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Yeung CHT, Verstegen RHJ, Greenberg R, Lewis TR. Pharmacokinetic and pharmacodynamic principles: unique considerations for optimal design of neonatal clinical trials. Front Pediatr 2024; 11:1345969. [PMID: 38283405 PMCID: PMC10811156 DOI: 10.3389/fped.2023.1345969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Core clinical pharmacology principles must be considered when designing and executing neonatal clinical trials. In this review, the authors discuss important aspects of drug dose selection, pharmacokinetics, pharmacogenetics and pharmacodynamics that stakeholders may consider when undertaking a neonatal or infant clinical trial.
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Affiliation(s)
- Cindy Hoi Ting Yeung
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ruud H. J. Verstegen
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Rachel Greenberg
- Duke Clinical Research Institute, Durham, NC, United States
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Tamorah Rae Lewis
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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2
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Simeoli R, Cairoli S, Decembrino N, Campi F, Dionisi Vici C, Corona A, Goffredo BM. Use of Antibiotics in Preterm Newborns. Antibiotics (Basel) 2022; 11:antibiotics11091142. [PMID: 36139921 PMCID: PMC9495226 DOI: 10.3390/antibiotics11091142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022] Open
Abstract
Due to complex maturational and physiological changes that characterize neonates and affect their response to pharmacological treatments, neonatal pharmacology is different from children and adults and deserves particular attention. Although preterms are usually considered part of the neonatal population, they have physiological and pharmacological hallmarks different from full-terms and, therefore, need specific considerations. Antibiotics are widely used among preterms. In fact, during their stay in neonatal intensive care units (NICUs), invasive procedures, including central catheters for parental nutrition and ventilators for respiratory support, are often sources of microbes and require antimicrobial treatments. Unfortunately, the majority of drugs administered to neonates are off-label due to the lack of clinical studies conducted on this special population. In fact, physiological and ethical concerns represent a huge limit in performing pharmacokinetic (PK) studies on these subjects, since they limit the number and volume of blood sampling. Therapeutic drug monitoring (TDM) is a useful tool that allows dose adjustments aiming to fit plasma concentrations within the therapeutic range and to reach specific drug target attainment. In this review of the last ten years’ literature, we performed Pubmed research aiming to summarize the PK aspects for the most used antibiotics in preterms.
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Affiliation(s)
- Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Nunzia Decembrino
- Neonatal Intensive Care Unit, University Hospital “Policlinico-San Marco” Catania, Integrated Department for Maternal and Child’s Health Protection, 95100 Catania, Italy
| | - Francesca Campi
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Carlo Dionisi Vici
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
- Correspondence: ; Tel.: +39-0668592174; Fax: + 39-0668593009
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3
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Wang J, van den Anker JN, Burckart GJ. Progress in Drug Development-Pediatric Dose Selection: Workshop Summary. J Clin Pharmacol 2021; 61 Suppl 1:S13-S21. [PMID: 34185909 DOI: 10.1002/jcph.1828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 12/20/2022]
Abstract
The "Pediatric Dose Selection" workshop was held in October 2020 and sponsored by the U.S. Food and Drug Administration and the University of Maryland Center for Excellence in Regulatory Science and Innovation. A summary of the presentations in the context of pediatric drug development is summarized in this article.
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Affiliation(s)
- Jian Wang
- Office of Specialty Medicine, Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - John N van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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O’Hara K, Martin JH, Schneider JJ. Barriers and Challenges in Performing Pharmacokinetic Studies to Inform Dosing in the Neonatal Population. PHARMACY 2020; 8:E16. [PMID: 32033361 PMCID: PMC7151681 DOI: 10.3390/pharmacy8010016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/31/2020] [Accepted: 02/02/2020] [Indexed: 12/22/2022] Open
Abstract
A number of barriers and challenges must be overcome in order to conduct the pharmacokinetic studies that are urgently needed to inform the selection and dosing of medication in neonates. However, overcoming these barriers can be difficult. This review outlines the common barriers researchers are confronted with, including issues with ethics approval and consent, study design for pharmacokinetic studies and the ability to measure the drug concentrations in the blood samples obtained. Strategies to overcome these challenges are also proposed.
