1
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Massaro AN, Boyer B, Gill M, Kim D, Laughon M, Walsh M, Lemmon ME, Pilon B, Baer G. Measuring Clinical Benefit in Neonatal Randomized Clinical Trials: Challenges and Opportunities. J Pediatr 2024; 269:113972. [PMID: 38401783 PMCID: PMC11181158 DOI: 10.1016/j.jpeds.2024.113972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/01/2024] [Accepted: 02/16/2024] [Indexed: 02/26/2024]
Affiliation(s)
- An N Massaro
- Office of Pediatric Therapeutics, Office of the Commisioner, US FDA, Silver Spring, MD.
| | - Beth Boyer
- Duke-Margolis Center for Health Policy, Washington, DC
| | - Mira Gill
- Duke-Margolis Center for Health Policy, Washington, DC
| | - Dure Kim
- Duke-Margolis Center for Health Policy, Washington, DC
| | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michele Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD
| | - Monica E Lemmon
- Duke-Margolis Center for Health Policy, Washington, DC; Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, Durham, NC
| | | | - Gerri Baer
- Office of Pediatric Therapeutics, Office of the Commisioner, US FDA, Silver Spring, MD
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2
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Ward RM. Editorial: Research challenges of drug utilization, data collection, data validation, and adverse drug reactions in neonates. Front Pharmacol 2024; 15:1376770. [PMID: 38533255 PMCID: PMC10964945 DOI: 10.3389/fphar.2024.1376770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/05/2024] [Indexed: 03/28/2024] Open
Affiliation(s)
- Robert M. Ward
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
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3
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Li C, Cheng L, Zhang X, Zhang L, Yan J. Evaluation of marketing authorization and labels of medicines in 2021 WHO Model List of Essential Medicines for Children in China, the Russian Federation and Brazil. Health Res Policy Syst 2024; 22:33. [PMID: 38443935 PMCID: PMC10913573 DOI: 10.1186/s12961-024-01117-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/02/2024] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVE This work compares the marketing authorization, labels and dosage forms of medicines in the WHO Model List of Essential Medicines for Children (EMLc) in China, the Russian Federation and Brazil to urge policymakers to pay more attention to paediatric medication. METHODS Medicines were selected from the 8th EMLc. By searching relevant databases, which include different types of medical information in China, the Russian Federation and Brazil, the marketing authorization, labels and dosage forms of paediatric medicines in the three countries were evaluated. RESULTS A total of 485 drug products containing 312 active pharmaceutical ingredients listed in the WHO EMLc were evaluated. Among them, 344 products were approved for use in China, 286 in the Russian Federation and 264 in Brazil. Out of the 344 approved medicines, 317 (92.15%) were authorized for paediatric use in China, 224 (78.32%) in the Russian Federation and 218 (82.58%) in Brazil. In terms of guidance information labelling on drug labels, 75.08%, 83.04% and 88.07% of paediatric drugs approved in China, the Russian Federation and Brazil, respectively, clearly indicated the usage and dosage for paediatric use. Additionally, injections and tablets were the most prevalent dosage forms in these three countries. CONCLUSION There is still scope for enhancing the marketing authorization and development of dosage forms for paediatric medicines in the three countries. Furthermore, additional measures are being implemented to enhance the information provided on drug labels for children, particularly in China.
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Affiliation(s)
- Caiyun Li
- School of International Pharmaceutical Business, China Pharmaceutical University, No. 639 Longmian Avenue, Jiangning District, Nanjing, 211198, China
- The Research Center of National Drug Policy and Ecosystem, China Pharmaceutical University, No. 639 Longmian Avenue, Jiangning District, Nanjing, 211198, China
| | - Luyan Cheng
- School of International Pharmaceutical Business, China Pharmaceutical University, No. 639 Longmian Avenue, Jiangning District, Nanjing, 211198, China
- The Research Center of National Drug Policy and Ecosystem, China Pharmaceutical University, No. 639 Longmian Avenue, Jiangning District, Nanjing, 211198, China
| | - Xuefang Zhang
- School of International Pharmaceutical Business, China Pharmaceutical University, No. 639 Longmian Avenue, Jiangning District, Nanjing, 211198, China
- The Research Center of National Drug Policy and Ecosystem, China Pharmaceutical University, No. 639 Longmian Avenue, Jiangning District, Nanjing, 211198, China
| | - Lingli Zhang
- School of Pharmacy, Nanjing Medical University, No. 101 Longmian Avenue, Jiangning District, Nanjing, 211166, China.
| | - Jianzhou Yan
- School of International Pharmaceutical Business, China Pharmaceutical University, No. 639 Longmian Avenue, Jiangning District, Nanjing, 211198, China.
- The Research Center of National Drug Policy and Ecosystem, China Pharmaceutical University, No. 639 Longmian Avenue, Jiangning District, Nanjing, 211198, China.
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Mease C, Miller KL, Fermaglich LJ, Best J, Liu G, Torjusen E. Analysis of the first ten years of FDA's rare pediatric disease priority review voucher program: designations, diseases, and drug development. Orphanet J Rare Dis 2024; 19:86. [PMID: 38403586 PMCID: PMC10895788 DOI: 10.1186/s13023-024-03097-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/21/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND The Rare Pediatric Disease (RPD) Priority Review Voucher (PRV) Program was enacted in 2012 to support the development of new products for children. Prior to requesting a voucher, applicants can request RPD designation, which confirms their product treats or prevents a rare disease in which the serious manifestations primarily affect children. This study describes the trends and characteristics of these designations. Details of RPD designations are not publicly disclosable; this research represents the first analysis of the RPD designation component of the program. RESULTS We used an internal US Food and Drug Administration database to analyze all RPD designations between 2013 and 2022. Multiple characteristics were analyzed, including the diseases targeted by RPD designation, whether the product targeted a neonatal disease, product type (drug/biologic), and the level of evidence (preclinical/clinical) to support designation. There were 569 RPD designations during the study period. The top therapeutic areas were neurology (26%, n = 149), metabolism (23%, n = 131), oncology (18%, n = 105). The top diseases targeted by RPD designation were Duchenne muscular dystrophy, neuroblastoma, and sickle cell disease. Neonatology products represented 6% (n = 33), over half were for drug products and 38% were supported by clinical data. CONCLUSIONS The RPD PRV program was created to encourage development of new products for children. The results of this study establish that a wide range of diseases have seen development-from rare pediatric cancers to rare genetic disorders. Continued support of product development for children with rare diseases is needed to find treatments for all children with unmet needs.
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Affiliation(s)
- Catherine Mease
- Office of Orphan Products Development, Office of the Commissioner, US Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA.
| | - Kathleen L Miller
- Office of Orphan Products Development, Office of the Commissioner, US Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Lewis J Fermaglich
- Office of Orphan Products Development, Office of the Commissioner, US Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Jeanine Best
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Gumei Liu
- Office of Therapeutic Products, Center for Biologics Evaluation and Research, US Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Erika Torjusen
- Office of Orphan Products Development, Office of the Commissioner, US Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
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5
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Rysavy MA, Bennett MM, Ahmad KA, Patel RM, Shah ZS, Ellsbury DL, Clark RH, Tolia VN. Neonatal Intensive Care Unit Resource Use for Infants at 22 Weeks' Gestation in the US, 2008-2021. JAMA Netw Open 2024; 7:e240124. [PMID: 38381431 PMCID: PMC10882422 DOI: 10.1001/jamanetworkopen.2024.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Importance During the past decade, clinical guidance about the provision of intensive care for infants born at 22 weeks' gestation has changed. The impact of these changes on neonatal intensive care unit (NICU) resource utilization is unknown. Objective To characterize recent trends in NICU resource utilization for infants born at 22 weeks' gestation compared with other extremely preterm infants (≤28 weeks' gestation) and other NICU-admitted infants. Design, Setting, and Participants This is a serial cross-sectional study of 137 continuously participating NICUs in 29 US states from January 1, 2008, through December 31, 2021. Participants included infants admitted to the NICU. Data analysis was performed from October 2022 to August 2023. Exposures Year and gestational age at birth. Main Outcomes and Measures Measures of resource utilization included NICU admissions, NICU bed-days, and ventilator-days. Results Of 825 112 infants admitted from 2008 to 2021, 60 944 were extremely preterm and 872 (466 [53.4%] male; 18 [2.1%] Asian; 318 [36.5%] Black non-Hispanic; 218 [25.0%] Hispanic; 232 [26.6%] White non-Hispanic; 86 [9.8%] other or unknown) were born at 22 weeks' gestation. NICU admissions at 22 weeks' gestation increased by 388%, from 5.7 per 1000 extremely preterm admissions in 2008 to 2009 to 27.8 per 1000 extremely preterm admissions in 2020 to 2021. The number of NICU admissions remained stable before the publication of updated clinical guidance in 2014 to 2016 and substantially increased thereafter. During the study period, bed-days for infants born at 22 weeks increased by 732%, from 2.5 per 1000 to 20.8 per 1000 extremely preterm NICU bed-days; ventilator-days increased by 946%, from 5.0 per 1000 to 52.3 per 1000 extremely preterm ventilator-days. The proportion of NICUs admitting infants born at 22 weeks increased from 22.6% to 45.3%. Increases in NICU resource utilization during the period were also observed for infants born at less than 22 and at 23 weeks but not for other gestational ages. In 2020 to 2021, infants born at less than or equal to 23 weeks' gestation comprised 1 in 117 NICU admissions, 1 in 34 of all NICU bed-days, and 1 in 6 of all ventilator-days. Conclusions and Relevance In this serial cross-sectional study of 137 US NICUs from 2008 to 2021, an increasing share of resources in US NICUs was allocated to infants born at 22 weeks' gestation, corresponding with changes in national clinical guidance.
