1
|
Guidance for pediatric use in prescription information for novel medicinal products in the EU and the US. PLoS One 2022; 17:e0266353. [PMID: 35377911 PMCID: PMC8979467 DOI: 10.1371/journal.pone.0266353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/18/2022] [Indexed: 11/29/2022] Open
Abstract
Pediatric legislations in the European Union (EU) and the United States (US) have increased medicines approved for use in the pediatric population. Despite many similarities between these frameworks, the EU Paediatric Regulation more often provides regulators with a mandate to require pediatric drug development for novel medicinal products compared to US regulators. If used, this could give rise to differences in the guidance for pediatric use provided for clinicians in the two regions. However, the level of discordance in the guidance for pediatric use between the two regions is unknown. This cross-sectional study compares guidance for pediatric use in the EU Summary of Product Characteristics (SmPC) and the US Prescription Information (USPI) on the level of indications granted for novel medicinal products approved after the pediatric legislations came in to force in both regions. For all indications granted as of March 2020 for novel medicinal products approved in both regions between 2010 and 2018, we compared the guidance for pediatric use in the EU SmPC and the USPI. The guidance for pediatric use differed for 18% (61/348) of the listed indications covering 21% (45/217) of the products, but without the guidance being contradictory. Where guidance differed, an equal share was observed for indications with a higher level of information for pediatric use in one region over the other (49% (30/61) in the US; 51% (31/61) in the EU). The discrepancies in pediatric information could be explained by differences in regulations for 21% (13/61) of the indications. Only a few conditions and diseases (EU n = 4; US n = 1) were observed to cover potential pediatric use outside the approved adult indication. Although the EU Paediatric Regulation more often provides regulators a mandate for requiring pediatric drug development as compared to the US PREA, this was not reflected in the prescription information approved by the two regulatory authorities.
Collapse
|
2
|
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.
Collapse
Affiliation(s)
- Klaus Rose
- klausrose Consulting, Riehen, BS, Switzerland
| | | |
Collapse
|
3
|
Affiliation(s)
- Florence T Bourgeois
- From the Pediatric Therapeutics and Regulatory Science Initiative and the Computational Health Informatics Program, Boston Children's Hospital, and the Department of Pediatrics, Harvard Medical School (F.T.B.), and the Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (A.S.K.) - all in Boston
| | - Aaron S Kesselheim
- From the Pediatric Therapeutics and Regulatory Science Initiative and the Computational Health Informatics Program, Boston Children's Hospital, and the Department of Pediatrics, Harvard Medical School (F.T.B.), and the Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (A.S.K.) - all in Boston
| |
Collapse
|
4
|
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.
Collapse
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
| | | |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Bakaki PM, Staley J, Liu R, Dawson N, Golchin N, Horace A, Johnson H, Waldron J, Winterstein A, Kleinman LC, Bolen SD. A transdisciplinary team approach to scoping reviews: the case of pediatric polypharmacy. BMC Med Res Methodol 2018; 18:102. [PMID: 30286720 PMCID: PMC6172739 DOI: 10.1186/s12874-018-0560-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 09/18/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Polypharmacy can be either beneficial or harmful to children. We conducted a scoping review to examine the concept of pediatric polypharmacy: its definition, prevalence, extent and gaps in research. In this manuscript, we report our transdisciplinary scoping review methodology. METHODS After establishing a transdisciplinary team, we iteratively developed standard operating procedures for the study's search strategy, inclusion/exclusion criteria, screening, and data extraction. We searched eight bibliographic databases, screened abstracts and full text articles, and extracted data from included studies using standardized forms. We held regular team meetings and performed ongoing internal validity measurements to maintain consistent and quality outputs. RESULTS With the aid of EPPI Reviewer collaborative software, our transdisciplinary team of nine members performed dual reviews of 363 included studies after dual screening of 4398 abstracts and 1082 full text articles. We achieved overall agreement of 85% and a kappa coefficient of 0.71 (95% CI 0.68-0.74) while screening full text articles. The screening and review processes required about seven hours per extracted study. The two pharmacists, an epidemiologist, a neurologist, and a librarian on the review team provided internal consultation in these key disciplines. A stakeholder group of 10 members with expertise in evidence synthesis, research implementation, pediatrics, mental health, epilepsy, pharmacoepidemiology, and pharmaceutical outcomes were periodically consulted to further characterize pediatric polypharmacy. CONCLUSIONS A transdisciplinary approach to scoping reviews, including internal and external consultation, should be considered when addressing complex cross-disciplinary questions.