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Affiliation(s)
- Kate O’Hara
- Discipline of Clinical Pharmacology, School of Medicine, University of Newcastle, Hunter Medical Research Institute Newcastle, Newcastle 2308, Australia; (J.H.M.); (J.J.S.)
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Malik PRV, Edginton AN. Integration of Ontogeny Into a Physiologically Based Pharmacokinetic Model for Monoclonal Antibodies in Premature Infants. J Clin Pharmacol 2019; 60:466-476. [DOI: 10.1002/jcph.1540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/10/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Paul R. V. Malik
- School of PharmacyUniversity of Waterloo Kitchener Ontario Canada
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Malik PRV, Edginton AN. Physiologically-Based Pharmacokinetic Modeling vs. Allometric Scaling for the Prediction of Infliximab Pharmacokinetics in Pediatric Patients. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:835-844. [PMID: 31343836 PMCID: PMC6875711 DOI: 10.1002/psp4.12456] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/06/2019] [Accepted: 06/17/2019] [Indexed: 12/17/2022]
Abstract
The comparative performances of physiologically‐based pharmacokinetic (PBPK) modeling and allometric scaling for predicting the pharmacokinetics (PKs) of large molecules in pediatrics are unknown. Therefore, both methods were evaluated for accuracy in translating knowledge of infliximab PKs from adults to children. PBPK modeling was performed using the base model for large molecules in PK‐Sim version 7.4 with modifications in Mobi. Eight population PK models from literature were reconstructed and scaled by allometry to pediatrics. Evaluation data included seven pediatric studies (~4–18 years). Both methods performed comparably with 66.7% and 68.6% of model‐predicted concentrations falling within twofold of the observed concentrations for PBPK modeling and allometry, respectively. Considerable variability was noted among the allometric models. Therefore, pediatric clinical trial planning would benefit from using approaches that require predictions depending on the specific question i.e., PBPK modeling and allometry.
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Affiliation(s)
- Paul R V Malik
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
| | - Andrea N Edginton
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
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van Dijkman SC, De Cock PAJG, Smets K, Decaluwe W, Smits A, Allegaert K, Vande Walle J, De Paepe P, Della Pasqua O. Dose rationale and pharmacokinetics of dexmedetomidine in mechanically ventilated new-borns: impact of design optimisation. Eur J Clin Pharmacol 2019; 75:1393-1404. [PMID: 31312867 DOI: 10.1007/s00228-019-02708-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 06/11/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE There is a need for alternative analgosedatives such as dexmedetomidine in neonates. Given the ethical and practical difficulties, protocol design for clinical trials in neonates should be carefully considered before implementation. Our objective was to identify a protocol design suitable for subsequent evaluation of the dosing requirements for dexmedetomidine in mechanically ventilated neonates. METHODS A published paediatric pharmacokinetic model was used to derive the dosing regimen for dexmedetomidine in a first-in-neonate study. Optimality criteria were applied to optimise the blood sampling schedule. The impact of sampling schedule optimisation on model parameter estimation was assessed by simulation and re-estimation procedures for different simulation scenarios. The optimised schedule was then implemented in a neonatal pilot study. RESULTS Parameter estimates were more precise and similarly accurate in the optimised scenarios, as compared to empirical sampling (normalised root mean square error: 1673.1% vs. 13,229.4% and relative error: 46.4% vs. 9.1%). Most importantly, protocol deviations from the optimal design still allowed reasonable parameter estimation. Data analysis from the pilot group (n = 6) confirmed the adequacy of the optimised trial protocol. Dexmedetomidine pharmacokinetics in term neonates was scaled using allometry and maturation, but results showed a 20% higher clearance in this population compared to initial estimates obtained by extrapolation from a slightly older paediatric population. Clearance for a typical neonate, with a post-menstrual age (PMA) of 40 weeks and weight 3.4 kg, was 2.92 L/h. Extension of the study with 11 additional subjects showed a further increased clearance in pre-term subjects with lower PMA. CONCLUSIONS The use of optimal design in conjunction with simulation scenarios improved the accuracy and precision of the estimates of the parameters of interest, taking into account protocol deviations, which are often unavoidable in this event-prone population.