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Affiliation(s)
- Matthew A Rysavy
- Department of Pediatrics, McGovern Medical School at UTHealth Houston, Houston, Texas
| | | | - Kaashif A Ahmad
- The Woman's Hospital of Texas, Houston, Texas
- Department of Clinical Sciences, University of Houston, Houston, Texas
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
| | - Ravi M Patel
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Zubin S Shah
- Department of Pediatrics, Baylor University Medical Center, Dallas, Texas
- Texas A&M Health Science Center School of Medicine, Dallas, Texas
| | - Dan L Ellsbury
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
- MercyOne Children's Hospital, Des Moines, Iowa
| | - Reese H Clark
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
| | - Veeral N Tolia
- Pediatrix Center for Research Education, Quality, and Safety, Sunrise, Florida
- Department of Pediatrics, Baylor University Medical Center, Dallas, Texas
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6
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Zhang W, Zhang Q, Cao Z, Zheng L, Hu W. Physiologically Based Pharmacokinetic Modeling in Neonates: Current Status and Future Perspectives. Pharmaceutics 2023; 15:2765. [PMID: 38140105 PMCID: PMC10747965 DOI: 10.3390/pharmaceutics15122765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/07/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
Rational drug use in special populations is a clinical problem that doctors and pharma-cists must consider seriously. Neonates are the most physiologically immature and vulnerable to drug dosing. There is a pronounced difference in the anatomical and physiological profiles be-tween neonates and older people, affecting the absorption, distribution, metabolism, and excretion of drugs in vivo, ultimately leading to changes in drug concentration. Thus, dose adjustments in neonates are necessary to achieve adequate therapeutic concentrations and avoid drug toxicity. Over the past few decades, modeling and simulation techniques, especially physiologically based pharmacokinetic (PBPK) modeling, have been increasingly used in pediatric drug development and clinical therapy. This rigorously designed and verified model can effectively compensate for the deficiencies of clinical trials in neonates, provide a valuable reference for clinical research design, and even replace some clinical trials to predict drug plasma concentrations in newborns. This review introduces previous findings regarding age-dependent physiological changes and pathological factors affecting neonatal pharmacokinetics, along with their research means. The application of PBPK modeling in neonatal pharmacokinetic studies of various medications is also reviewed. Based on this, we propose future perspectives on neonatal PBPK modeling and hope for its broader application.
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Affiliation(s)
| | | | | | - Liang Zheng
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (W.Z.); (Q.Z.); (Z.C.)
| | - Wei Hu
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (W.Z.); (Q.Z.); (Z.C.)
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7
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King B, Patel RM. Using Quality Improvement to Improve Value and Reduce Waste. Clin Perinatol 2023; 50:489-506. [PMID: 37201993 DOI: 10.1016/j.clp.2023.01.009] [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: 05/20/2023]
Abstract
Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.
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Affiliation(s)
- Brian King
- Department of Pediatrics, University of Pittsburg School of Medicine.
| | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
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8
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Ward RM. Improving Drug Therapy for Pediatric Patients: Unfinished History of Pediatric Drug Development. J Pediatr Pharmacol Ther 2023; 28:4-9. [PMID: 36777985 PMCID: PMC9901325 DOI: 10.5863/1551-6776-28.1.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Robert M. Ward
- University of Utah Department of Pediatrics, Divisions of Clinical Pharmacology and Neonatology
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9
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Kabir M, Padilha EC, Shah P, Huang R, Sakamuru S, Gonzalez E, Ye L, Hu X, Henderson MJ, Xia M, Xu X. Identification of Selective CYP3A7 and CYP3A4 Substrates and Inhibitors Using a High-Throughput Screening Platform. Front Pharmacol 2022; 13:899536. [PMID: 35847040 PMCID: PMC9283723 DOI: 10.3389/fphar.2022.899536] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/27/2022] [Indexed: 11/26/2022] Open
Abstract
Cytochrome P450 (CYP) 3A7 is one of the major xenobiotic metabolizing enzymes in human embryonic, fetal, and newborn liver. CYP3A7 expression has also been observed in a subset of the adult population, including pregnant women, as well as in various cancer patients. The characterization of CYP3A7 is not as extensive as other CYPs, and health authorities have yet to provide guidance towards DDI assessment. To identify potential CYP3A7-specific molecules, we used a P450-Glo CYP3A7 enzyme assay to screen a library of ∼5,000 compounds, including FDA-approved drugs and drug-like molecules, and compared these screening data with that from a P450-Glo CYP3A4 assay. Additionally, a subset of 1,000 randomly selected compounds were tested in a metabolic stability assay. By combining the data from the qHTS P450-Glo and metabolic stability assays, we identified several chemical features important for CYP3A7 selectivity. Halometasone was chosen for further evaluation as a potential CYP3A7-selective inhibitor using molecular docking. From the metabolic stability assay, we identified twenty-two CYP3A7-selective substrates over CYP3A4 in supersome setting. Our data shows that CYP3A7 has ligand promiscuity, much like CYP3A4. Furthermore, we have established a large, high-quality dataset that can be used in predictive modeling for future drug metabolism and interaction studies.
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Affiliation(s)
- Md Kabir
- Division of Pre-Clinical Innovation, National Center for Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, MD, United States
- Department of Pharmacology, The Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Elias C. Padilha
- Division of Pre-Clinical Innovation, National Center for Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, MD, United States
| | - Pranav Shah
- Division of Pre-Clinical Innovation, National Center for Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, MD, United States
| | - Ruili Huang
- Division of Pre-Clinical Innovation, National Center for Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, MD, United States
| | - Srilatha Sakamuru
- Division of Pre-Clinical Innovation, National Center for Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, MD, United States
| | - Eric Gonzalez
- Division of Pre-Clinical Innovation, National Center for Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, MD, United States
- Novartis Institutes for BioMedical Research, Cambridge, MA, United States
| | - Lin Ye
- Division of Pre-Clinical Innovation, National Center for Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, MD, United States
| | - Xin Hu
- Division of Pre-Clinical Innovation, National Center for Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, MD, United States
| | - Mark J. Henderson
- Division of Pre-Clinical Innovation, National Center for Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, MD, United States
| | - Menghang Xia
- Division of Pre-Clinical Innovation, National Center for Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, MD, United States
- *Correspondence: Menghang Xia, ; Xin Xu,
| | - Xin Xu
- Division of Pre-Clinical Innovation, National Center for Translational Sciences (NCATS), National Institutes of Health (NIH), Rockville, MD, United States
- *Correspondence: Menghang Xia, ; Xin Xu,
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10
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Nurses' and Parents' Roles in Drug Development. J Perinat Neonatal Nurs 2022; 36:225-227. [PMID: 35894716 DOI: 10.1097/jpn.0000000000000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Ways to Improve Insights into Clindamycin Pharmacology and Pharmacokinetics Tailored to Practice. Antibiotics (Basel) 2022; 11:antibiotics11050701. [PMID: 35625345 PMCID: PMC9137603 DOI: 10.3390/antibiotics11050701] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 02/07/2023] Open
Abstract
Given the increase in bacterial resistance and the decrease in the development of new antibiotics, the appropriate use of old antimicrobials has become even more compulsory. Clindamycin is a lincosamide antibiotic approved for adults and children as a drug of choice for systemic treatment of staphylococcal, streptococcal, and gram-positive anaerobic bacterial infections. Because of its profile and high bioavailability, it is commonly used as part of an oral multimodal alternative for prolonged parenteral antibiotic regimens, e.g., to treat bone and joint or prosthesis-related infections. Clindamycin is also frequently used for (surgical) prophylaxis in the event of beta-lactam allergy. Special populations (pediatrics, pregnant women) have altered cytochrome P450 (CYP)3A4 activity. As clindamycin is metabolized by the CYP3A4/5 enzymes to bioactive N-demethyl and sulfoxide metabolites, knowledge of the potential relevance of the drug’s metabolites and disposition in special populations is of interest. Furthermore, drug–drug interactions derived from CYP3A4 inducers and inhibitors, and the data on the impact of the disease state on the CYP system, are still limited. This narrative review provides a detailed survey of the currently available literature on pharmacology and pharmacokinetics and identifies knowledge gaps (special patient population, drug–drug, and drug–disease interactions) to describe a research strategy for precision medicine.
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12
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Kroelinger CD, Rice ME, Okoroh EM, DeSisto CL, Barfield WD. Seven years later: state neonatal risk-appropriate care policy consistency with the 2012 American Academy of Pediatrics Policy. J Perinatol 2022; 42:595-602. [PMID: 34253843 PMCID: PMC9198846 DOI: 10.1038/s41372-021-01146-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/30/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess consistency of state neonatal risk-appropriate care policies with the 2012 AAP policy seven years post-publication. STUDY DESIGN Systematic, web-based review of all publicly available 2019 state neonatal levels of care policies. Information on infant risk (gestational age, birth weight), technology and equipment capabilities, and availability of specialty staffing used to define neonatal levels of care was extracted for review. RESULT Half of states (50%) had a neonatal risk-appropriate care policy. Of those states, 88% had language consistent with AAP-defined Level I criteria, 80% with Level II, 56% with Level III, and 55% with Level IV. Comparing policies (2014-2019), consistency increased in state policies among all levels of care with the greatest increase among level IV criteria. CONCLUSION States improved consistency of policy language by each level of care, though half of states still lack policy to provide minimum standards of care to the most vulnerable infants.
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Affiliation(s)
- Charlan D. Kroelinger
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.,Correspondence and requests for materials should be addressed to C.D.K.
| | - Marion E. Rice
- Centers for Disease Control and Prevention Foundation, Atlanta, GA, USA
| | - Ekwutosi M. Okoroh
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Carla L. DeSisto
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wanda D. Barfield
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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13
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Okazaki K, Fukuoka N, Kuboi T, Unemoto J, Kondo M, Kusaka T, Itoh S. Furosemide clearance in very preterm neonates early in life: A pilot study using scavenged samples. Pediatr Int 2022; 64:e14735. [PMID: 33848384 DOI: 10.1111/ped.14735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 04/03/2021] [Accepted: 04/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Furosemide is an off-label drug, frequently used as a diuretic in neonates with oliguria and/or edema. Its clearance in preterm neonates is lower than in term neonates or children. We aimed, herein, to clarify furosemide clearance (CL) in very preterm (VP) neonates (<28 weeks' gestation) within the first 2 weeks of life and identify the factors predictive of the pharmacokinetics (PK) parameters, such as CL. METHODS Furosemide was administered at 0.5 or 1 mg/kg in a 0.5-h infusion via a syringe pump; blood samples were drawn from an artery or vein after the intravenous injection. The serum furosemide concentration was measured using high-performance liquid chromatography. The PK parameters were then analyzed using Bayesian estimation. RESULTS Thirteen blood samples were obtained from 10 VP neonates after intravenous injection. The mean postconceptional age and mean postnatal days at exposure to furosemide were 26.9 weeks and 7.1 days, respectively. The estimated mean CL was 16.5 mL/kg/h. The mean distribution volume (Vd) and elimination half-life (t1/2) were 0.37 L/kg and 15.3 h, respectively. Furosemide CL was negatively associated with serum creatinine (SCr) [CL = 84.2 - 67.1 × SCr (mg/dL)]. CONCLUSIONS Very preterm neonates within the first 2 weeks of life had a higher CL than subjects in other preterm neonatal studies. The SCr level was the sole parameter influencing furosemide CL and might serve as a good index for furosemide dosing in VP neonates.
