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Durairaj C, Bhattacharya I. Challenges, approaches and enablers: effectively triangulating towards dose selection in pediatric rare diseases. J Pharmacokinet Pharmacodyn 2023; 50:445-459. [PMID: 37296230 DOI: 10.1007/s10928-023-09868-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Abstract
Dose selection is an integral part of a molecule's journey to become medicine. On top of typical challenges faced in dose selection for more common diseases, pediatric rare disease has additional unique challenges due to the combination of 'rare' and 'pediatric' populations. Using the central theme of maximizing 'relevant' information to overcome information paucity, dose selection strategy in pediatric rare diseases is discussed using a triangulation concept involving challenges, approaches and very importantly, enablers. Using actual examples, unique scenarios are discussed where specific enablers allowed certain approaches to be used to overcome the challenges. The continued need for model-informed drug development is also discussed using examples of where modeling and simulation tools have been successfully used in bridging available information to select pediatric doses in rare disease. Additionally, challenges with translation and associated dose selection of new modalities such as gene therapy in rare diseases are examined with the lens of continuous learning and knowledge development that will enable pediatric dose selection of these modalities with confidence.
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Munafo A, Terranova N, Li D, Liu P, Venkatakrishnan K. Model-informed assessment of ethnic sensitivity and dosage justification for Asian populations in the global clinical development and use of cladribine tablets. Clin Transl Sci 2021; 15:297-308. [PMID: 34704362 PMCID: PMC8841458 DOI: 10.1111/cts.13166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/13/2021] [Accepted: 09/16/2021] [Indexed: 11/04/2022] Open
Abstract
Cladribine tablets have been approved in many countries for the treatment of patients with various forms of relapsing multiple sclerosis (MS). Cladribine has a unique pharmacokinetic/pharmacodynamic (PK/PD) profile with a short elimination half‐life (~ 1 day) relative to a prolonged PD effect on specific immune cells (most notably a reversible reduction in B and T lymphocyte counts). This results in a short dosing schedule (up to 20 days over 2 years of treatment) to sustain efficacy for at least another 2 years. Global clinical studies were conducted primarily in White patients, in part due to the distinctly higher prevalence of MS in White patients. Given the very low prevalence in Asian countries, MS is considered as a rare disease there. In spite of the limited participation of Asian patients, to demonstrate favorable benefit/risk profile in the treatment of MS demanded application of a Totality of Evidence approach to assess ethnic sensitivity for informing regulatory filings in Asian countries and supporting clinical use of cladribine in Asian patients. Population PD modeling and simulation of treatment‐related reduction in absolute lymphocyte count, as a mechanism‐related biomarker of drug effect, confirmed consistent PDs in Asian and non‐Asian patients with MS, supporting absence of ethnic sensitivity and a common dosage across populations. Through this example, we demonstrate the value of holistic integration of all available data using a model‐informed drug development (MIDD) framework and a Totality of Evidence mindset to evaluate ethnic sensitivity in support of Asia‐inclusive development and use of the drug across populations.