Collapse
Affiliation(s)
- Paul M Bakaki
- Department of Population & Quantitative Health Sciences, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Jennifer Staley
- Rainbow Babies and Children's Hospital, University Hospitals, Cleveland, OH, USA
| | - Rujia Liu
- Department of Population & Quantitative Health Sciences, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Neal Dawson
- Department of Population & Quantitative Health Sciences, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA.,Department of Medicine, MetroHealth Medical Center, Cleveland, OH, USA
| | - Negar Golchin
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Alexis Horace
- Department of Clinical Sciences, University of Louisiana at Monroe College of Pharmacy, Monroe, LA, USA
| | - Hannah Johnson
- Department of Population & Quantitative Health Sciences, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Jennifer Waldron
- Rainbow Babies and Children's Hospital, University Hospitals, Cleveland, OH, USA.,School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | - Lawrence C Kleinman
- Rainbow Babies and Children's Hospital, University Hospitals, Cleveland, OH, USA.,School of Medicine, Case Western Reserve University, Cleveland, OH, USA.,The Center for Child Health and Policy at Rainbow, University Hospitals, Cleveland, OH, USA
| | - Shari D Bolen
- Department of Population & Quantitative Health Sciences, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA.,Department of Medicine, MetroHealth Medical Center, Cleveland, OH, USA.,Center for Health Care Research and Policy, Case Western Reserve University at the MetroHealth System, Cleveland, OH, USA
| |
Collapse
|
7
|
Aamir M, Khan JA, Shakeel F, Shareef R, Shah N. Drug utilization in neonatal setting of Pakistan: focus on unlicensed and off label drug prescribing. BMC Pediatr 2018; 18:242. [PMID: 30045715 PMCID: PMC6060516 DOI: 10.1186/s12887-018-1211-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 07/05/2018] [Indexed: 11/10/2022] Open
Abstract
Background Unlicensed and off label drug use is an issue recognized worldwide in pediatric pharmacotherapy. The study was designed to assess the prevalence and predictors of unlicensed and off label drug use in neonatal population of Pakistan. Method A prospective, observation study was conducted in nursery units at pediatric department of four tertiary care hospitals during the 1 year. Micromedex DRUGDEX was used to evaluate the case notes of 1300 patients. Logistic regression was employed to calculate the odds ratio for the predictors of unlicensed and off label drug use. Results A total of 1300 patients were included in this study who were treated with 52 different drugs. The prevalence of off label drug use was higher (52.14%) as compared to unlicensed drug use (33.35%). Dose (61.29%) and indication (13.68%) were the most frequent reasons for off label prescribing. In comparison to the corresponding reference categories, females and preterm infants were less likely to receive unlicensed prescriptions. While patients staying at hospital more than 5 days and infants receiving 3 or more medications were significantly more likely to receive unlicensed prescriptions. Moreover, in comparison to the corresponding reference categories, females were less likely to receive off label prescriptions while infants receiving 3 or more medications were 7 times more likely to receive off label prescriptions. Conclusion The significant prevalence of unlicensed and off label drug prescriptions was found in neonatal population of Pakistan. The findings imply that more data on prevalence of unlicensed and off label prescriptions are required to provide a better picture of pediatric therapy in developing countries. Furthermore, advance formulations with new dosing in pediatrics is also necessary to minimize the risk of adverse drug events. Electronic supplementary material The online version of this article (10.1186/s12887-018-1211-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Muhammad Aamir
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | | | - Faisal Shakeel
- Department of Pharmacy, Sarhad University of Science and Information Technology, Peshawar, Pakistan
| | - Rabeea Shareef
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Nazia Shah
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| |
Collapse
|
8
|
EU Paediatric Investigation Plans (Pips) Might Harm Children. ACTA MEDICA BULGARICA 2018. [DOI: 10.2478/amb-2018-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Aim/objective: Since 2007, companies in the EU must submit paediatric investigation plans (PIPs) for new drugs, unless the PIP is waived and the review article investigated if that improve the child healthcare. Methods: We analysed the EU Paediatric Regulation (EUPR), PIP decisions, PIP decision patterns, EU key documents on "better medicines for children" and examined PIP studies versus the epidemiology described in the reference literature. We examined how PIPs translate into studies by checking www. clinicaltrials.gov and www.clinicaltrialsregister.org. We also investigated the medical sense of PIP-demanded clinical studies in adolescents. Results: The EUPR in Art. 2 (1) defines “paediatric population” as those between birth and 18 years. It lists challenges in dosing and safety of drugs in neonates and infants as if these challenges apply to anybody < 18 years. PIPs demand studies in adolescents although this group needs separate dose finding and efficacy studies only in exceptional cases, if at all. Most PIP studies in rare diseases are unfeasible: too many studies for too few patients in general. Two questionable PIP studies were discontinued in 2016, in one of them several patients died. Conclusions: Neonates and infants have immature organs, with resulting potential for drug over/underdosing. PIPs equalize the legal definition of childhood with a biological limit. The resulting automatism leads to a worldwide threat to children. Most PIP-demanded studies are medically senseless, some even worse. Ethics committees should reject questionable PIP studies and suspend such ongoing studies immediately.