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Affiliation(s)
- Kaoru Okazaki
- Department of Neonatology, Shikoku Medical Center for Children and Adults, Kagawa, Japan.,Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Noriyasu Fukuoka
- Laboratory of Hospital Pharmacy, School of Pharmacy, Nihon University, Chiba, Japan
| | - Toru Kuboi
- Department of Neonatology, Shikoku Medical Center for Children and Adults, Kagawa, Japan
| | - Jun Unemoto
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masatoshi Kondo
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Kagawa University, Kagawa, Japan
| | - Susumu Itoh
- Department of Pediatrics, Kagawa University, Kagawa, Japan
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14
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Challenges and opportunities for improving access to approved neonatal drugs and devices. J Perinatol 2022; 42:825-828. [PMID: 35132149 PMCID: PMC8819193 DOI: 10.1038/s41372-021-01304-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/02/2021] [Accepted: 12/15/2021] [Indexed: 11/30/2022]
Abstract
Neonatal drug and device development has lagged behind other patient populations. Oftentimes, providers are using drugs and devices without adequate study of safety and efficacy. Neonates deserve dedicated drug and device development programs, which will require novel approaches and unique collaborations between multiple key stakeholders. Legislative efforts, infrastructure, clinical trial methodology, and international collaborations have all contributed to improvements in neonatal drug and device development, but more work is still needed. Leadership from neonatologists, clinical care providers, and parents is essential to implement needed changes.
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Abstract
Almost 50% of prescription drugs lack age-appropriate dosing guidelines and therefore are used "off-label." Only ~10% drugs prescribed to neonates and infants have been studied for safety or efficacy. Immaturity of drug metabolism in children is often associated with drug toxicity. This chapter summarizes data on the ontogeny of major human metabolizing enzymes involved in oxidation, reduction, hydrolysis, and conjugation of drugs. The ontogeny data of individual drug-metabolizing enzymes are important for accurate prediction of drug pharmacokinetics and toxicity in children. This information is critical for designing clinical studies to appropriately test pharmacological hypotheses and develop safer pediatric drugs, and to replace the long-standing practice of body weight- or surface area-normalized drug dosing. The application of ontogeny data in physiologically based pharmacokinetic model and regulatory submission are discussed.
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Wang K, Jiang K, Wei X, Li Y, Wang T, Song Y. Physiologically Based Pharmacokinetic Models Are Effective Support for Pediatric Drug Development. AAPS PharmSciTech 2021; 22:208. [PMID: 34312742 PMCID: PMC8312709 DOI: 10.1208/s12249-021-02076-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/16/2021] [Indexed: 12/30/2022] Open
Abstract
Pediatric drug development faces many difficulties. Traditionally, pediatric drug doses are simply calculated linearly based on the body weight, age, and body surface area of adults. Due to the ontogeny of children, this simple linear scaling may lead to drug overdose in pediatric patients. The physiologically based pharmacokinetic (PBPK) model, as a mathematical model, contributes to the research and development of pediatric drugs. An example of a PBPK model guiding drug dose selection in pediatrics has emerged and has been approved by the relevant regulatory agencies. In this review, we discuss the principle of the PBPK model, emphasize the necessity of establishing a pediatric PBPK model, introduce the absorption, distribution, metabolism, and excretion of the pediatric PBPK model, and understand the various applications and related prospects of the pediatric PBPK model.
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Challis P, Nydert P, Håkansson S, Norman M. Association of Adherence to Surfactant Best Practice Uses With Clinical Outcomes Among Neonates in Sweden. JAMA Netw Open 2021; 4:e217269. [PMID: 33950208 PMCID: PMC8100866 DOI: 10.1001/jamanetworkopen.2021.7269] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE While surfactant therapy for respiratory distress syndrome (RDS) in preterm infants has been evaluated in clinical trials, less is known about how surfactant is used outside such a framework. OBJECTIVE To evaluate registered use, off-label use, and omissions of surfactant treatment by gestational age (GA) and associations with outcomes, mainly among very preterm infants (GA <32 weeks). DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study used registry data for 97 377 infants born in Sweden between 2009 and 2018. Infants did not have malformations and were admitted for neonatal care. Data analysis was conducted from June 2019 to June 2020. EXPOSURES Timing and number of surfactant administrations, off-label use, and omission of use. Registered use was defined by drug label (1-3 administrations for RDS). Omissions were defined as surfactant not administered despite mechanical ventilation for RDS. MAIN OUTCOME AND MEASURES In-hospital survival, pneumothorax, intraventricular hemorrhage grade 3 to 4, duration of mechanical ventilation, use of postnatal systemic corticosteroids for lung disease, treatment with supplemental oxygen at 28 days' postnatal age and at 36 weeks' postmenstrual age. Odds ratios (ORs) were calculated and adjusted for any prenatal corticosteroid treatment, cesarean delivery, GA, infant sex, Apgar score at 10 minutes, and birth weight z score of less than -2. RESULTS In total, 7980 surfactant administrations were given to 5209 infants (2233 [42.9%] girls; 2976 [57.1%] boys): 629 (12.1%) born at full term, 691 (13.3%) at 32 to 36 weeks' GA, 1544 (29.6%) at 28 to 31 weeks' GA, and 2345 (45.0%) at less than 28 weeks' GA. Overall, 977 infants (18.8%) received off-label use. In 1364 of 3508 infants (38.9%) with GA of 22 to 31 weeks, the first administration of surfactant was given more than 2 hours after birth, and this was associated with higher odds of pneumothorax (adjusted OR [aOR], 2.59; 95% CI, 1.76-3.83), intraventricular hemorrhage grades 3 to 4 (aOR, 1.71; 95% CI, 1.23-2.39), receipt of postnatal corticosteroids (aOR, 1.57; 95% CI, 1.22-2.03), and longer duration of assisted ventilation (aOR, 1.34; 95% CI, 1.04-1.72) but also higher survival (aOR, 1.45; 95% CI, 1.10-1.91) than among infants treated within 2 hours of birth. In 146 infants (2.8%), the recommended maximum of 3 surfactant administrations was exceeded but without associated improvements in outcome. Omission of surfactant treatment occurred in 203 of 3551 infants (5.7%) who were receiving mechanical ventilation and was associated with lower survival (aOR, 0.49; 95% CI, 0.30-0.82). In full-term infants, 336 (53.4%) of those receiving surfactant had a diagnosis of meconium aspiration syndrome. Surfactant for meconium aspiration was not associated with improved neonatal outcomes. CONCLUSIONS AND RELEVANCE In this study, adherence to best practices and labels for surfactant use in newborn infants varied, with important clinical implications for neonatal outcomes.
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Affiliation(s)
- Pontus Challis
- Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
| | - Per Nydert
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Stellan Håkansson
- Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
| | - Mikael Norman
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
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Naji-Talakar S, Sharma S, Martin LA, Barnhart D, Prasad B. Potential implications of DMET ontogeny on the disposition of commonly prescribed drugs in neonatal and pediatric intensive care units. Expert Opin Drug Metab Toxicol 2021; 17:273-289. [PMID: 33256492 PMCID: PMC8346204 DOI: 10.1080/17425255.2021.1858051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Introduction: Pediatric patients, especially neonates and infants, are more susceptible to adverse drug events as compared to adults. In particular, immature small molecule drug metabolism and excretion can result in higher incidences of pediatric toxicity than adults if the pediatric dose is not adjusted.Area covered: We reviewed the top 29 small molecule drugs prescribed in neonatal and pediatric intensive care units and compiled the mechanisms of their metabolism and excretion. The ontogeny of Phase I and II drug metabolizing enzymes and transporters (DMETs), particularly relevant to these drugs, are summarized. The potential effects of DMET ontogeny on the metabolism and excretion of the top pediatric drugs were predicted. The current regulatory requirements and recommendations regarding safe and effective use of drugs in children are discussed. A few representative examples of the use of ontogeny-informed physiologically based pharmacokinetic (PBPK) models are highlighted.Expert opinion: Empirical prediction of pediatric drug dosing based on body weight or body-surface area from the adult parameters can be inaccurate because DMETs are not mature in children and the age-dependent maturation of these proteins is different. Ontogeny-informed-PBPK modeling provides a better alternative to predict the pharmacokinetics of drugs in children.
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Affiliation(s)
- Siavosh Naji-Talakar
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Sheena Sharma
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Leslie A. Martin
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Derek Barnhart
- Pediatrics and Neonatology, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, USA
| | - Bhagwat Prasad
- Department of Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
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19
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Li H, Deng J, Yu P, Deng L, Ren X. Gaining insight into irrational off-label use of vidarabine through analysis of a spontaneous reporting system in China. J Clin Pharm Ther 2020; 45:1301-1311. [PMID: 32614099 DOI: 10.1111/jcpt.13209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/30/2020] [Accepted: 06/08/2020] [Indexed: 12/13/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Although superseded by other antiviral agents in many Western countries, vidarabine is still widely used in some countries, including China; hence, the extent and appropriateness of vidarabine prescriptions in children require better characterization. This study examined the rationale, extent, and health risks associated with irrational off-label vidarabine use in China. METHODS Data used in the study were extracted from a multi-provincial joint adverse drug reactions monitoring platform from 2002 to 2018. Descriptive statistics were used to analyse the characteristics of individual case safety reports (ICSRs) related to vidarabine use. RESULTS AND DISCUSSION Among 2772 individual ICSRs related to vidarabine, 2223 (80.19%) cases occurred in patients aged 0-9. In all patients, the median age and interquartile range were 2 (0-6). Although most adverse events were mild, five deaths were recorded, all in children below 7 years of age. Paediatric use is the most prominent off-label use of vidarabine. Additionally, several other irrational off-label uses were identified, including 218 (7.86%) cases of overdosing and numerous applications beyond the approved indications, dosages, routes of administration, and solvents. WHAT IS NEW AND CONCLUSION Data indicate that vidarabine was mainly prescribed for suspected common viral infections in paediatric patients, demonstrating serious inappropriate off-label uses. The problem was further complicated by the lack of sufficient information regarding safety, efficacy, and dosing regimens in children, as well as by several additional risk factors such as inappropriate solvents, routes of administration, and overdose. In the case of children, the physicians' lack of understanding of antiviral activities and compassionate prescriptions were mainly responsible for drug overuse. The health risks associated with the paediatric use of vidarabine in China require greater attention and further investigation.