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Affiliation(s)
- Alain Munafo
- Merck Institute for Pharmacometrics, Merck Serono S.A., Lausanne, Switzerland.,An Affiliate of Merck KGaA, Darmstadt, Germany
| | - Nadia Terranova
- Merck Institute for Pharmacometrics, Merck Serono S.A., Lausanne, Switzerland.,An Affiliate of Merck KGaA, Darmstadt, Germany
| | - Dandan Li
- An Affiliate of Merck KGaA, Darmstadt, Germany.,Merck Serono Pharmaceutical R&D Co. Ltd. China, Beijing, China
| | - Ping Liu
- Clinical Pharmacology, Linking Truth Technology Co., Ltd., Beijing, China
| | - Karthik Venkatakrishnan
- An Affiliate of Merck KGaA, Darmstadt, Germany.,EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts, USA
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Ahmed MA, Okour M, Brundage R, Kartha RV. Orphan drug development: the increasing role of clinical pharmacology. J Pharmacokinet Pharmacodyn 2019; 46:395-409. [PMID: 31338634 DOI: 10.1007/s10928-019-09646-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 07/04/2019] [Indexed: 12/11/2022]
Abstract
Over the last few decades there has been a paradigm shift in orphan drug research and development. The development of the regulatory framework, establishment of rare disease global networks that support drug developments, and advances in technology, has resulted in tremendous growth in orphan drug development. Nevertheless, several challenges during orphan drug development such as economic constraints; insufficient clinical information; fewer patients and thus inadequate power; etc. still exist. While the standard regulatory requirements for drug approval stays the same, applications of scientific judgment and regulatory flexibility is significantly important to help meeting some of the immense unmet medical need in rare diseases. Clinical pharmacology presents a vital role in accelerating orphan drug development and overcoming some of these challenges. This review highlights the critical contributions of clinical pharmacology in orphan drug development; for example, dose finding, optimizing clinical trial design, indication expansion, and population extrapolation. Examples of such applications are reviewed in this article.
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Affiliation(s)
- Mariam A Ahmed
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Twin Cities, MN, USA.
- , 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA.
| | - Malek Okour
- Clinical Pharmacology Modeling and Simulation (CPMS), GlaxoSmithKline, Upper Providence, PA, USA
| | - Richard Brundage
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Twin Cities, MN, USA
- Center for Orphan Drug Research, University of Minnesota, Twin Cities, MN, USA
| | - Reena V Kartha
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Twin Cities, MN, USA
- Center for Orphan Drug Research, University of Minnesota, Twin Cities, MN, USA
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Yoneyama K, Schmitt C, Kotani N, Levy GG, Kasai R, Iida S, Shima M, Kawanishi T. A Pharmacometric Approach to Substitute for a Conventional Dose-Finding Study in Rare Diseases: Example of Phase III Dose Selection for Emicizumab in Hemophilia A. Clin Pharmacokinet 2018; 57:1123-1134. [PMID: 29214439 PMCID: PMC6061395 DOI: 10.1007/s40262-017-0616-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Emicizumab (ACE910) is a bispecific antibody mimicking the cofactor function of activated coagulation factor VIII. In phase I-I/II studies, emicizumab reduced the bleeding frequency in patients with severe hemophilia A, regardless of the presence of factor VIII inhibitors, at once-weekly subcutaneous doses of 0.3, 1, and 3 mg/kg. METHODS Using the phase I-I/II study data, population pharmacokinetic and repeated time-to-event (RTTE) modeling were performed to quantitatively characterize the relationship between the pharmacokinetics of emicizumab and reduction in bleeding frequency. Simulations were then performed to identify the minimal exposure expected to achieve zero bleeding events for 1 year in at least 50% of patients and to select the dosing regimens to be tested in phase III studies. RESULTS The RTTE model adequately predicted the bleeding onset over time as a function of plasma emicizumab concentration. Simulations suggested that plasma emicizumab concentrations of ≥ 45 μg/mL should result in zero bleeding events for 1 year in at least 50% of patients. This efficacious exposure provided the basis for selecting previously untested dosing regimens of 1.5 mg/kg once weekly, 3 mg/kg every 2 weeks, and 6 mg/kg every 4 weeks for phase III studies. CONCLUSIONS A pharmacometric approach guided the phase III dose selection of emicizumab in hemophilia A, without conducting a conventional dose-finding study. Phase III studies with the selected dosing regimens are currently ongoing. This case study indicates that a pharmacometric approach can substitute for a conventional dose-finding study in rare diseases and will streamline the drug development process.