Collapse
|
9
|
Gautier I, Janiaud P, Rollet N, André N, Tsimaratos M, Cornu C, Malik S, Gentile S, Kassaï B. Trends in the number and the quality of trial protocols involving children submitted to a French Institutional Review Board. BMC Med Res Methodol 2017; 17:130. [PMID: 28835231 PMCID: PMC5569539 DOI: 10.1186/s12874-017-0395-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 08/02/2017] [Indexed: 02/07/2023] Open
Abstract
Background There is a great need for high quality clinical research for children. The European Pediatric Regulation aimed to improve the quality of clinical trials in order to increase the availability of treatments for children. The main purpose of this study was to assess the evolution of both the number and the quality of pediatric trial protocols that were submitted to a French Institutional Review Board (IRB00009118) before and after the initiation of the EU Pediatric Regulation. Methods All protocols submitted to the IRB00009118 between 2003 and 2014 and conducting research on subjects under eighteen years of age were eligible. The quality of randomized clinical trials was assessed according to the guidelines developed by the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network and ranked using the Jadad score. Results Out of 622 protocols submitted to the Institutional Review Board (IRB), 21% (133/622) included children. Among these 133 pediatric protocols, the number of submitted pediatric protocols doubled between the two studied periods. From 2003 to 2008, 47 protocols including 21 institutionally sponsored were submitted to the IRB and from 2009 until 2014, 86 protocols including 48 institutionally sponsored were submitted. No significant trend was observed on the quality of RCTs. The overall median score of RCTs on the Jadad scale was high (3.5), 70.0% of protocols had a Jadad score ≥ 3, and 30.0% had a score < 3. Conclusion Following the EU Pediatric Regulation, the number of pediatric protocols submitted to the IRB00009118 tends to increase, but no change was noticed regarding their quality.
Collapse
Affiliation(s)
- Isabelle Gautier
- Centre d'investigation Clinique Pédiatrique, INSERM CIC 9502, Hôpital d'Enfants de la Timone, AP-HM, 264, rue Saint-Pierre, 13005, Marseille, France. .,EA3279 - Santé Publique: Maladies Chroniques et Qualité de Vie, Aix-Marseille Université, 13385, Marseille, France.
| | - Perrine Janiaud
- Evolutive Biology and Biometric Laboratory UMR5558 CNRS, Université Claude Bernard Lyon 1, 8 rue Guillaume Paradin, BP8071, 69376-CEDEX-08, Lyon, France
| | - Nelly Rollet
- Evolutive Biology and Biometric Laboratory UMR5558 CNRS, Université Claude Bernard Lyon 1, 8 rue Guillaume Paradin, BP8071, 69376-CEDEX-08, Lyon, France
| | - Nicolas André
- Centre d'investigation Clinique Pédiatrique, INSERM CIC 9502, Hôpital d'Enfants de la Timone, AP-HM, 264, rue Saint-Pierre, 13005, Marseille, France
| | - Michel Tsimaratos
- Centre d'investigation Clinique Pédiatrique, INSERM CIC 9502, Hôpital d'Enfants de la Timone, AP-HM, 264, rue Saint-Pierre, 13005, Marseille, France
| | - Catherine Cornu
- Evolutive Biology and Biometric Laboratory UMR5558 CNRS, Université Claude Bernard Lyon 1, 8 rue Guillaume Paradin, BP8071, 69376-CEDEX-08, Lyon, France.,EPICIME, Centre d'Investigation Clinique, INSERM CIC 1407, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677-CEDEX, Bron, France