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Affiliation(s)
- Haona Li
- Huaihe Hospital of Henan University, Kaifeng, China.,Institutes of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, China
| | - Jianxiong Deng
- Adverse Drug Reaction Monitoring Centre of Guangdong Province, Guangzhou, China
| | - Peiming Yu
- School of Pharmacy, Henan University, Kaifeng, China
| | - Lewen Deng
- Adverse Drug Reaction Monitoring Centre of Guangdong Province, Guangzhou, China
| | - Xuequn Ren
- Huaihe Hospital of Henan University, Kaifeng, China.,Institutes of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, China
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20
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Tyson RJ, Park CC, Powell JR, Patterson JH, Weiner D, Watkins PB, Gonzalez D. Precision Dosing Priority Criteria: Drug, Disease, and Patient Population Variables. Front Pharmacol 2020; 11:420. [PMID: 32390828 PMCID: PMC7188913 DOI: 10.3389/fphar.2020.00420] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/19/2020] [Indexed: 12/12/2022] Open
Abstract
The administered dose of a drug modulates whether patients will experience optimal effectiveness, toxicity including death, or no effect at all. Dosing is particularly important for diseases and/or drugs where the drug can decrease severe morbidity or prolong life. Likewise, dosing is important where the drug can cause death or severe morbidity. Since we believe there are many examples where more precise dosing could benefit patients, it is worthwhile to consider how to prioritize drug–disease targets. One key consideration is the quality of information available from which more precise dosing recommendations can be constructed. When a new more precise dosing scheme is created and differs significantly from the approved label, it is important to consider the level of proof necessary to either change the label and/or change clinical practice. The cost and effort needed to provide this proof should also be considered in prioritizing drug–disease precision dosing targets. Although precision dosing is being promoted and has great promise, it is underutilized in many drugs and disease states. Therefore, we believe it is important to consider how more precise dosing is going to be delivered to high priority patients in a timely manner. If better dosing schemes do not change clinical practice resulting in better patient outcomes, then what is the use? This review paper discusses variables to consider when prioritizing precision dosing candidates while highlighting key examples of precision dosing that have been successfully used to improve patient care.
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Affiliation(s)
- Rachel J Tyson
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Christine C Park
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - J Robert Powell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - J Herbert Patterson
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Daniel Weiner
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Paul B Watkins
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Institute for Drug Safety Sciences, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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21
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Trends in Drug Trial Publications Involving Neonates: Has the Legislation Helped? Am J Ther 2020; 26:e714-e716. [PMID: 31162156 DOI: 10.1097/mjt.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Davis JM, Baer GR, McCune S, Klein A, Sato J, Fabbri L, Mangili A, Short MA, Tansey S, Mangum B, Hokuto I, Nakamura H, Salaets T, Allegaert K, Yao L, Blum M, Toerner J, Turner M, Portman R. Standardizing Safety Assessment and Reporting for Neonatal Clinical Trials. J Pediatr 2020; 219:243-249.e1. [PMID: 31708158 PMCID: PMC7096275 DOI: 10.1016/j.jpeds.2019.09.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Jonathan M Davis
- The Floating Hospital for Children at Tufts Medical Center and the Tufts Clinical and Translational Science Institute, Boston, MA.
| | - Gerri R Baer
- US Food and Drug Administration, Office of Pediatric Therapeutics, Silver Spring, MD
| | - Susan McCune
- US Food and Drug Administration, Office of Pediatric Therapeutics, Silver Spring, MD
| | | | - Junko Sato
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | | | | | | | - Susan Tansey
- Independent Consultant Pharmaceutical Physician, Durham, NC
| | | | | | | | - Thomas Salaets
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Lynne Yao
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD
| | - Michael Blum
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD
| | - Joseph Toerner
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD
| | - Mark Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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23
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Bueters R, Bael A, Gasthuys E, Chen C, Schreuder MF, Frazier KS. Ontogeny and Cross-species Comparison of Pathways Involved in Drug Absorption, Distribution, Metabolism, and Excretion in Neonates (Review): Kidney. Drug Metab Dispos 2020; 48:353-367. [DOI: 10.1124/dmd.119.089755] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/04/2020] [Indexed: 02/06/2023] Open
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24
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Fang JL, Mara KC, Weaver AL, Clark RH, Carey WA. Outcomes of outborn extremely preterm neonates admitted to a NICU with respiratory distress. Arch Dis Child Fetal Neonatal Ed 2020; 105:33-40. [PMID: 31079068 DOI: 10.1136/archdischild-2018-316244] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 04/04/2019] [Accepted: 04/07/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the risk of mortality and morbidity between outborn and propensity score-matched inborn extremely preterm neonates. SETTING Multiple neonatal intensive care units (NICU) across the USA. PATIENTS Singleton neonates born at 22-29 weeks' gestation with no major anomalies who were admitted to a NICU and discharged between 2000 and 2014. Outborn neonates were restricted to those who transferred into a NICU on the day of birth. METHODS The association between inborn-outborn status and the time-to-event outcomes of in-hospital mortality and necrotising enterocolitis (NEC) were assessed using Cox proportional hazards regression. Logistic regression was used to assess the remaining secondary outcomes: retinopathy of prematurity requiring treatment (tROP), chronic lung disease (CLD), periventricular leucomalacia (PVL) and severe intraventricular haemorrhage (IVH). Since outborn status was not random, we used 1:1 propensity score matching to reduce the imbalance in illness severity. RESULTS There were 59 942 neonates (7991 outborn) included in the study. Outborn neonates had poorer survival than inborns and higher rates of NEC, severe IVH, tROP and PVL. Inborn-outborn disparities in mortality were reduced over the study period. When analysing the matched cohort (6524 matched pairs), outborns were less likely to die in-hospital compared with inborns (HR 0.84, 95% CI 0.77 to 0.91). However, outborns experienced higher rates of NEC (HR 1.14, 95% CI 1.04 to 1.25), severe IVH (OR 1.52, 95% CI 1.38 to 1.68), tROP (OR 1.45, 95% CI 1.25 to 1.69) and CLD (OR 1.12, 95% CI 1.01 to 1.24). CONCLUSION Additional research is needed to understand the contributors to increased morbidity for outborn extremely preterm neonates and identify interventions that mitigate this risk.
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Affiliation(s)
- Jennifer L Fang
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Reese H Clark
- CREQS, Pediatrix Medical Group, Sunrise, Florida, USA
| | - William A Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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25
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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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26
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Bucci-Rechtweg CM, Ward RM. Tiny and Forgotten: A Call for Focused Neonatal Policy Reform. Ther Innov Regul Sci 2019; 53:615-617. [DOI: 10.1177/2168479018821922] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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27
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Song YK, Han N, Burckart GJ, Oh JM. International Coherence of Pediatric Drug Labeling for Drug Safety: Comparison of Approved Labels in Korea and the United States. Clin Pharmacol Ther 2019; 107:530-540. [PMID: 31544241 PMCID: PMC7028218 DOI: 10.1002/cpt.1640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/06/2019] [Indexed: 01/24/2023]
Abstract
The objective of this study was to analyze information on pediatric use in Korean drug product labels and compare it with that in US Food and Drug Administration (FDA) labeling information. Prescription information on pediatric use contained in the commonly used drugs’ product labels approved by Korean government was compared with that approved by the FDA. Among the top 50 commonly prescribed drugs, 20 drugs were deemed to have insufficient prescribing information in Korean drug labels. Pediatric prescribing information regarding indication, approved age, formulations, and safety was insufficient in Korean drug labels compared with those in the FDA. Most important, the adverse events frequently reported in Korean children were not sufficiently presented in drug labels. In conclusion, this study highlights the urgent need for the Korean regulatory agency to encourage and accelerate research and development to increase the extent of pediatric prescribing information to be added to drug labels to promote appropriate drug prescribing for children.
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Affiliation(s)
- Yun-Kyoung Song
- College of Pharmacy, Daegu Catholic University, Gyeongsan-si, Gyeongbuk, Korea
| | - Nayoung Han
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Seoul National University, Gwanak-gu, Seoul, Korea
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jung Mi Oh
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Seoul National University, Gwanak-gu, Seoul, Korea
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28
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Schiller RM, Allegaert K, Hunfeld M, van den Bosch GE, van den Anker J, Tibboel D. Analgesics and Sedatives in Critically Ill Newborns and Infants: The Impact on Long-Term Neurodevelopment. J Clin Pharmacol 2019; 58 Suppl 10:S140-S150. [PMID: 30248203 DOI: 10.1002/jcph.1139] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/23/2018] [Indexed: 12/12/2022]
Abstract
Inadequate pain and/or stress management in preterm- and term-born infants has been associated with increased morbidity and even mortality. However, exposure to analgosedatives during early infancy may also be one of the risk factors for subsequent neurodevelopmental impairment, at least in animal studies. Because infants admitted to neonatal or pediatric intensive care units may receive high amounts of these drugs for prolonged periods of time and the majority of these infants nowadays survive to discharge, this is of major concern. A balanced approach that incorporates the assessment and quantification of both wanted effects as well as unwanted side effects is therefore needed. In this article, the optimal dose determination of commonly used analgosedative drugs as well as their potential long-term effects on the developing human brain and neuropsychological functioning are reviewed.