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Affiliation(s)
- Sven C van Dijkman
- Division of Pharmacology, Leiden Academic Centre for Drug Research, Leiden, The Netherlands
| | - Pieter A J G De Cock
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Koenraad Smets
- Department of Neonatology, Ghent University Hospital, Ghent, Belgium
| | - Wim Decaluwe
- Department of Neonatology, AZ Sint Jan Brugge-Oostende AV, Bruges, Belgium
| | - Anne Smits
- Neonatal Intensive Care Unit, University Hospital Leuven, Leuven, Belgium
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Johan Vande Walle
- Department of Paediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Oscar Della Pasqua
- Clinical Pharmacology and Therapeutics, University College London, BMA House, Tavistock Square, London, WC1H 9JP, UK.
- Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline, Uxbridge, UK.
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Wang J, Kumar SS, Sherwin CM, Ward R, Baer G, Burckart GJ, Wang Y, Yao LP. Renal Clearance in Newborns and Infants: Predictive Performance of Population-Based Modeling for Drug Development. Clin Pharmacol Ther 2019; 105:1462-1470. [PMID: 30565653 DOI: 10.1002/cpt.1332] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/25/2018] [Indexed: 01/07/2023]
Abstract
The objective of this study was to evaluate the predictive performance of population models to predict renal clearance in newborns and infants. Pharmacokinetic (PK) data from eight drugs in 788 newborns and infants were used to evaluate the predictive performance of the population models based on postmenstrual age (PMA), postnatal age, gestational age, and body weight. For the PMA model, the average fold error for clearance (CL)predicted /CLobserved was within a twofold range for each drug in all subgroups. For drugs with > 90% renal elimination, the prediction bias ranged from 0.7-1.3. For drugs with 60-80% renal elimination, the prediction bias ranged 0.6-2.0. Our results suggest that PMA-based sigmoidal maximum effect (Emax ) model, in combination with bodyweight-based scaling and kidney function assessment, can be used in population PK (PopPK) modeling for drugs that are primarily eliminated via renal pathway to inform initial dose selection for newborns and infants with normal renal function in clinical trials.
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Affiliation(s)
- Jian Wang
- Office of Drug Evaluation IV, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shaun S Kumar
- Department of Pediatrics, Division of Clinical Pharmacology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Catherine M Sherwin
- Department of Pediatrics, Division of Clinical Pharmacology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Robert Ward
- Department of Pediatrics, Division of Clinical Pharmacology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Gerri Baer
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yaning Wang
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lynne P Yao
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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van den Anker J. Paediatric extrapolation: the panacea for paediatric drug development? Br J Clin Pharmacol 2018; 85:672-674. [PMID: 30536691 DOI: 10.1111/bcp.13836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 12/07/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- John van den Anker
- Paediatric Pharmacology and Pharmacometrics Research Program, University of Basel Children's Hospital, Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA
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10
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Euteneuer JC, Kamatkar S, Fukuda T, Vinks AA, Akinbi HT. Suggestions for Model-Informed Precision Dosing to Optimize Neonatal Drug Therapy. J Clin Pharmacol 2018; 59:168-176. [PMID: 30204236 DOI: 10.1002/jcph.1315] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/17/2018] [Indexed: 12/19/2022]
Abstract
Evidence for dosing, efficacy, and safety of most medications used to treat neonates is sparse. Thus, dosing is usually derived by extrapolation from adult and pediatric pharmacologic data with scaling by body weight or body surface area. This may lead to drug dosing that is unsafe or ineffective. However, new strategies are being developed and studied to dose medications in critically ill neonates. Mass spectroscopy technology capable of quickly analyzing drug levels is readily available. Software that integrates population pharmacokinetics and pharmacodynamics with data from sparse samples from neonates allows for timely adjustments of dosing to achieve the desired effect while minimizing adverse outcomes. Some genetic polymorphisms that affect drug response in neonates have also been reported. This review highlights aspects of drug response and how it is impacted by prematurity, assesses pharmacogenomic studies in neonates, and offers suggestions for innovative pharmacokinetic/pharmacodynamic model-based approaches that combine population- or physiology-based pharmacology data, Bayesian analysis, and electronic decision support tools for precision dosing in neonates while illustrating examples where this approach can be used to optimize medical therapy in neonates. Barriers to implementing precision dosing in neonates and how to overcome them are also discussed.
