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Rose K, Grant-Kels JM. The Meanings of "Pediatric Drug Development". Ther Innov Regul Sci 2019; 53:767-774. [PMID: 30526039 DOI: 10.1177/2168479018812060] [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: 08/08/2018] [Accepted: 10/18/2018] [Indexed: 07/09/2024]
Abstract
Pediatric drug development (PDD) became an industry goal when the Food and Drug Administration (FDA) granted patent extensions. This was later expanded to obligations for pediatric studies and to the European Medicines Agency's (EMA's) strict pediatric investigation plans (PIPs). Industry now sponsors many often international studies in young patients that are difficult or impossible to recruit. PDD's intellectual foundations characterize children as "therapeutic orphans," allegedly discriminated in drug treatment and development. While toxicities occured in newborns, demanding separate efficacy and safety (E&S) studies in all age groups is wasteful and reflects hidden conflicts of interest. The American Academy of Pediatrics (AAP) successfully procured pediatric research funds; the FDA dislikes pediatric off-label use and envisions labels as instructions for physicians. Pediatricians have continuously improved child health care by careful use of available drugs. Instead of physiologically defining children vis-à-vis drug treatment, the FDA defines children as ≤16 years old, offering convincing pretense for the need for mostly senseless "pediatric" studies in young adults, adolescents, and children. Although these studies may help advance pediatric academic careers, they do not improve pediatric health care. The EMA defines children as <18 years old and demands even more senseless and potentially harmful "pediatric" studies. Young patients need pharmacokinetic/pharmacodynamic and dose finding, but not separate E&S, studies. Institutional review boards and ethics committees should suspend or reject questionable FDA/EMA-demanded "pediatric" studies. Industry and science need repositioning towards "PDD"; US/EU pediatric laws need revision. We hope this will not take decades.
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Affiliation(s)
- Klaus Rose
- klausrose Consulting, Riehen, BS, Switzerland
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Barone A, Casey D, McKee AE, Reaman G. Cancer drugs approved for use in children: Impact of legislative initiatives and future opportunities. Pediatr Blood Cancer 2019; 66:e27809. [PMID: 31144772 DOI: 10.1002/pbc.27809] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 04/26/2019] [Accepted: 04/27/2019] [Indexed: 11/10/2022]
Abstract
It is well appreciated that the number of anticancer drugs approved for use in children is a fraction of the number approved for use in cancers that occur in adults. We address this fact by summarizing the relevant U.S. legislation that provides the framework for the evaluation and approval of drugs used to treat children with cancer. In total, the Food and Drug Administration (FDA) has approved 38 new drug applications for pediatric oncology indications, 12 of which were new molecular entities. FDA continues to collaborate with multistakeholders regarding the development of products intended for pediatric cancer and encourages the submission of marketing applications.
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Affiliation(s)
- Amy Barone
- Office of Hematology and Oncology Products, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Denise Casey
- Office of Hematology and Oncology Products, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Amy E McKee
- Oncology Center for Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Gregory Reaman
- Oncology Center for Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
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Rose K, Neubauer D, Grant-Kels JM. Rational Use of Medicine in Children-The Conflict of Interests Story. A Review. Rambam Maimonides Med J 2019; 10:RMMJ.10371. [PMID: 31335307 PMCID: PMC6649781 DOI: 10.5041/rmmj.10371] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND United States (US) and European Union (EU) legislation attempts to counterbalance the presumed discrimination in pediatric drug treatment and development. METHODS We analyzed the history of drug development, US/EU pediatric laws, and pediatric studies required by US/EU regulatory authorities and reviewed relevant literature. RESULTS The US and EU definitions of a child are defined administratively (rather than physiologically) as being aged <17 years and <18 years, respectively. However, children mature physiologically well before their seventeenth or eighteenth birthdays. The semantic blur for these differing definitions may indicate certain conflicts of interest. CONCLUSIONS Pediatric healthcare today is better than ever. Regulatory-related requirements for "pediatric" studies focus on labeling. Most of these studies lack medical usefulness and may even harm "pediatric" patients through administration of placebo and/or substandard treatment, despite the resultant publications, networking, patent extensions, and strengthened regulatory standing. Clinicians, parents, and ethics committees should be aware of these issues. New rules are needed to determine new pharmaceutical dose estimates in prepubescent patients, and when/how to clinically confirm them. Internet-based structures to divulge this information should be established between drug developers, clinicians, and regulatory authorities. A prerequisite for the rational use of pharmaceuticals in children would be to correct the flawed concept that children are discriminated against in drug treatment and development, and to abandon separate "pediatric" drug approval processes.