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Affiliation(s)
- R M Schiller
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - K Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Maayke Hunfeld
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - G E van den Bosch
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - John van den Anker
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Division of Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - D Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
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29
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Noteworthy Professional News. Adv Neonatal Care 2019. [DOI: 10.1097/anc.0000000000000662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Gouyon B, Martin-Mons S, Iacobelli S, Razafimahefa H, Kermorvant-Duchemin E, Brat R, Caeymaex L, Couringa Y, Alexandre C, Lafon C, Ramful D, Bonsante F, Binson G, Flamein F, Moussy-Durandy A, Di Maio M, Mazeiras G, Girard O, Desbruyeres C, Mourdie J, Escourrou G, Flechelles O, Abasse S, Rosenthal JM, Pages AS, Dorsi M, Karaoui L, ElGellab A, Le Bail Dantec F, Yangui MA, Norbert K, Kugbe Y, Lorrain S, Pignolet A, Garnier EM, Lapillonne A, Mitanchez D, Jacqz-Aigrain E, Gouyon JB. Characteristics of prescription in 29 Level 3 Neonatal Wards over a 2-year period (2017-2018). An inventory for future research. PLoS One 2019; 14:e0222667. [PMID: 31536560 PMCID: PMC6752821 DOI: 10.1371/journal.pone.0222667] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022] Open
Abstract
Objectives The primary objective of this study is to determine the current level of patient medication exposure in Level 3 Neonatal Wards (L3NW). The secondary objective is to evaluate in the first month of life the rate of medication prescription not cited in the Summary of Product Characteristics (SmPC). A database containing all the medication prescriptions is collected as part of a prescription benchmarking program in the L3NW. Material and methods The research is a two-year observational cohort study (2017–2018) with retrospective analysis of medications prescribed in 29 French L3NW. Seventeen L3NW are present since the beginning of the study and 12 have been progressively included. All neonatal units used the same computerized system of prescription, and all prescription data were completely de-identified within each hospital before being stored in a common data warehouse. Results The study population includes 27,382 newborns. Two hundred and sixty-one different medications (International Nonproprietary Names, INN) were prescribed. Twelve INN (including paracetamol) were prescribed for at least 10% of patients, 55 for less than 10% but at least 1% and 194 to less than 1%. The lowest gestational ages (GA) were exposed to the greatest number of medications (18.0 below 28 weeks of gestation (WG) to 4.1 above 36 WG) (p<0.0001). In addition, 69.2% of the 351 different combinations of an medication INN and a route of administration have no indication for the first month of life according to the French SmPC. Ninety-five percent of premature infants with GA less than 32 weeks received at least one medication not cited in SmPC. Conclusion Neonates remain therapeutic orphans. The consequences of polypharmacy in L3NW should be quickly assessed, especially in the most immature infants.
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Affiliation(s)
- Béatrice Gouyon
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | - Séverine Martin-Mons
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | - Silvia Iacobelli
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | | | | | - Roselyne Brat
- Centre Hospitalier Régional d’Orléans, Orléans, France
| | | | - Yvan Couringa
- Centre Hospitalier Andrée-Rosemon, Guyane Française, France
| | | | | | - Duksha Ramful
- Centre Hospitalier Universitaire de La Réunion – Site Nord, Saint Denis, Réunion, France
| | - Francesco Bonsante
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | | | | | | | | | - Gaël Mazeiras
- Centre Hospitalier de la Côte Basque, Bayonne, France
| | | | | | - Julien Mourdie
- Hôpital Jacques Monod – Groupe Hospitalier du Havre, Montivilliers, France
| | | | - Olivier Flechelles
- Centre Hospitalier Universitaire de Fort-de-France, Fort de France, Martinique, France
| | | | | | - Anne-Sophie Pages
- Centre Hospitalier Public du Cotentin, Cherbourg-en-Cotentin, France
| | - Marine Dorsi
- Centre Hospitalier Territorial Gaston-Bourret, Dumbéa, Nouvelle Calédonie, France
| | | | | | | | | | | | - Yaovi Kugbe
- Centre Hospitalier de l’Ouest Guyanais – Franck Joly, Saint Laurent du Maroni, Guyane Française, France
| | - Simon Lorrain
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | - Anaelle Pignolet
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | - Elodie Marie Garnier
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
| | | | | | | | - Jean-Bernard Gouyon
- Centre d’Etudes Périnatales de l’Océan Indien (EA 7388), Centre Hospitalier Universitaire de La Réunion – Site Sud, Saint Pierre, Réunion, France
- * E-mail:
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Perico N, Askenazi D, Cortinovis M, Remuzzi G. Maternal and environmental risk factors for neonatal AKI and its long-term consequences. Nat Rev Nephrol 2019; 14:688-703. [PMID: 30224767 DOI: 10.1038/s41581-018-0054-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute kidney injury (AKI) is a common and life-threatening complication in critically ill neonates. Gestational risk factors for AKI include premature birth, intrauterine growth restriction and low birthweight, which are associated with poor nephron development and are often the consequence of pre-gestational and gestational factors, such as poor nutritional status. Our understanding of how to best optimize renal development and prevent AKI is in its infancy; however, the identification of pre-gestational and gestational factors that increase the risk of adverse neonatal outcomes and the implementation of interventions, such as improving nutritional status early in pregnancy, have the potential to optimize fetal growth and reduce the risk of preterm birth, thereby improving kidney health. The overall risk of AKI among critically ill and premature neonates is exacerbated postnatally as these infants are often exposed to dehydration, septic shock and potentially nephrotoxic medications. Strategies to improve outcomes - for example, through careful evaluation of nephrotoxic drugs - may reduce the incidence of AKI and its consequences among this population. Management strategies and updated technology that will support neonates with AKI are greatly needed. Extremely premature infants and those who survive an episode of AKI should be screened for chronic kidney disease until early adulthood. Here, we provide an overview of our current understanding of neonatal AKI, focusing on its relationship to preterm birth and growth restriction. We describe factors that prevent optimal nephrogenesis during pregnancy and provide a framework for future explorations designed to maximize outcomes in this vulnerable population.
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Affiliation(s)
- Norberto Perico
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - David Askenazi
- Pediatric and Infant Center for Acute Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Monica Cortinovis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy. .,Unit of Nephrology and Dialysis, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy. .,L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.
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McCune SK, Mulugeta YA, Baer GR. Collaboration in Regulatory Science to Facilitate Therapeutic Development for Neonates. Curr Pharm Des 2019; 23:5801-5804. [PMID: 28950828 DOI: 10.2174/1381612823666170926114857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/18/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Historically, neonatal therapeutic interventions were derived from adult therapeutics, and tragedies resulting from this approach have demonstrated differences in the pathophysiologic and developmental processes between neonates and older patients. Over the past 3 decades, researchers and collaborative research networks have made progress in the systematic evaluation of neonatal therapies, yet most neonatal therapeutic products have been incompletely assessed for safety and efficacy, and remain unlabeled and unapproved. APPROACH This work describes the legislative initiatives that have stimulated an increase in pediatric and neonatal studies. It highlights examples of successful neonatal drug studies that have resulted in informative neonatal labeling changes, as well as studies that have produced incomplete information. Strategies that support the design of successful studies, including targeting specific subpopulations, modeling and simulation to inform dose selection, innovative design strategies, biomarkers, and endpoints are discussed. Multi-stakeholder consortia such as the International Neonatal Consortium (INC), are working to improve the tools needed for the development of neonatal therapies. These research tools may be used by trial networks to inform consistent and efficient multicenter studies. CONCLUSION More data are needed to support safe and effective use of drugs in neonates, and to obtain these data, a thorough understanding of pathophysiology, drug disposition, biomarkers, and clinically-meaningful endpoints is required. This information will be derived from clinical trials, registries, real-world evidence, and the medical literature. Collaboration of consortia and the development of research networks are essential to achieving these goals.
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Affiliation(s)
- Susan K McCune
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration, Silver Spring, MD, United States
| | - Yeruk Ager Mulugeta
- Division of Pediatric and Maternal Health, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, United States
| | - Gerri R Baer
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration, Silver Spring, MD, United States
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Taylor G, Jackson W, Hornik CP, Koss A, Mantena S, Homsley K, Gattis B, Kudumu-Clavell M, Clark R, Smith PB, Laughon MM. Surfactant Administration in Preterm Infants: Drug Development Opportunities. J Pediatr 2019; 208:163-168. [PMID: 30580975 PMCID: PMC6486873 DOI: 10.1016/j.jpeds.2018.11.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/26/2018] [Accepted: 11/26/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate how frequently surfactant is used off-label in preterm infants. STUDY DESIGN We conducted a retrospective cohort analysis of prospectively collected administrative data for 2005-2015 from 348 neonatal intensive care units in the US. We quantified off-label administration of poractant alfa, calfactant, or beractant in inborn infants born at <37 weeks of gestational age (GA). Off-label surfactant administration was defined according to the Food and Drug Administration (FDA) label. RESULTS Of a total of 110 822 preterm infants who received surfactant, 68 226 (62%) received the surfactant off-label. The majority of infants who received surfactant off-label had a higher birth weight than those who received surfactant on-label (40 716 [37%]), had an older GA than those who received surfactant on-label (35 191 [32%]), or were treated with intubation and surfactant administration followed by immediate extubation (INSURE) (32 310 [29%]). Poractant alfa was administered via INSURE more frequently than beractant or calfactant (16 688 [38%], 7137 [20%], and 8485 [27%], respectively). An increasing number of infants received surfactant via INSURE from 2005 to 2015 (from 1697 [19%] to 3368 [36%]). CONCLUSIONS The majority of surfactant given to preterm infants is administered off-label. The uptrend in administration via INSURE coincides with increased supporting evidence. The gap between FDA labeling and current clinic practice exemplifies an opportunity for label expansion, which may require additional prospective or retrospective safety and/or effectiveness data for infants of older GA and higher birth weight.
