22/2022] [Indexed: 02/04/2023] Open
Abstract
Neonates continue to be treated with off-label or unlicensed drugs while in hospital. However, some medications that have previously been used in adults underwent clinical testing and licensure for use with a different indication in the neonatal and pediatric population. Almost always, the marketing of these newly approved substances in a niche indication is accompanied by a steep increase in the price of the compound. We investigated the use of the approved formulation or the cheaper off-label alternative of Ibuprofen (Pedea®), Propanolol (Hemangiol®) and Caffeine Citrate (Peyona®) in neonatal clinical practice by conducting a National Survey of 214 Perinatal Centers in Germany. We also assessed price differences between on- and off-label alternatives and the extend of the clinical development program of the on-label medication in the neonatal population. On-label medication was more frequently used than the off-label alternative in all indications (PDA: on-label to off-label ratio 1:0.26, Apnea: 1:0.56, Hemangioma 1:0.76). All sponsors did conduct placebo-controlled Phase III trials with efficacy and safety endpoints in the target population and the number of participants in the target population varied between 82 and 497. Costs for the three drugs in their approved and marketed formulations increased in median 405-fold compared with the corresponding off-label alternative. Overall, about one out of three neonatologists prescribed an off-label or non-approved drug to patients despite an alternative medication that is approved for the indication in the target population being available.
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Affiliation(s)
- Alex Veldman
- Department of Pediatrics, Helios HSK, 65199 Wiesbaden, Germany;
- Department of Pediatrics, Justus-Liebig University, 35385 Giessen, Germany;
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia
- Correspondence: ; Tel.: +49-611-43-2557
| | - Eva Richter
- Department of Pediatrics, Justus-Liebig University, 35385 Giessen, Germany;
| | | | - Doris Fischer
- Department of Pediatrics, Helios HSK, 65199 Wiesbaden, Germany;
- Department of Pediatrics, J.W. Goethe University Hospital, 60590 Frankfurt, Germany
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5
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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.
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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
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6
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Sahragardjoonegani B, Beall RF, Kesselheim AS, Hollis A. Repurposing existing drugs for new uses: a cohort study of the frequency of FDA-granted new indication exclusivities since 1997. J Pharm Policy Pract 2021; 14:3. [PMID: 33397471 PMCID: PMC7780607 DOI: 10.1186/s40545-020-00282-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
Background Drug repurposing (i.e., finding novel uses for existing drugs) is essential for maximizing medicines’ therapeutic utility, but obtaining regulatory approval for new indications is costly. Policymakers have therefore created temporary indication-specific market exclusivities to incentivize drug innovators to run new clinical investigations. The effectiveness of these exclusivities is poorly understood. Objective To determine whether generic entry impacts the probability of new indication additions. Methods For a cohort of all new small-molecule drugs approved by the FDA between July 1997 and May 2020, we tracked new indications added for the subset of drugs that experienced generic entry during the observation period and then analyzed how the probability of a new indication changed with the number of years since/to generic entry. Results Of the 197 new drugs that subsequently experienced generic entry, only 64 (32%) had at least one new indication added. The probability of a new indication addition peaked above 4% between 7 and 8 years prior to generic entry and then to dropped to near zero 15 years after FDA approval. We show that the limited duration of exclusivity reduces the number of secondary indications significantly. Conclusion Status quo for most drug innovators is creating novel one-indication products. Despite indication-specific exclusivities, the imminence of generic entry still has a detectable impact on reducing the chances of new indication additions. There is much room for improvement when it comes to incentivizing clinical investigations for new uses and unlocking existing medicines’ full therapeutic potential.
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Affiliation(s)
- Babak Sahragardjoonegani
- Department of Economics, University of Calgary, 527 Campus Place N.W., Calgary, AB, T2N 4Z6, Canada
| | - Reed F Beall
- Department of Community Health Sciences, Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital / Harvard Medical School, 1620 Tremont St., Suite 3030, 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 / Harvard Medical School, 1620 Tremont St., Suite 3030, Boston, MA, 02120, USA
| | - Aidan Hollis
- Department of Economics, University of Calgary, 527 Campus Place N.W., Calgary, AB, T2N 4Z6, Canada.
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7
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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.
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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.
