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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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Belzer LT, Wright SM, Goodwin EJ, Singh MN, Carter BS. Psychosocial Considerations for the Child with Rare Disease: A Review with Recommendations and Calls to Action. CHILDREN 2022; 9:children9070933. [PMID: 35883917 PMCID: PMC9325007 DOI: 10.3390/children9070933] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/10/2022] [Accepted: 06/11/2022] [Indexed: 01/07/2023]
Abstract
Rare diseases (RD) affect children, adolescents, and their families infrequently, but with a significant impact. The diagnostic odyssey undertaken as part of having a child with RD is immense and carries with it practical, emotional, relational, and contextual issues that are not well understood. Children with RD often have chronic and complex medical conditions requiring a complicated milieu of care by numerous clinical caregivers. They may feel isolated and may feel stigmas in settings of education, employment, and the workplace, or a lack a social support or understanding. Some parents report facing similar loneliness amidst a veritable medicalization of their homes and family lives. We searched the literature on psychosocial considerations for children with rare diseases in PubMed and Google Scholar in English until 15 April 2022, excluding publications unavailable in full text. The results examine RD and their psychosocial ramifications for children, families, and the healthcare system. The domains of the home, school, community, and medical care are addressed, as are the implications of RD management as children transition to adulthood. Matters of relevant healthcare, public policies, and more sophisticated translational research that addresses the intersectionality of identities among RD are proposed. Recommendations for interventions and supportive care in the aforementioned domains are provided while emphasizing calls to action for families, clinicians, investigators, and advocacy agents as we work toward establishing evidence-based care for children with RD.
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Affiliation(s)
- Leslee T. Belzer
- Division of Developmental and Behavioral Health, Section of Pediatric Psychology, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA; (S.M.W.); (E.J.G.); (B.S.C.)
- Division of General Academic Pediatrics, The Beacon Program, Children’s Mercy Kansas City, Kansas City, MO 64111, USA
- Correspondence: ; Tel.: +1-816-960-2849
| | - S. Margaret Wright
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA; (S.M.W.); (E.J.G.); (B.S.C.)
- Division of General Academic Pediatrics, The Beacon Program, Children’s Mercy Kansas City, Kansas City, MO 64111, USA
- School of Medicine, University of Kansas, Kansas City, KS 66160, USA
| | - Emily J. Goodwin
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA; (S.M.W.); (E.J.G.); (B.S.C.)
- Division of General Academic Pediatrics, The Beacon Program, Children’s Mercy Kansas City, Kansas City, MO 64111, USA
- School of Medicine, University of Kansas, Kansas City, KS 66160, USA
| | - Mehar N. Singh
- Department of Psychology, Clinical Child Psychology Program, University of Kansas, Lawrence, KS 66045, USA;
| | - Brian S. Carter
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA; (S.M.W.); (E.J.G.); (B.S.C.)
- Department of Medical Humanities & Bioethics, University of Missouri-Kansas City, Kansas City, MO 64108, USA
- Bioethics Center, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
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Wang L, Wang J, Feng J, Doi M, Pepe S, Pacanowski M, Schuck RN. Dose-finding studies in drug development for rare genetic diseases. Orphanet J Rare Dis 2022; 17:156. [PMID: 35382851 PMCID: PMC8985255 DOI: 10.1186/s13023-022-02298-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The small patient populations inherent to rare genetic diseases present many challenges to the traditional drug development paradigm. One major challenge is generating sufficient data in early phase studies to inform dose selection for later phase studies and dose optimization for clinical use of the drug. However, optimizing the benefit-risk profile of drugs through appropriate dose selection during drug development is critical for all drugs, including those being developed to treat rare diseases. Recognizing the challenges of conducting dose finding studies in rare disease populations and the importance of dose selection and optimization for successful drug development, we assessed the dose-finding studies and analyses conducted for drugs recently approved for rare genetic diseases. RESULTS Of the 40 marketing applications for new molecular entity (NME) drugs and biologics approved by the United States Food and Drug Administration for rare genetic diseases from 2015 to 2020, 21 (53%) of the development programs conducted at least one dedicated dose-finding study. In addition, the majority of drug development programs conducted clinical studies in healthy subjects and included population pharmacokinetic and exposure-response analyses; some programs also conducted clinical studies in patient populations other than the disease for which the drug was initially approved. The majority of primary endpoints utilized in dedicated dose-finding studies were biomarkers, and the primary endpoint of the safety and efficacy study matched the primary endpoint used in the dose finding study in 9 of 13 (69%) drug development programs where primary study endpoints were assessed. CONCLUSIONS Our study showed that NME drug development programs for rare genetic diseases utilize multiple data sources for dosing information, including studies in healthy subjects, population pharmacokinetic analyses, and exposure-response analyses. In addition, our results indicate that biomarkers play a key role in dose-finding studies for rare genetic disease drug development programs. Our findings highlight the need to develop study designs and methods to allow adequate dose-finding efforts within rare disease drug development programs that help overcome the challenges presented by low patient prevalence and other factors. Furthermore, the frequent reliance on biomarkers as endpoints for dose-finding studies underscores the importance of biomarker development in rare diseases.
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Affiliation(s)
- Lingshan Wang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Jie Wang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ji Feng
- Office of Translational Sciences Immediate Office, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Mary Doi
- Office of Translational Sciences Immediate Office, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Salvatore Pepe
- Office of Translational Sciences Immediate Office, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Michael Pacanowski
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Robert N Schuck
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.
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