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Affiliation(s)
- Genevieve Taylor
- Department of Pediatrics, The University of North Carolina, Chapel Hill, NC.
| | - Wesley Jackson
- Department of Pediatrics, The University of North Carolina, Chapel Hill, NC
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Alec Koss
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Sreekar Mantena
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Kenya Homsley
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Blair Gattis
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Reese Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina, Chapel Hill, NC
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Yen E, Davis JM, Milne CP. Impact of Regulatory Incentive Programs on the Future of Pediatric Drug Development. Ther Innov Regul Sci 2019; 53:609-614. [PMID: 30983385 DOI: 10.1177/2168479019837522] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Surveys evaluating industry experience with performing pediatric studies under the Best Pharmaceutical for Children Act (BPCA) and Pediatric Research Equity Act (PREA) regulatory regime were conducted by Tufts Center for the Study of Drug Development (Tufts CSDD) in 2000, 2006, and 2016. These survey results are being used to assess the future impact of regulatory incentive programs on generating pediatric specific labeling information and development of age-appropriate drug formulations. A second perspective will be provided through the experience and expertise of neonatal/pediatric clinicians and researchers with a focus on the urgent need for the study of new and existing drugs in this vulnerable population (especially with 90% of drugs in neonates still being used off-label). This group will also address the impact of existing regulations and the likely trajectory of future pediatric drug development efforts after nearly 2 decades of regulatory incentives (both mandatory and voluntary). Finally, this review will provide input on approaches that are needed to continue to advance pediatric drug development with an emphasis on rare diseases.
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Affiliation(s)
- Elizabeth Yen
- 1 Department of Pediatrics, The Floating Hospital for Children at Tufts Medical Center, Boston, MA, USA
| | - Jonathan M Davis
- 1 Department of Pediatrics, The Floating Hospital for Children at Tufts Medical Center, Boston, MA, USA.,2 The Tufts Clinical and Translational Research Institute, Boston, MA, USA
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Lee KEM, Diacovo TG, Calderon J, Byrne MW, Ing C. Outcomes Research in Vulnerable Pediatric Populations. J Neurosurg Anesthesiol 2019; 31:140-143. [PMID: 30767939 PMCID: PMC9109709 DOI: 10.1097/ana.0000000000000544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Pediatric Anesthesia and Neurodevelopment Assessment (PANDA) study team held its biennial symposium in April 2018 to discuss issues on anesthetic neurotoxicity in the developing brain. One of the sessions invited speakers with different areas of expertise to discuss "Outcomes Research in Vulnerable Pediatric Populations." The vulnerable populations included neonates, children with congenital heart disease, children from low socioeconomic status, and children with incarcerated parents. Each speaker presented some of the ongoing research efforts in these groups as well as the challenges encountered in studying them.
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Affiliation(s)
- Ka-Eun M Lee
- Department of Anesthesiology, Columbia University Medical Center, Columbia University College of Physicians and Surgeons
| | - Thomas G Diacovo
- Departments of Pediatrics and Pharmacology, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Johanna Calderon
- Department of Psychiatry, Harvard Medical School, Boston Children's Hospital, Boston, MA
| | - Mary W Byrne
- Columbia University School of Nursing, Columbia University College of Physicians and Surgeons
| | - Caleb Ing
- Department of Anesthesiology and Epidemiology, Columbia University College of Physicians and Surgeons and Mailman School of Public Health, New York, NY
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Neal-Kluever A, Fisher J, Grylack L, Kakiuchi-Kiyota S, Halpern W. Physiology of the Neonatal Gastrointestinal System Relevant to the Disposition of Orally Administered Medications. Drug Metab Dispos 2018; 47:296-313. [DOI: 10.1124/dmd.118.084418] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/14/2018] [Indexed: 12/13/2022] Open
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Duan P, Wu F, Moore JN, Fisher J, Crentsil V, Gonzalez D, Zhang L, Burckart GJ, Wang J. Assessing CYP2C19 Ontogeny in Neonates and Infants Using Physiologically Based Pharmacokinetic Models: Impact of Enzyme Maturation Versus Inhibition. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2018; 8:158-166. [PMID: 30520273 PMCID: PMC6430158 DOI: 10.1002/psp4.12350] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 08/13/2018] [Indexed: 12/18/2022]
Abstract
The objective of this study was to develop pediatric physiologically based pharmacokinetic (PBPK) models for pantoprazole and esomeprazole. Pediatric PBPK models were developed by Simcyp version 15 by incorporating cytochrome P450 (CYP)2C19 maturation and auto-inhibition. The predicted-to-observed pantoprazole clearance (CL) ratio ranged from 0.96-1.35 in children 1-17 years of age and 0.43-0.70 in term infants. The predicted-to-observed esomeprazole CL ratio ranged from 1.08-1.50 for children 6-17 years of age, and 0.15-0.33 for infants. The prediction was markedly improved by assuming no auto-inhibition of esomeprazole in infants in the PBPK model. Our results suggested that the CYP2C19 auto-inhibition model was appropriate for esomeprazole in adults and older children but could not be directly extended to infants. A better understanding of the complex interplay of enzyme maturation, inhibition, and compensatory mechanisms for CYP2C19 is necessary for PBPK modeling in infants.
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Affiliation(s)
- Peng Duan
- Office of New Drug Product, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Fang Wu
- Office of New Drug Product, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jason N Moore
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jeffrey Fisher
- Division of Biochemical Toxicology, National Center for Toxicological Research, Jefferson, Arkansas, USA
| | - Victor Crentsil
- Office of Drug Evaluation III, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lei Zhang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jian Wang
- Office of Drug Evaluation IV, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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Ellsworth KR, Ellsworth MA, Weaver AL, Mara KC, Clark RH, Carey WA. Association of Early Inhaled Nitric Oxide With the Survival of Preterm Neonates With Pulmonary Hypoplasia. JAMA Pediatr 2018; 172:e180761. [PMID: 29800952 PMCID: PMC6137510 DOI: 10.1001/jamapediatrics.2018.0761] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE Pulmonary hypoplasia affects a very small percentage of preterm neonates, but its presence is associated with high rates of mortality. OBJECTIVE To determine whether treatment with inhaled nitric oxide during the first week of life was associated with improved in-hospital survival in a cohort of extremely preterm neonates with pulmonary hypoplasia. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the Pediatrix Medical Group's Clinical Data Warehouse, a data set containing information from more than 350 neonatal intensive care units in 35 US states and Puerto Rico. Since inhaled nitric oxide was not randomly prescribed, we used 1-to-1 propensity score matching to reduce the imbalance of measured covariates between the 2 treatment groups. The initial, unmatched cohort included singleton neonates who were born between 22 and 29 weeks' gestation, had a birth weight of 400 g or more, were diagnosed with pulmonary hypoplasia as a cause of their respiratory distress, remained free of major anomalies, and were discharged between January 1, 2000, and December 31, 2014. We defined exposure as the initiation of inhaled nitric oxide on day t in days 0 to 7 of the life of a neonate. Each exposed neonate was matched 1-to-1 to a neonate who had not initiated inhaled nitric oxide on a given day. MAIN OUTCOMES AND MEASURES The primary outcome was mortality defined as death prior to transfer or discharge home. Secondary outcomes were any-stage necrotizing enterocolitis, retinopathy of prematurity requiring treatment, chronic lung disease, and periventricular leukomalacia. RESULTS Among 92 635 neonates in our study sample, we identified 767 (0.8%) with pulmonary hypoplasia who met all study inclusion criteria, of whom 185 (0.2%) were exposed to inhaled nitric oxide. Among 151 matched pairs of exposed and unexposed neonates, we did not identify a significant association between inhaled nitric oxide use and mortality (hazard ratio [HR], 0.79; 95% CI, 0.57-1.11). Subgroup analyses of neonates with and without persistent pulmonary hypertension (PPHN) likewise revealed no significant association between inhaled nitric oxide use and mortality (pulmonary hypoplasia with PPHN: HR, 0.67; 95% CI, 0.45-1.01; pulmonary hypoplasia without PPHN: HR, 1.11; 95% CI, 0.61-2.02), but these findings may have been influenced by ascertainment bias. CONCLUSIONS AND RELEVANCE Early treatment with inhaled nitric oxide is not associated with improved survival among extremely preterm neonates with pulmonary hypoplasia. Clinical trials are warranted to clarify the matter.
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Affiliation(s)
| | | | - Amy L. Weaver
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Kristin C. Mara
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Reese H. Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - William A. Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota
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Flint RB, van Beek F, Andriessen P, Zimmermann LJ, Liem KD, Reiss IKM, de Groot R, Tibboel D, Burger DM, Simons SHP. Large differences in neonatal drug use between NICUs are common practice: time for consensus? Br J Clin Pharmacol 2018; 84:1313-1323. [PMID: 29624207 PMCID: PMC5980600 DOI: 10.1111/bcp.13563] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/24/2018] [Accepted: 02/11/2018] [Indexed: 01/27/2023] Open
Abstract
Aims Evidence for drug use in newborns is sparse, which may cause large differences in drug prescriptions. We aimed to investigate the differences between neonatal intensive care units (NICUs) in the Netherlands in currently prescribed drugs. Methods This multicentre study included neonates admitted during 12 months to four different NICUs. Drugs were classified in accordance with the Anatomical Therapeutic Chemical (ATC) classification system and assessed for on/off‐label status in relation to neonatal age. The treatment protocols for four common indications for drug use were compared: pain, intubation, convulsions and hypotension. Results A total of 1491 neonates (GA range 23+6–42+2 weeks) were included with a total of 32 182 patient days, 181 different drugs and 10 895 prescriptions of which 23% was off‐label in relation to neonatal age. Overall, anti‐infective drugs were most frequently used with a total of 3161 prescriptions, of which 4% was off‐label in relation to neonatal age. Nervous system drugs included 2500 prescriptions of which 31% was off‐label in relation to neonatal age. Nervous system drugs, blood and blood forming organs, and cardiovascular drugs showed the largest differences between NICUs with ranges of 919–2278, 554–1465, and 238–952 total prescriptions per 1000 patients per ATC class, respectively. Conclusions We showed that drug use varies widely in neonatal clinical practice. The drug classes with the highest proportion of off‐label drugs in relation to neonatal age showed the largest differences between NICUs, i.e. cardiovascular and nervous system drugs. Drug research in neonates should receive high priority to guarantee safe and appropriate medicines and optimal treatment.