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Affiliation(s)
- Klaus Rose
- klausrose Consulting, Pediatric Drug Development & More, Riehen, Switzerland
| | - David Neubauer
- Department of Child, Adolescent and Developmental Neurology, University Children’s Hospital, Ljubljana, Slovenia
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Rose K, Grant-Kels JM. Pediatric melanoma-The whole (conflicts of interest) story. Int J Womens Dermatol 2019; 5:110-115. [PMID: 30997384 PMCID: PMC6451736 DOI: 10.1016/j.ijwd.2018.10.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/25/2018] [Accepted: 10/09/2018] [Indexed: 01/13/2023] Open
Affiliation(s)
- Klaus Rose
- klausrose Consulting, Riehen, Switzerland
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Tanemura N, Asawa M, Kuroda M, Sasaki T, Iwane Y, Urushihara H. Pediatric off-label use of psychotropic drugs approved for adult use in Japan in the light of approval information regarding pediatric patients in the United States: a study of a pharmacy prescription database. World J Pediatr 2019; 15:92-99. [PMID: 30506238 DOI: 10.1007/s12519-018-0213-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 11/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Off-label use of psychotropic prescriptions for pediatric patients has been increasing in Japan. This study sought to clarify pediatric patients' off-label use of psychotropics approved only for adults in Japan. METHODS This retrospective study on psychotropic utilization employed a pharmaceutical health insurance claims database supplied by a pharmacy for the fiscal year 2016. Seven psychotropic drugs were examined. For each drug, we calculated the proportion of patients aged < 16 years or who were under the approved age limit set in the United States out of all patients. The maximum daily dose of each drug within the study period was plotted by age. RESULTS Data of 45,715 patients (female: 26,799, male: 18,916) with 331,920 prescriptions were examined in this study. For each drug, the proportion of pediatric patients aged < 16 years ranged from 0.15 to 1.1%, while the proportion of those under the approved age limit in the United States ranged from 0 to 0.27%. Olanzapine had the highest reported proportion. No drugs other than olanzapine were taken under the approved age limit in the United States. CONCLUSIONS We identified the pediatric off-label use of psychotropics that were limited to adult use in Japan. The results indicated the possibility of referring to international guidelines or evidence in clinical practice, but these factors do not discount the existing problems with off-label use. More clinical trials within the pediatric population in Japan are needed to address the issue of off-label use and obtain useful and reliable information in the package inserts for rational use in future pediatric patients.
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Affiliation(s)
- Nanae Tanemura
- Division of Drug Development and Regulatory Science, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Maika Asawa
- Division of Drug Development and Regulatory Science, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Mayuko Kuroda
- Division of Drug Development and Regulatory Science, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Tsuyoshi Sasaki
- Department of Child Psychiatry, Chiba University Hospital, Chiba, Japan
| | | | - Hisashi Urushihara
- Division of Drug Development and Regulatory Science, Faculty of Pharmacy, Keio University, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan.