| | - Salma Malik
- Evolutive Biology and Biometric Laboratory UMR5558 CNRS, Université Claude Bernard Lyon 1, 8 rue Guillaume Paradin, BP8071, 69376-CEDEX-08, Lyon, France.,EPICIME, Centre d'Investigation Clinique, INSERM CIC 1407, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677-CEDEX, Bron, France
| | - Stéphanie Gentile
- EA3279 - Santé Publique: Maladies Chroniques et Qualité de Vie, Aix-Marseille Université, 13385, Marseille, France
| | - Behrouz Kassaï
- Evolutive Biology and Biometric Laboratory UMR5558 CNRS, Université Claude Bernard Lyon 1, 8 rue Guillaume Paradin, BP8071, 69376-CEDEX-08, Lyon, France.,EPICIME, Centre d'Investigation Clinique, INSERM CIC 1407, Hospices Civils de Lyon, 28 Avenue du Doyen Lépine, 69677-CEDEX, Bron, France
| |
Collapse
|
10
|
Schandelmaier S, Tomonaga Y, Bassler D, Meerpohl JJ, von Elm E, You JJ, Bluemle A, Lamontagne F, Saccilotto R, Amstutz A, Bengough T, Stegert M, Olu KK, Tikkinen KAO, Neumann I, Carrasco-Labra A, Faulhaber M, Mulla SM, Mertz D, Akl EA, Sun X, Busse JW, Ferreira-González I, Nordmann A, Gloy V, Raatz H, Moja L, Rosenthal R, Ebrahim S, Vandvik PO, Johnston BC, Walter MA, Burnand B, Schwenkglenks M, Hemkens LG, Guyatt G, Bucher HC, Kasenda B, Briel M. Premature Discontinuation of Pediatric Randomized Controlled Trials: A Retrospective Cohort Study. J Pediatr 2017; 184:209-214.e1. [PMID: 28410086 DOI: 10.1016/j.jpeds.2017.01.071] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 12/30/2016] [Accepted: 01/30/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To determine the proportion of pediatric randomized controlled trials (RCTs) that are prematurely discontinued, examine the reasons for discontinuation, and compare the risk for recruitment failure in pediatric and adult RCTs. STUDY DESIGN A retrospective cohort study of RCTs approved by 1 of 6 Research Ethics Committees (RECs) in Switzerland, Germany, and Canada between 2000 and 2003. We recorded trial characteristics, trial discontinuation, and reasons for discontinuation from protocols, corresponding publications, REC files, and a survey of trialists. RESULTS We included 894 RCTs, of which 86 enrolled children and 808 enrolled adults. Forty percent of the pediatric RCTs and 29% of the adult RCTs were discontinued. Slow recruitment accounted for 56% of pediatric RCT discontinuations and 43% of adult RCT discontinuations. Multivariable logistic regression analyses suggested that pediatric RCT was not an independent risk factor for recruitment failure after adjustment for other potential risk factors (aOR, 1.22; 95% CI, 0.57-2.63). Independent risk factors were acute care setting (aOR, 4.00; 95% CI, 1.72-9.31), nonindustry sponsorship (aOR, 4.45; 95% CI, 2.59-7.65), and smaller planned sample size (aOR, 1.05; 95% CI 1.01-1.09, in decrements of 100 participants). CONCLUSION Forty percent of pediatric RCTs were discontinued prematurely, owing predominately to slow recruitment. Enrollment of children was not an independent risk factor for recruitment failure.
Collapse
Affiliation(s)
- Stefan Schandelmaier
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Academy of Swiss Insurance Medicine, University Hospital Basel, Basel, Switzerland.