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Affiliation(s)
- Robert B Flint
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pharmacy and Radboud Institute of Health Sciences (RIHS), Radboudumc, Nijmegen, The Netherlands.,Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Floor van Beek
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Peter Andriessen
- Department of Pediatrics, Division of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Luc J Zimmermann
- Department of Pediatrics, Maastricht University Medical Center, School of Oncology and Developmental Biology, School of Mental Health and Neuroscience, Maastricht, The Netherlands
| | - Kian D Liem
- Department of Pediatrics, Division of Neonatology, Radboudumc, Nijmegen, Nijmegen, The Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ronald de Groot
- Laboratory of Pediatric Infectious Diseases, Department of Pediatrics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Department of Pediatrics, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - David M Burger
- Department of Pharmacy and Radboud Institute of Health Sciences (RIHS), Radboudumc, Nijmegen, The Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
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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: 38] [Impact Index Per Article: 6.3] [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
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Cuzzolin L, Agostino R. Antibiotic Use in a Cohort of Extremely Low Birth Weight Neonates: Focus on Off-Label Uses and Prescription Behaviour. ACTA ACUST UNITED AC 2018. [DOI: 10.4236/pp.2018.99029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Duan P, Fisher JW, Yoshida K, Zhang L, Burckart GJ, Wang J. Physiologically Based Pharmacokinetic Prediction of Linezolid and Emtricitabine in Neonates and Infants. Clin Pharmacokinet 2017; 56:383-394. [PMID: 27596256 DOI: 10.1007/s40262-016-0445-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Modeling and simulation approaches are increasingly being utilized in pediatric drug development. Physiologically based pharmacokinetic (PBPK) modeling offers an enhanced ability to predict age-related changes in pharmacokinetics in the pediatric population. METHODS In the current study, adult PBPK models were developed for the renally excreted drugs linezolid and emtricitabine. PBPK models were then utilized to predict pharmacokinetics in pediatric patients for various age groups from the oldest to the youngest patients in a stepwise approach. RESULTS Pharmacokinetic predictions for these two drugs in the pediatric population, including infants and neonates, were within a twofold range of clinical observations. Based on this study, linezolid and emtricitabine pediatric PBPK models incorporating the ontogeny in renal maturation describe the pharmacokinetic differences between adult and pediatric populations, even though the contribution of renal clearance to the total clearance of two drugs was very different (30 % for linezolid vs. 86 % for emtricitabine). CONCLUSION These results suggest that PBPK modeling may provide one option to help predict the pharmacokinetics of renally excreted drugs in neonates and infants.
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Affiliation(s)
- Peng Duan
- Office of New Drug Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Jeffrey W Fisher
- National Center for Toxicological Research, US Food and Drug Administration, 3900 NCTR Rd, Jefferson, AR, 72079, USA
| | - Kenta Yoshida
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Building 51, Rm 2154, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Lei Zhang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Building 51, Rm 2154, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Building 51, Rm 2154, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Jian Wang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Building 51, Rm 2154, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA.
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Rivera-Chaparro ND, Cohen-Wolkowiez M, Greenberg RG. Dosing antibiotics in neonates: review of the pharmacokinetic data. Future Microbiol 2017; 12:1001-1016. [PMID: 28758800 PMCID: PMC5627030 DOI: 10.2217/fmb-2017-0058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 05/23/2017] [Indexed: 12/20/2022] Open
Abstract
Antibiotics are often used in neonates despite the absence of relevant dosing information in drug labels. For neonatal dosing, clinicians must extrapolate data from studies for adults and older children, who have strikingly different physiologies. As a result, dosing extrapolation can lead to increased toxicity or efficacy failures in neonates. Driven by these differences and recent legislation mandating the study of drugs in children and neonates, an increasing number of pharmacokinetic studies of antibiotics are being performed in neonates. These studies have led to new dosing recommendations with particular consideration for neonate body size and maturation. Herein, we highlight the available pharmacokinetic data for commonly used systemic antibiotics in neonates.
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Affiliation(s)
- Nazario D Rivera-Chaparro
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Rachel G Greenberg
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
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Carpenter D, Gonzalez D, Retsch-Bogart G, Sleath B, Wilfond B. Methodological and Ethical Issues in Pediatric Medication Safety Research. Pediatrics 2017; 140:e20170195. [PMID: 28778857 PMCID: PMC5574727 DOI: 10.1542/peds.2017-0195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 12/26/2022] Open
Abstract
In May 2016, the Eshelman School of Pharmacy at The University of North Carolina at Chapel Hill convened the PharmSci conference to address the topic of "methodological and ethical issues in pediatric medication safety research." A multidisciplinary group of experts representing a diverse array of perspectives, including those of the US Food and Drug Administration, children's hospitals, and academia, identified important considerations for pediatric medication safety research and opportunities to advance the field. This executive summary describes current challenges that clinicians and researchers encounter related to pediatric medication safety research and identifies innovative and ethically sound methodologies to address these challenges to improve children's health. This article addresses 5 areas: (1) pediatric drug development and drug trials; (2) conducting comparative effectiveness research in pediatric populations; (3) child and parent engagement on study teams; (4) improving communication with children and parents; and (5) assessing child-reported outcomes and adverse drug events.
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Affiliation(s)
| | | | - George Retsch-Bogart
- Department of Pediatrics, School of Medicine
- Clinical and Translational Research Center of the North Carolina Translational and Clinical Sciences Institute, and
- Cystic Fibrosis Therapeutics Development Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | | | - Benjamin Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, University of Washington, Seattle, Washington
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Bucci-Rechtweg C. Enhancing the Pediatric Drug Development Framework to Deliver Better Pediatric Therapies Tomorrow. Clin Ther 2017; 39:1920-1932. [PMID: 28818298 DOI: 10.1016/j.clinthera.2017.07.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/24/2017] [Accepted: 06/27/2017] [Indexed: 12/18/2022]
Abstract
Health care professionals involved in the clinical management of children have long appreciated the limited number of therapies suitably evaluated for their optimal use in the pediatric population. In the past century, advances in regulatory policy significantly evolved adult drug evaluation. The scarcity of available patient populations, practical complexities of drug development research, and minimal financial returns have hampered pharmaceutical investment in the study of therapies for children. More recently, pediatric policy and legislation in the United States and Europe have instituted a system of obligations and incentives to stimulate investment in pediatric drug development. These initiatives, in conjunction with a more sophisticated process of drug discovery and development, have led to significant advancements in the labeling of drugs for pediatric use. Facilitated by the emergence of new targets, precision medicine, and innovations in regulatory science, there is now a subtle shift in focus toward drug development research for children rather than simply in children. Although there has been an increase in pediatric studies of investigational agents and labeling of pediatric information for use, there have been unintended consequences of existing policies. As a result, limited progress has been made in certain therapeutic areas and for off-patent therapies. Future policy reform to enhance the availability and accessibility of pediatric medicines should not only reflect an understanding not only of the successes of existing policy and legislative initiatives but also constructively address failures and unintended consequences. Taken together, policy reform, global cooperation, and innovation in regulatory science will more ably deliver better pediatric therapies tomorrow.
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Garite TJ, Combs CA, Maurel K, Das A, Huls K, Porreco R, Reisner D, Lu G, Bush M, Morris B, Bleich A, Mallory K, Bono J, Artis D, Weis G, Rael J, Lech J, Swearingen K, Braescu A, Games M, Mullen G, Engelke C, Yeoman J, Rigdon J, Tyler W, Garza F. A multicenter prospective study of neonatal outcomes at less than 32 weeks associated with indications for maternal admission and delivery. Am J Obstet Gynecol 2017; 217:72.e1-72.e9. [PMID: 28267444 DOI: 10.1016/j.ajog.2017.02.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/17/2017] [Accepted: 02/24/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Counseling for patients with impending premature delivery traditionally has been based primarily on the projected gestational age at delivery. There are limited data regarding how the indications for the preterm birth affect the neonatal outcome and whether this issue should be taken into account in decisions regarding management and patient counseling. OBJECTIVE We performed a prospective study of pregnancies resulting in premature delivery at less than 32 weeks to determine the influence of both the indications for admission and their associated indications for delivery on neonatal mortality and complications of prematurity. STUDY DESIGN This is a multicenter, prospective study in 10 hospitals where all data from the neonatal intensive care unit routinely was imported to a deidentified data warehouse. Maternal data were collected prospectively at or near the time of delivery. Eligible subjects included singleton deliveries in these hospitals between 23 0/7 and 31 6/7 weeks. The primary hypothesis of the study was to determine whether there was a difference in the primary outcome, which was defined as neonatal composite morbidity, between those neonates delivered after admission for premature labor vs premature rupture of membranes, because these were expected to be the 2 most frequent diagnoses leading to premature birth. The sample size was calculated based on a 10% difference in outcomes for these 2 entities. We based this hypothesis on the knowledge that premature rupture of membranes has a greater incidence of intra-amniotic infection and inflammation than premature labor and that outcomes for premature neonates are worse when delivery is associated with intra-amniotic infection. Additional outcomes were analyzed for all other indications for admission and delivery. Composite morbidity was defined as ≥1 of the following: respiratory distress syndrome (oxygen requirement, clinical diagnosis, and consistent chest radiograph), bronchopulmonary dysplasia (requirement for oxygen support at 28 days of life), severe intraventricular hemorrhage (grades 3 or 4), periventricular leukomalacia, blood culture-proven sepsis present within 72 hours of birth, necrotizing enterocolitis, or neonatal death before discharge from the hospital. A secondary composite of serious neonatal morbidity also was defined prospectively. RESULTS The study included 1089 mother/baby pairs. Composite morbidity between those with premature labor (77.2%) and premature rupture of membranes (73.2%) was not significantly different (P = .29). A few neonatal complications were associated with indications for admission and delivery, but on logistic regression adjusting for gestational age and other confounders, suspected intrauterine growth restriction was the only indication for admission or delivery associated with an increase in serious morbidity (odds ratio 4.5, [2.1 to 9.8], P < .003). Other factors not related to the indications for admission including cesarean delivery, and low 5-minute Apgar were associated with an increase in morbidity. CONCLUSION Studies of many single factors related to the indications for preterm delivery have been shown to be associated with adverse neonatal outcome. In this study evaluating all of the most frequent indications, however, we found only suspected intrauterine growth restriction as an indication for admission and delivery was found to be so. Thus, it seems that in almost all situations counseling patients can be based primarily on gestational age along with other factors including estimated fetal weight, sex, race, plurality, and completion of a course of antenatal corticosteroids.