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Sinha MS, Najafzadeh M, Rajasingh EK, Love J, Kesselheim AS. Labeling Changes and Costs for Clinical Trials Performed Under the US Food and Drug Administration Pediatric Exclusivity Extension, 2007 to 2012. JAMA Intern Med 2018; 178:1458-1466. [PMID: 30264138 PMCID: PMC6248195 DOI: 10.1001/jamainternmed.2018.3933] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/22/2018] [Indexed: 12/19/2022]
Abstract
Importance Pharmaceutical manufacturers can receive 6 additional months of market exclusivity for performing pediatric clinical trials of brand-name drugs widely used in adults. Congress created this incentive in 1997 because these drugs were being used off-label in children without such trials. Objective To review updates to drug labeling and the cost to consumers of extending market exclusivity related to the pediatric exclusivity program. Design From government records, we identified 54 drugs that earned the pediatric exclusivity incentive between 2007 and 2012. We evaluated labeling changes from the pediatric studies. We then extracted trial details from clinical review documents and used industry estimates of trial costs on a per-patient basis to estimate cost of investment for trials (with a 10% cost of capital). To calculate the net return and cost to consumers during the 6-month exclusivity period, we estimated additional revenue for the 48 drugs with available information. Main Outcomes and Measures For each drug, we evaluated labeling changes and costs associated with pediatric trials under the Best Pharmaceuticals for Children Act and the cost to consumers of 6-month market exclusivity extensions. Results The 141 trials in our sample enrolled 20 240 children (interquartile range [IQR], 2-3 trials and 127-556 patients per drug). These trials led to 29 extended indications and 3 new indications, as well as new safety information for 16 drugs. Median cost of investment for trials was $36.4 million (IQR, $16.6 to $100.6 million). Among 48 drugs with available financial information, median net return was $176.0 million (IQR, $47.0 million to $404.1 million), with a median ratio of net return to cost of investment of 680% (IQR, 80% to 1270%). Conclusions and Relevance Clinical trials conducted under the US Food and Drug Administration's pediatric exclusivity program have provided important information about the effectiveness and safety of drugs used in children. The costs to consumers have been high, exceeding the estimated costs of investment for conducting the trials. As an alternative, policymakers should consider direct funding of such studies.
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Affiliation(s)
- Michael S. Sinha
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mehdi Najafzadeh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - James Love
- Knowledge Ecology International (KEI), Washington, DC
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Characteristics and Changes of Pediatric Therapeutic Trials under the Best Pharmaceuticals for Children Act. J Pediatr 2018; 192:8-12. [PMID: 29029810 PMCID: PMC5732867 DOI: 10.1016/j.jpeds.2017.08.048] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/21/2017] [Accepted: 08/18/2017] [Indexed: 12/13/2022]
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Patel SK, Leong R, Zhao H, Barone A, Casey D, Liu Q, Burckart GJ, Reaman G. Pediatric Development of Molecularly Targeted Oncology Drugs. Clin Pharmacol Ther 2017; 104:384-389. [DOI: 10.1002/cpt.942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Shivam Kamlesh Patel
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
- University of North Carolina at Chapel Hill; Chapel Hill North Carolina USA
| | - Ruby Leong
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Hong Zhao
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Amy Barone
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Denise Casey
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Qi Liu
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Gilbert J. Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
| | - Gregory Reaman
- Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation and Research; Food and Drug Administration; Silver Spring Maryland USA
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Wharton GT, Murphy MD, Avant D, Goldsmith JV, Chai G, Rodriguez WJ, Eisenstein EL. Impact of pediatric exclusivity on drug labeling and demonstrations of efficacy. Pediatrics 2014; 134:e512-8. [PMID: 25022732 DOI: 10.1542/peds.2013-2987] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Besides vaccines and otitis media medicines, most products prescribed for children have not been studied in the pediatric population. To remedy this, Congress enacted legislation in 1997, known as pediatric exclusivity (PE), which provides 6 months of additional market protection to drug sponsors in exchange for studying their products in children. METHODS We reviewed requests for pediatric studies and subsequent labeling for drugs granted PE from 1998 through 2012. Regression analysis estimates the probability of demonstrating efficacy in PE trials. Variables include therapeutic group, year of exclusivity, product sales, initiation process, and small disease population. RESULTS From 1998 through 2012, the US Food and Drug Administration issued 401 pediatric study requests. For 189 drugs, studies were completed and granted exclusivity. A total of 173 drugs (92%) received new pediatric labeling, with 108 (57%) receiving a new or expanded pediatric indication. Three drugs had non-efficacy trials. Efficacy was not established for 78 drugs. Oncology, cardiovascular, and endocrine drugs were less likely to demonstrate efficacy (P < .01) compared with gastrointestinal and pain/anesthesia drugs. Drugs studied later in the program were less likely to demonstrate efficacy (P < .05). Sales, initiation process, and small disease population were not significant predictors. CONCLUSIONS Most drugs (173; 92%) granted exclusivity added pediatric information to their labeling as a result of PE, with 108 (57%) receiving a new or expanded pediatric indication. Therapeutic area and year of exclusivity influenced the likelihood of obtaining a pediatric indication. Positive and negative outcomes continue to inform the construct of future pediatric trials.