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MESH Headings
- Adolescent
- Adult
- Antibodies, Bispecific/administration & dosage
- Antibodies, Bispecific/pharmacokinetics
- Antibodies, Bispecific/therapeutic use
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Dose-Response Relationship, Drug
- Factor VIII/antagonists & inhibitors
- Factor VIII/immunology
- Hemophilia A/drug therapy
- Hemorrhage/prevention & control
- Humans
- Male
- Models, Biological
- Rare Diseases/drug therapy
- Young Adult
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Affiliation(s)
- Koichiro Yoneyama
- Chugai Pharmaceutical Co., Ltd., 2-1-1 Nihonbashi-Muromachi, Chuo-ku, Tokyo, 103-8324, Japan.
| | | | - Naoki Kotani
- Chugai Pharmaceutical Co., Ltd., 2-1-1 Nihonbashi-Muromachi, Chuo-ku, Tokyo, 103-8324, Japan
| | | | - Ryu Kasai
- Chugai Pharmaceutical Co., Ltd., 2-1-1 Nihonbashi-Muromachi, Chuo-ku, Tokyo, 103-8324, Japan
| | - Satofumi Iida
- Chugai Pharmaceutical Co., Ltd., 2-1-1 Nihonbashi-Muromachi, Chuo-ku, Tokyo, 103-8324, Japan
| | | | - Takehiko Kawanishi
- Chugai Pharmaceutical Co., Ltd., 2-1-1 Nihonbashi-Muromachi, Chuo-ku, Tokyo, 103-8324, Japan
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Bhattacharya I, Manukyan Z, Chan P, Heatherington A, Harnisch L. Application of Quantitative Pharmacology Approaches in Bridging Pharmacokinetics and Pharmacodynamics of Domagrozumab From Adult Healthy Subjects to Pediatric Patients With Duchenne Muscular Disease. J Clin Pharmacol 2017; 58:314-326. [DOI: 10.1002/jcph.1015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 08/17/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Indranil Bhattacharya
- Prior employees of Pfizer Inc; Currently at Summit Therapeutics PLC Cambridge, MA USA
| | | | | | - Anne Heatherington
- Prior employees of Pfizer Inc; Currently at Summit Therapeutics PLC Cambridge, MA USA
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Jia J, Shi T. Towards efficiency in rare disease research: what is distinctive and important? SCIENCE CHINA-LIFE SCIENCES 2017. [PMID: 28639105 DOI: 10.1007/s11427-017-9099-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Characterized by their low prevalence, rare diseases are often chronically debilitating or life threatening. Despite their low prevalence, the aggregate number of individuals suffering from a rare disease is estimated to be nearly 400 million worldwide. Over the past decades, efforts from researchers, clinicians, and pharmaceutical industries have been focused on both the diagnosis and therapy of rare diseases. However, because of the lack of data and medical records for individual rare diseases and the high cost of orphan drug development, only limited progress has been achieved. In recent years, the rapid development of next-generation sequencing (NGS)-based technologies, as well as the popularity of precision medicine has facilitated a better understanding of rare diseases and their molecular etiology. As a result, molecular subclassification can be identified within each disease more clearly, significantly improving diagnostic accuracy. However, providing appropriate care for patients with rare diseases is still an enormous challenge. In this review, we provide a brief introduction to the challenges of rare disease research and make suggestions on where and how our efforts should be focused.
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Affiliation(s)
- Jinmeng Jia
- The Center for Bioinformatics and Computational Biology, Shanghai Key Laboratory of Regulatory Biology, the Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - Tieliu Shi
- The Center for Bioinformatics and Computational Biology, Shanghai Key Laboratory of Regulatory Biology, the Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China.
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Don't Do Different Things…Do Things Differently! Drug Development in Rare Diseases. Clin Pharmacol Ther 2016; 100:333-5. [DOI: 10.1002/cpt.424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 06/20/2016] [Accepted: 07/06/2016] [Indexed: 11/07/2022]
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Smith BP. Challenges and Opportunities in Rare Disease Drug Development. Clin Pharmacol Ther 2016; 100:312-4. [DOI: 10.1002/cpt.430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- BP Smith
- Novartis Institutes of Biomedical Research, Inc.; Cambridge Massachusetts USA
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