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Powell JR, Cook J, Wang Y, Peck R, Weiner D. Drug Dosing Recommendations for All Patients: A Roadmap for Change. Clin Pharmacol Ther 2020; 109:65-72. [PMID: 32453862 PMCID: PMC7818440 DOI: 10.1002/cpt.1923] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/15/2020] [Indexed: 12/16/2022]
Abstract
Most drug labels do not contain dosing recommendations for a significant portion of real‐world patients for whom the drug is prescribed. Current label recommendations predominately reflect the population studied in pivotal trials that typically exclude patients who are very young or old, emaciated or morbidly obese, pregnant, or have multiple characteristics likely to influence dosing. As a result, physicians may need to guess the correct dose and regimen for these patients. It is now feasible to provide dose and regimen recommendations for these patients by integrating available scientific knowledge and by utilizing or modifying current regulatory agency‐industry practices. The purpose of this commentary is to explore several factors that should be considered in creating a process that will provide more effective, safe, and timely drug dosing recommendations for most, if not all, patients. These factors include the availability of real‐world data, development of predictive models, experience with the US Food and Drug Administration (FDA)’s pediatric exclusivity program, development of clinical decision software, funding mechanisms like the Prescription Drug Users Fee Act (PDUFA), and harmonization of global regulatory policies. From an examination of these factors, we recommend a relatively simple, efficient expansion of current practices designed to predict, confirm, and continuously improve drug dosing for more patients. We believe implementing these recommendations will benefit patients, payers, industry, and regulatory agencies.
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Affiliation(s)
- J Robert Powell
- Clinical Pharmacology Consultant, Chapel Hill, North Carolina, USA
| | - Jack Cook
- Clinical Pharmacology, Pfizer Inc, Groton, Connecticut, USA
| | - Yaning Wang
- Office of Clinical Pharmacology, Office of Translational Sciences, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Richard Peck
- Roche Innovation Center Basel, Pharma Research & Early Development (pRED), Basel, Switzerland
| | - Dan Weiner
- Pharmacometrics Consultant, Chapel Hill, North Carolina, USA
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Dave CV, Sinha MS, Beall RF, Kesselheim AS. Estimating The Cost Of Delayed Generic Drug Entry To Medicaid. Health Aff (Millwood) 2020; 39:1011-1017. [DOI: 10.1377/hlthaff.2019.00673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Chintan V. Dave
- Chintan V. Dave is a fellow in the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, in Boston, Massachusetts; and an assistant professor at the Center for Pharmacoepidemiology and Treatment Sciences, Rutgers University, in New Brunswick, New Jersey
| | - Michael S. Sinha
- Michael S. Sinha is a fellow at the Harvard-MIT Center for Regulatory Science, part of the Harvard Program in Therapeutic Science at Harvard Medical School, and an affiliated researcher in the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
| | - Reed F. Beall
- Reed F. Beall is an assistant professor in the Department of Community Health Sciences and in the O’Brien Institute for Public Health in the Cumming School of Medicine, University of Calgary, in Alberta, Canada, and is affiliated faculty at the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
| | - Aaron S. Kesselheim
- Aaron S. Kesselheim is a professor of medicine at Harvard Medical School and director of the Program on Regulation, Therapeutics, and Law in the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School
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10
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Tanaudommongkon I, John Miyagi S, Green DJ, Burnham JM, van den Anker JN, Park K, Wu J, McCune SK, Yao L, Burckart GJ. Combined Pediatric and Adult Trials Submitted to the US Food and Drug Administration 2012-2018. Clin Pharmacol Ther 2020; 108:1018-1025. [PMID: 32394430 DOI: 10.1002/cpt.1886] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/24/2020] [Indexed: 01/23/2023]
Abstract
Despite legislation incentivizing and requiring drug companies to conduct pediatric clinical trials, there still is a 9-year delay in drug approval for pediatric labeling after the initial adult drug approval. The aim of this study was to review the experience of the US Food and Drug Administration (FDA) with combined pediatric and adult trials as a means for expediting pediatric approval and labeling. Combined pediatric and adult trials submitted to the FDA from 2012 to 2018 were reviewed. Only the publicly available labels and reviews were utilized for this analysis. Combined trials were identified for 72 products, with a total of 156 combined adult and pediatric trials. The therapeutic areas with the largest number of combined trials were in pulmonology for products reviewed under the Best Pharmaceuticals for Children Act (BPCA) and/or the Pediatric Research Equity Act (PREA), and hematology reviewed under the Orphan Drug Act (ODA). All drugs that utilized combined pediatric and adult clinical trials were approved simultaneously for both the adults and that part of the pediatric population. A separate pediatric subgroup efficacy analysis was reported in 57% and 48% of products under BPCA/PREA and the ODA, respectively, with a separate safety analysis in 48% and 38% of these products. When considering both BPCA/PREA and orphan drug studies, all the combined pediatric and adult trials allowed concurrent approval and labeling for part of the pediatric population at the time of the adult approval.