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Affiliation(s)
- Joshua C Euteneuer
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.,Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Suyog Kamatkar
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Henry T Akinbi
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Van Donge T, Mian P, Tibboel D, Van Den Anker J, Allegaert K. Drug metabolism in early infancy: opioids as an illustration. Expert Opin Drug Metab Toxicol 2018; 14:287-301. [PMID: 29363349 DOI: 10.1080/17425255.2018.1432595] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Drug dosing in infants frequently depends on body weight as a crude indicator for maturation. Fentanyl (metabolized by Cytochrome P450 3A4) and morphine (glucuronidated by UDP-glucuronosyltransferase-2B7) served as model drugs to provide insight in maturation patterns of these enzymes and provide understanding of the impact of non-maturational factors to optimize dosing in infants. Areas covered: Systematic searches on metabolism and population pharmacokinetic (Pop-PK) models for fentanyl and morphine were performed. Pre- and post-model selection criteria were applied to assess and evaluate the validity of these models. It was observed that maturational changes have been rather well investigated, be it with variability in the maturational function estimates. The same holds true for Pop-PK models, where non-maturational covariates have also been reported (pharmacogenetics, disease state or external influences), although less incorporated in the PK models and with limited knowledge on mechanisms involved. Expert opinion: PK models for fentanyl and morphine are currently available. Consequently, we suggest that researchers should not continue to develop new models, but should investigate whether collected data fit in already existing models and provide additional value concerning the impact of (non)-maturational factors like drug-drug interactions or pharmacogenetics.
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Affiliation(s)
- Tamara Van Donge
- a Intensive Care and Department of Paediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Systems Biomedicine and Pharmacology , LACDR, Leiden University , Leiden , The Netherlands
| | - Paola Mian
- a Intensive Care and Department of Paediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Dick Tibboel
- a Intensive Care and Department of Paediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - John Van Den Anker
- a Intensive Care and Department of Paediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,c Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland.,d Division of Clinical Pharmacology , Children's National Health System , Washington , DC , USA
| | - Karel Allegaert
- a Intensive Care and Department of Paediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,e Department of Development and Regeneration , KU Leuven , Leuven , Belgium
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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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Abstract
Pharmacotherapy is a powerful tool to improve the outcome of neonates. Unfortunately, the potential health impact of pharmacotherapy in neonates remains underexplored. This necessitates a structured approach to go beyond the current practice of trial and error, reflected in off-label prescription. The existing regulatory framework hereby provides a structure to reflect about aspects like pharmacokinetic models for dose selection and outcome assessment, including long-term safety. Future medicine development should also be driven by neonatal needs, diseases and pathophysiology, since surfactant is the latest product developed for preterm neonates. The potential impact is illustrated by ongoing repurposing (propranolol, allopurinol, erythropoietin, Insulin-like Growth Factor-1) projects. Clinical researchers will be crucial to close the knowledge gap by developing dose selection tools and outcome assessment tools and by exploring pathophysiological mechanisms. The final step of such a structured approach cycle is the subsequent translation of accumulated knowledge into improved prescribing.