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Avant D, Baer G, Moore J, Zheng P, Sorbello A, Ariagno R, Yao L, Burckart GJ, Wang J. Neonatal Safety Information Reported to the FDA During Drug Development Studies. Ther Innov Regul Sci 2017; 2017:1-9. [PMID: 28804696 DOI: 10.1177/2168479017716713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Relatively few neonatal drug development studies have been conducted, but an increase is expected with the enactment of the Food and Drug Administration Safety and Innovation Act (FDASIA). Understanding the safety of drugs studied in neonates is complicated by the unique nature of the population and the level of illness. The objective of this study was to examine neonatal safety data submitted to the FDA in studies pursuant to the Best Pharmaceuticals for Children Act (BPCA) and the Pediatric Research Equity Act (PREA) between 1998 and 2015. METHODS FDA databases were searched for BPCA and/or PREA studies that enrolled neonates. Studies that enrolled a minimum of 3 neonates were analyzed for the presence and content of neonatal safety data. RESULTS The analysis identified 40 drugs that were studied in 3 or more neonates. Of the 40 drugs, 36 drugs received a pediatric labeling change as a result of studies between 1998 and 2015, that included information from studies including neonates. Fourteen drugs were approved for use in neonates. Clinical trials for 20 of the drugs reported serious adverse events (SAEs) in neonates. The SAEs primarily involved cardiovascular events such as bradycardia and/or hypotension or laboratory abnormalities such as anemia, neutropenia, and electrolyte disturbances. Deaths were reported during studies of 9 drugs. CONCLUSIONS Our analysis revealed that SAEs were reported in studies involving 20 of the 40 drugs evaluated in neonates, with deaths identified in 9 of those studies. Patients enrolled in studies were often critically ill, which complicated determination of whether an adverse event was drug-related. We conclude that the traditional means for collecting safety information in drug development trials needs to be adjusted for neonates and will require the collaboration of regulators, industry, and the clinical and research communities to establish appropriate definitions and reporting strategies for the neonatal population.
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Affiliation(s)
- Debbie Avant
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD, USA
| | - Gerri Baer
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD, USA
| | - Jason Moore
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research (CDER), US Food and Drug Administration, Silver Spring, MD, USA.,Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
| | - Panli Zheng
- University of North Carolina School of Pharmacy, Chapel Hill, NC, USA
| | - Alfred Sorbello
- Office of Translational Sciences, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ron Ariagno
- Office of Pediatric Therapeutics, Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | - Lynne Yao
- Division of Pediatric and Maternal Health, Office of New Drugs, CDER, US Food and Drug Administration, Silver Spring, MD, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research (CDER), US Food and Drug Administration, Silver Spring, MD, USA
| | - Jian Wang
- Office of Drug Evaluation IV, CDER, US Food and Drug Administration, Silver Spring, MD, USA
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Safety, dosing, and pharmaceutical quality for studies that evaluate medicinal products (including biological products) in neonates. Pediatr Res 2017; 81:692-711. [PMID: 28248319 DOI: 10.1038/pr.2016.221] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/21/2016] [Indexed: 12/13/2022]
Abstract
The study of medications among pediatric patients has increased worldwide since 1997 in response to new legislation and regulations, but these studies have not yet adequately addressed the therapeutic needs of neonates. Additionally, extant guidance developed by regulatory agencies worldwide does not fully address the specificities of neonatal drug development, especially among extremely premature newborns who currently survive. Consequently, an international consortium from Canada, Europe, Japan, and the United States was organized by the Critical Path Institute to address the content of guidance. This group included neonatologists, neonatal nurses, parents, regulators, ethicists, clinical pharmacologists, specialists in pharmacokinetics, specialists in clinical trials and pediatricians working in the pharmaceutical industry. This group has developed a comprehensive, referenced White Paper to guide neonatal clinical trials of medicines - particularly early phase studies. Key points include: the need to base product development on neonatal physiology and pharmacology while making the most of knowledge acquired in other settings; the central role of families in research; and the value of the whole neonatal team in the design, implementation and interpretation of studies. This White Paper should facilitate successful clinical trials of medicines in neonates by informing regulators, sponsors, and the neonatal community of existing good practice.
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Vermeulen E, van den Anker JN, Della Pasqua O, Hoppu K, van der Lee JH. How to optimise drug study design: pharmacokinetics and pharmacodynamics studies introduced to paediatricians. J Pharm Pharmacol 2017; 69:439-447. [PMID: 27671925 PMCID: PMC6084327 DOI: 10.1111/jphp.12637] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/10/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES In children, there is often lack of sufficient information concerning the pharmacokinetics (PK) and pharmacodynamics (PD) of a study drug to support dose selection and effective evaluation of efficacy in a randomised clinical trial (RCT). Therefore, one should consider the relevance of relatively small PKPD studies, which can provide the appropriate data to optimise the design of an RCT. METHODS Based on the experience of experts collaborating in the EU-funded Global Research in Paediatrics consortium, we aimed to inform clinician-scientists working with children on the design of investigator-initiated PKPD studies. KEY FINDINGS The importance of the identification of an optimal dose for the paediatric population is explained, followed by the differences and similarities of dose-ranging and efficacy studies. The input of clinical pharmacologists with modelling expertise is essential for an efficient dose-finding study. CONCLUSIONS The emergence of new laboratory techniques and statistical tools allows for the collection and analysis of sparse and unbalanced data, enabling the implementation of (observational) PKPD studies in the paediatric clinic. Understanding of the principles and methods discussed in this study is essential to improve the quality of paediatric PKPD investigations, and to prevent the conduct of paediatric RCTs that fail because of inadequate dosing.
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Affiliation(s)
- Eric Vermeulen
- Pediatric Clinical Research OfficeEmma Children's HospitalAcademic Medical CenterAmsterdamThe Netherlands
| | - John N. van den Anker
- Division of Pediatric Clinical PharmacologyChildren's National Health SystemWashingtonDCUSA
- Division of Paediatric Pharmacology and PharmacometricsUniversity of Basel Children's HospitalBaselSwitzerland
- Intensive Care and Department of Pediatric SurgeryErasmus Medical CenterSophia Children's HospitalRotterdamThe Netherlands
| | - Oscar Della Pasqua
- Clinical Pharmacology Modelling & SimulationGlaxoSmithKlineStockley ParkUK
- Clinical Pharmacology & TherapeuticsUniversity College LondonLondonUK
| | - Kalle Hoppu
- Poison Information CentreHelsinki University Central HospitalHelsinkiFinland
| | - Johanna H. van der Lee
- Pediatric Clinical Research OfficeEmma Children's HospitalAcademic Medical CenterAmsterdamThe Netherlands
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50
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Boberg M, Vrana M, Mehrotra A, Pearce RE, Gaedigk A, Bhatt DK, Leeder JS, Prasad B. Age-Dependent Absolute Abundance of Hepatic Carboxylesterases (CES1 and CES2) by LC-MS/MS Proteomics: Application to PBPK Modeling of Oseltamivir In Vivo Pharmacokinetics in Infants. Drug Metab Dispos 2017; 45:216-223. [PMID: 27895113 PMCID: PMC5267516 DOI: 10.1124/dmd.116.072652] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 11/22/2016] [Indexed: 12/17/2022] Open
Abstract
The age-dependent absolute protein abundance of carboxylesterase (CES) 1 and CES2 in human liver was investigated and applied to predict infant pharmacokinetics (PK) of oseltamivir. The CES absolute protein abundance was determined by liquid chromatography-tandem mass spectrometry proteomics in human liver microsomal and cytosolic fractions prepared from tissue samples obtained from 136 pediatric donors and 35 adult donors. Two surrogate peptides per protein were selected for the quantification of CES1 and CES2 protein abundance. Purified CES1 and CES2 protein standards were used as calibrators, and the heavy labeled peptides were used as the internal standards. In hepatic microsomes, CES1 and CES2 abundance (in picomoles per milligram total protein) increased approximately 5-fold (315.2 vs. 1664.4) and approximately 3-fold (59.8 vs. 174.1) from neonates to adults, respectively. CES1 protein abundance in liver cytosol also showed age-dependent maturation. Oseltamivir carboxylase activity was correlated with protein abundance in pediatric and adult liver microsomes. The protein abundance data were then used to model in vivo PK of oseltamivir in infants using pediatric physiologically based PK modeling and incorporating the protein abundance-based ontogeny function into the existing pediatric Simcyp model. The predicted pediatric area under the curve, maximal plasma concentration, and time for maximal plasma concentration values were below 2.1-fold of the clinically observed values, respectively.
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Affiliation(s)
- Mikael Boberg
- Department of Pharmaceutics, University of Washington, Seattle, Washington (M.B., M.V., A.M., D.K.B., B.P.); Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (M.B.); Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.); and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.)
| | - Marc Vrana
- Department of Pharmaceutics, University of Washington, Seattle, Washington (M.B., M.V., A.M., D.K.B., B.P.); Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (M.B.); Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.); and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.)
| | - Aanchal Mehrotra
- Department of Pharmaceutics, University of Washington, Seattle, Washington (M.B., M.V., A.M., D.K.B., B.P.); Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (M.B.); Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.); and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.)
| | - Robin E Pearce
- Department of Pharmaceutics, University of Washington, Seattle, Washington (M.B., M.V., A.M., D.K.B., B.P.); Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (M.B.); Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.); and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.)
| | - Andrea Gaedigk
- Department of Pharmaceutics, University of Washington, Seattle, Washington (M.B., M.V., A.M., D.K.B., B.P.); Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (M.B.); Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.); and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.)
| | - Deepak Kumar Bhatt
- Department of Pharmaceutics, University of Washington, Seattle, Washington (M.B., M.V., A.M., D.K.B., B.P.); Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (M.B.); Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.); and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.)
| | - J Steven Leeder
- Department of Pharmaceutics, University of Washington, Seattle, Washington (M.B., M.V., A.M., D.K.B., B.P.); Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (M.B.); Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.); and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.)
| | - Bhagwat Prasad
- Department of Pharmaceutics, University of Washington, Seattle, Washington (M.B., M.V., A.M., D.K.B., B.P.); Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (M.B.); Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.); and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri (R.E.P., A.G., J.S.L.)
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