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Affiliation(s)
- Irin Tanaudommongkon
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shogo John Miyagi
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Dionna J Green
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Janelle M Burnham
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - John N van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Kyunghun Park
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Johanna Wu
- Western University of Health Sciences, Pomona, California, USA
| | - Susan K McCune
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lynne Yao
- Division of Pediatric and Maternal Health, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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Brothers KB, Clayton EW, Goldenberg AJ. Online Pediatric Research: Addressing Consent, Assent, and Parental Permission. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2020; 48:129-137. [PMID: 32342755 DOI: 10.1177/1073110520917038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This article provides practical guidance for researchers who wish to enroll and collect data from pediatric research participants through online and mobile platforms, with a focus on the involvement of both children and their parents in the decision to participate.
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Affiliation(s)
- Kyle B Brothers
- Kyle B. Brothers, M.D., Ph.D., is an Associate Professor in the Department of Pediatrics at the University of Louisville, where he is also affiliated with the Institute for Bioethics, Health Policy, and Law. Ellen Wright Clayton, M.D., J.D., is the Craig-Weaver Professor of Pediatrics, Professor of Health Policy, and Member of the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center, and Professor of Law at the Vanderbilt University School of Law. Aaron J. Goldenberg, Ph.D., is an Associate Professor and Vice Chair for the Department of Bioethics at Case Western Reserve University (CWRU). He is also Co-Director of the Center for Genetic Research Ethics and Law at CWRU
| | - Ellen Wright Clayton
- Kyle B. Brothers, M.D., Ph.D., is an Associate Professor in the Department of Pediatrics at the University of Louisville, where he is also affiliated with the Institute for Bioethics, Health Policy, and Law. Ellen Wright Clayton, M.D., J.D., is the Craig-Weaver Professor of Pediatrics, Professor of Health Policy, and Member of the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center, and Professor of Law at the Vanderbilt University School of Law. Aaron J. Goldenberg, Ph.D., is an Associate Professor and Vice Chair for the Department of Bioethics at Case Western Reserve University (CWRU). He is also Co-Director of the Center for Genetic Research Ethics and Law at CWRU
| | - Aaron J Goldenberg
- Kyle B. Brothers, M.D., Ph.D., is an Associate Professor in the Department of Pediatrics at the University of Louisville, where he is also affiliated with the Institute for Bioethics, Health Policy, and Law. Ellen Wright Clayton, M.D., J.D., is the Craig-Weaver Professor of Pediatrics, Professor of Health Policy, and Member of the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center, and Professor of Law at the Vanderbilt University School of Law. Aaron J. Goldenberg, Ph.D., is an Associate Professor and Vice Chair for the Department of Bioethics at Case Western Reserve University (CWRU). He is also Co-Director of the Center for Genetic Research Ethics and Law at CWRU
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13
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Abstract
IMPORTANCE US law requires testing of new drugs before approval to ensure that they provide a well-defined benefit that is commensurate with their risks. A major challenge for the US Food and Drug Administration (FDA) is to achieve an appropriate balance between rigorous testing and the need for timely approval of drugs that have benefits that outweigh their risks. OBJECTIVE To describe the evolution of laws and standards affecting drug testing, the use of new approval programs and standards, expansions of the role and authority of the FDA, and changes in the number of drugs approved from the 1980s to 2018. EVIDENCE Sources of evidence included principal federal laws and FDA regulations (1962-2018) and FDA databases of approved new drugs (1984-2018), generic drugs (1970-2018), biologics (1984-2018), and vaccines (1998-2018); special development and approval programs (Orphan drug [1984-2018], Fast-Track [1988-2018], Priority Review and its predecessors [1984-2018], Accelerated Approval [1992-2018], and Breakthrough Therapy [2012-2018]); expanded access (2010-2017) and Risk Evaluation and Mitigation Strategies (2008-2018); and user fees paid to the FDA by industry (1993-2018). FINDINGS From 1983 to 2018, legislation and regulatory initiatives have substantially changed drug approval at the FDA. The mean annual number of new drug approvals, including biologics, was 34 from 1990-1999, 25 from 2000-2009, and 41 from 2010-2018. New biologic product approvals increased from a median of 2.5 from 1990-1999, to 5 from 2000-2013, to 12 from 2014-2018. The median annual number of generic drugs approved was 136 from 1970 to the enactment of the Hatch-Waxman Act in 1984; 284 from 1985 to the enactment of the Generic Drug User Fee Act in 2012; and 588 from 2013-2018. Prescription drug user fee funding expanded from new drugs and biologics in 1992 to generic and biosimilar drugs in 2012. The amount of Prescription Drug User Fee Act fees collected from industry increased from an annual mean of $66 million in 1993-1997 to $820 million in 2013-2017, and in 2018, user fees accounted for approximately 80% of the salaries of review personnel responsible for the approval of new drugs. The proportion of drugs approved with an Orphan Drug Act designation increased from 18% (55/304) in 1984-1995, to 22% (82/379) in 1996-2007, to 41% (154/380) in 2008-2018. Use of Accelerated Approval, Fast-Track, and Priority Review for new drugs has increased over time, with 81% (48/59) of new drugs benefiting from at least 1 such expedited program in 2018. The proportion of new approvals supported by at least 2 pivotal trials decreased from 80.6% in 1995-1997 to 52.8% in 2015-2017, based on 124 and 106 approvals, respectively, while the median number of patients studied did not change significantly (774 vs 816). FDA drug review times declined from more than 3 years in 1983 to less than 1 year in 2017, but total time from the authorization of clinical testing to approval has remained at approximately 8 years over that period. CONCLUSIONS AND RELEVANCE Over the last 4 decades, the approval and regulation processes for pharmaceutical agents have evolved and increased in complexity as special programs have been added and as the use of surrogate measures has been encouraged. The FDA funding needed to implement and manage these programs has been addressed by expanding industry-paid user fees. The FDA has increasingly accepted less data and more surrogate measures, and has shortened its review times.