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Affiliation(s)
- Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands; Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands; Department of Development and Regeneration, KU Leuven, Leuven, Belgium..
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14
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Elder DP, Holm R, Kuentz M. Medicines for Pediatric Patients-Biopharmaceutical, Developmental, and Regulatory Considerations. J Pharm Sci 2016; 106:950-960. [PMID: 28041968 DOI: 10.1016/j.xphs.2016.12.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 11/24/2016] [Accepted: 12/14/2016] [Indexed: 01/19/2023]
Abstract
This commentary reflects current developments in pediatric medicine. The underpinning legislation in both Europe and the United States has led to the initiation of an increased number of clinical trials in the pediatric population, but there are still a number of outstanding issues within this field. These include the differences in the physiology between adults and the very heterogeneous nature of pediatric patients. There is an ongoing scientific debate on the applicability of a Pediatric Biopharmaceutical Classification System to define when waivers for bioequivalence studies can be supported by in vitro dissolution. However, a challenge is that in vitro models should adequately mimic the physiology of different pediatric age-groups and dose definition is another critical aspect. There is a tendency for off-label use of established adult medicines, resulting in increased adverse events and decreased efficacy in the target population. Recent advances in physiologically based pharmacokinetic modelling may be used to provide valuable input into these discussions, but there are currently still many knowledge gaps. It is encouraging that there is a global recognition of these deficiencies and substantial funding in the field of basic research is being provided, for example, within Europe the Innovative Medicines Initiative consortium.
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Affiliation(s)
- David P Elder
- GlaxoSmithKline, Park Road, Ware, Hertfordshire SG12 0DP, UK
| | - René Holm
- Drug Product Development, Jansen Research & Development, Johnson & Johnson, Turnhoutseweg 30, Beerse B-2340, Belgium
| | - Martin Kuentz
- University of Applied Sciences and Arts Northwestern Switzerland, Institute of Pharmaceutical Technology, Muttenz CH-4132, Switzerland.
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Abstract
Antibiotics are invaluable in the management of neonatal infections. However, overuse or misuse of antibiotics in neonates has been associated with adverse outcomes, including increased risk for future infection, necrotizing enterocolitis, and mortality. Strategies to optimize the use of antibiotics in the neonatal intensive care unit include practicing effective infection prevention, improving the diagnostic evaluation and empiric therapy for suspected infections, timely adjustment of therapy as additional information becomes available, and treating proven infections with an effective, narrow-spectrum agent for the minimum effective duration. Antibiotic stewardship programs provide support for these strategies but require the participation and input of neonatologists as stakeholders to be most effective.
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Affiliation(s)
- Joseph B Cantey
- Division of Neonatal/Perinatal Medicine, Division of Infectious Diseases, Texas A&M Health Science Center College of Medicine, Baylor Scott & White Health, Temple, TX, USA.
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16
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Allegaert K, van den Anker J. Neonatal drug therapy: The first frontier of therapeutics for children. Clin Pharmacol Ther 2015; 98:288-97. [PMID: 26095519 DOI: 10.1002/cpt.166] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023]
Abstract
Knowledge about the safe and effective use of medicines in neonates has increased substantially but has resulted in few label changes. Drugs developed for use in adults are reshaped and tailored to specific neonatal indications. However, the use of drugs in neonates should not only mirror adult pharmacotherapy, but should be driven by their own specific needs. Therefore, building collaborative networks may assist to develop a newborn-driven research agenda addressing their clinical needs and diseases.
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Affiliation(s)
- K Allegaert
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU, Leuven, Belgium
| | - J van den Anker
- Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA
- Departments of Pediatrics, Integrative Systems Biology, Pharmacology and Physiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland
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