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Affiliation(s)
| | | | | | - John V Goldsmith
- Policy and Planning, Office of the Commissioner, US Food and Drug Administration, Silver Spring, Maryland
| | - Grace Chai
- Office of Surveillance and Epidemiology, Center of Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland;United States Public Health Service; and
| | | | - Eric L Eisenstein
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
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Turner MA, Catapano M, Hirschfeld S, Giaquinto C. Paediatric drug development: the impact of evolving regulations. Adv Drug Deliv Rev 2014; 73:2-13. [PMID: 24556465 DOI: 10.1016/j.addr.2014.02.003] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 01/20/2014] [Accepted: 02/11/2014] [Indexed: 01/07/2023]
Abstract
Children deserve medicines that are adapted to their needs. The need to include children in drug development has been recognised increasingly over the past few decades. Legal and regulatory frameworks are well established in the EU and US. The amount of work done to study medicines for children is significantly greater than it was 10 years go. Proof-of-concept has been demonstrated for all segments of the paediatric drug development pipeline. It is now time to examine how the practice of developing medicines for children has evolved within those frameworks and to determine how that work should be generalised. This review describes the development of medicines for children and critically appraises the work that has been done within those frameworks. Significant effort is needed to realize the potential provided by the current regulatory framework. Using the work programme of the Global Research in Paediatrics (GRiP) Network of Excellence as a template we outline current work and future growing points.
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Affiliation(s)
- M A Turner
- University of Liverpool, Department of Women's and Children's Health, Institute of Translational Medicine, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool L8 7SS, UK.
| | - M Catapano
- University of Pavia, Italian Group for the Study of Pharmacoeconomics (GISF), Via Luigi Porta 14, 27100 Pavia, Italy.
| | - S Hirschfeld
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), 31 Center Drive, Building 31, Room 2A32, Bethesda, MD 20892-2425, USA.
| | - C Giaquinto
- Azienda Ospedaliera di Padova (AOPD), Department of Paediatrics, Via Giustiniani 1, 35128 Padova, Italy.
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Abstract
PURPOSE OF REVIEW To provide current information on off-label medication use in pediatric gastroenterology, including a discussion on US legislative efforts to address the issue. RECENT FINDINGS Medications used to treat pediatric gastrointestinal illnesses are frequently prescribed off-label. Acid suppressors, antiemetics, laxatives, and antitumor necrosis factor therapies are types of medications frequently used off-label in the pediatric gastroenterology arena. Pediatric studies conducted under US Federal laws are generating much-needed data on the safety and effectiveness of medications used to treat pediatric patients. Moreover, a new US law, the Food and Drug Administration Safety and Innovation Act, may further the development of pediatric medications in part by requiring pediatric-specific study plans earlier in the overall drug development process. As of today, there still are gaps in our knowledge about these medications, including for the treatment of pediatric gastroenterology diseases. SUMMARY Medications are widely used off-label in pediatrics, including medications intended to treat gastrointestinal diseases, such as antitumor necrosis factor and laxatives. Although legislation is helping to generate and make available important information about pediatric medications, most still do not contain pediatric data. Therefore, providers need to understand the potential risks and benefits of prescribing off-label products to pediatric patients.
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