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Affiliation(s)
- Jonathan J Darrow
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jerry Avorn
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Bionetworks, system biology, and superorganisms. INSECT-BORNE DISEASES IN THE 21ST CENTURY 2020. [PMCID: PMC7441993 DOI: 10.1016/b978-0-12-818706-7.00004-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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15
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Hirota S, Yamaguchi T. Timing of Pediatric Drug Approval and Clinical Evidence Submitted to Regulatory Authorities: International Comparison Among Japan, the United States, and the European Union. Clin Pharmacol Ther 2019; 108:985-994. [PMID: 31869436 DOI: 10.1002/cpt.1757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/13/2019] [Indexed: 11/08/2022]
Abstract
Many prescription drugs approved for adult use lack pediatric labeling information, resulting in their off-label use in children. Drug regulatory authorities have developed legal and regulatory frameworks to promote pediatric drug development. However, the current state of pediatric indication approval and quality of efficacy evidence, which forms the basis of regulatory approvals, is unknown. Here, we analyzed novel therapeutics approved in Japan, the United States, and the European Union during 2005-2014 to investigate the timing and frequency of pediatric indication approval, and characterized the design of pediatric studies supporting regulatory approval. We found that the United States and European Union experienced a higher frequency of supplemental indication approval in pediatrics based on better-designed studies than Japan. The speed and efficiency of pediatric drug development will improve by coordinating pediatric studies on an international basis. The results also implied the necessity for a robust system of postmarketing monitoring of pediatric efficacy and safety.
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Affiliation(s)
- Saeko Hirota
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan
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Affiliation(s)
- Florence T Bourgeois
- From the Pediatric Therapeutics and Regulatory Science Initiative and the Computational Health Informatics Program, Boston Children's Hospital, and the Department of Pediatrics, Harvard Medical School (F.T.B.), and the Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (A.S.K.) - all in Boston
| | - Aaron S Kesselheim
- From the Pediatric Therapeutics and Regulatory Science Initiative and the Computational Health Informatics Program, Boston Children's Hospital, and the Department of Pediatrics, Harvard Medical School (F.T.B.), and the Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (A.S.K.) - all in Boston
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Kunnumakkara AB, Bordoloi D, Sailo BL, Roy NK, Thakur KK, Banik K, Shakibaei M, Gupta SC, Aggarwal BB. Cancer drug development: The missing links. Exp Biol Med (Maywood) 2019; 244:663-689. [PMID: 30961357 PMCID: PMC6552400 DOI: 10.1177/1535370219839163] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPACT STATEMENT The success rate for cancer drugs which enter into phase 1 clinical trials is utterly less. Why the vast majority of drugs fail is not understood but suggests that pre-clinical studies are not adequate for human diseases. In 1975, as per the Tufts Center for the Study of Drug Development, pharmaceutical industries expended 100 million dollars for research and development of the average FDA approved drug. By 2005, this figure had more than quadrupled, to $1.3 billion. In order to recover their high and risky investment cost, pharmaceutical companies charge more for their products. However, there exists no correlation between drug development cost and actual sale of the drug. This high drug development cost could be due to the reason that all patients might not respond to the drug. Hence, a given drug has to be tested in large number of patients to show drug benefits and obtain significant results.
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Affiliation(s)
- Ajaikumar B Kunnumakkara
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Devivasha Bordoloi
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Bethsebie Lalduhsaki Sailo
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Nand Kishor Roy
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Krishan Kumar Thakur
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Kishore Banik
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Mehdi Shakibaei
- Faculty of Medicine, Institute of Anatomy, Ludwig Maximilian University of Munich, Munich D-80336, Germany
| | - Subash C Gupta
- Department of Biochemistry, Institute of Science, Banaras Hindu University, Varanasi 221005, India
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