| | - Yuki Tomonaga
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Joerg J Meerpohl
- German Cochrane Centre, Medical Center, University of Freiburg, Freiburg, Germany; Center of Research in Epidemiology and Statistics Sorbonne Paris Cité-U1153, INSERM/Université Paris Descartes, Cochrane France, Hôpital Hôtel-Dieu, Paris Cedex 04, France
| | - Erik von Elm
- Cochrane Switzerland, Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - John J You
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anette Bluemle
- German Cochrane Centre, Medical Center, University of Freiburg, Freiburg, Germany
| | - Francois Lamontagne
- Centre de Recherche Clinique du Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Ramon Saccilotto
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Alain Amstutz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Theresa Bengough
- Department of Health and Society, Austrian Federal Institute for Health Care, Vienna, Austria
| | - Mihaela Stegert
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Kelechi K Olu
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Kari A O Tikkinen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ignacio Neumann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Alonso Carrasco-Labra
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
| | - Markus Faulhaber
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sohail M Mulla
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Dominik Mertz
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Institute for Infectious Diseases Research, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Xin Sun
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jason W Busse
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Ignacio Ferreira-González
- Epidemiology Unit, Department of Cardiology, Vall d'Hebron Hospital and CIBER de Epidemiología y Salud Publica (CIBERESP), Barcelona, Spain
| | - Alain Nordmann
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Viktoria Gloy
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Institute of Nuclear Medicine, University Hospital Bern, Bern, Switzerland
| | - Heike Raatz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Lorenzo Moja
- IRCCS Orthopedic Institute Galeazzi, Milano, Italy
| | - Rachel Rosenthal
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - Shanil Ebrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada; Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Stanford Prevention Research Center, Stanford University, Stanford, CA
| | - Per O Vandvik
- Department of Medicine, Innlandet Hospital Trust-Division Gjøvik, Oppland, Norway
| | - Bradley C Johnston
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Martin A Walter
- Institute of Nuclear Medicine, University Hospital Bern, Bern, Switzerland
| | - Bernard Burnand
- Cochrane Switzerland, Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Matthias Schwenkglenks
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Lars G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Benjamin Kasenda
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Haematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Clinical Research, University of Basel, Basel, Switzerland
| |
Collapse
|
11
|
Desselas E, Pansieri C, Leroux S, Bonati M, Jacqz-Aigrain E. Drug versus placebo randomized controlled trials in neonates: A review of ClinicalTrials.gov registry. PLoS One 2017; 12:e0171760. [PMID: 28192509 PMCID: PMC5305102 DOI: 10.1371/journal.pone.0171760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 01/25/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Despite specific initiatives and identified needs, most neonatal drugs are still used off-label, with variable dosage administrations and schedules. In high risk preterm and term neonates, drug evaluation is challenging and randomized controlled trials (RCT) are difficult to conduct and even more is the use of a placebo, required in the absence of a reference validated drug to be used as comparator. METHODS We analyzed the complete ClinicalTrials.gov registry 1) to describe neonatal RCT involving a placebo, 2) to report on the medical context and ethical aspects of placebo use. RESULTS Placebo versus drug RCT (n = 146), either prevention trials (n = 57, 39%) or therapeutic interventions (n = 89, 61%), represent more than a third of neonatal trials registered in the National Institute of Health clinical trial database (USA) since 1999. They mainly concerned preterm infants, evaluating complications of prematurity. Most trials were conducted in the USA, were single centered, and funded by non-profit organizations. For the three top drug trials evaluating steroids (n = 13, 9.6%), erythropoietin (EPO, n = 10, 6.8%) and nitric oxide (NO, n = 9, 6.2%), the objectives of the trial and follow-up were analyzed in more details. CONCLUSION Although a matter of debate, the use of placebo should be promoted in neonates to evaluate a potential new treatment, in the absence of reference drug. Analysis of the trials evaluating steroids showed that long-term follow-up of exposed patients, although required by international guidelines, is frequently missing and should be planned to collect additional information and optimize drug evaluation in these high-risk patients.
Collapse
Affiliation(s)
- Emilie Desselas
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
| | - Claudia Pansieri
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Stephanie Leroux
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
| | - Maurizio Bonati
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
- Université Paris 7 Diderot, Paris, France
| |
Collapse
|
12
|
Rose K. New Drugs for Rare Diseases in Children. Clin Ther 2017; 39:246-252. [PMID: 28161117 DOI: 10.1016/j.clinthera.2017.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/09/2017] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE United States (US) Pediatric Legislation (PL) was introduced in 1997 to improve children's health. The European Union PL (EUPL) has been in force since 2007. Both PLs facilitate additional pediatric research on primarily adult drugs. The EUPL declares that the forces of the market are not sufficient for children. Without a pediatric investigation plan, new drugs can no longer be registered with the European Union. New ways on how to facilitate drug development for rare pediatric diseases are being proposed. METHODS US PL, EUPL, and implications of modern labels for medical decision making are discussed. FINDINGS Modern drug labels constituted a step from eminence-based towards data-based medical decision making. However, approval by regulatory authorities did not replace knowledge transfer in medicine, which continued in university education, through conferences, consensus papers, and so on. Children were successfully treated with off-label drugs in pediatric oncology and in many other diseases. Describing children as "therapeutic orphans" reflected an overestimation of drug labels and an underestimation of nonregulatory systematic clinical testing. Therapeutic breakthroughs have occurred, for example, in acute myelogenous leukemia and cystic fibrosis. Rare diseases need new innovative drugs and therapeutic concepts for further breakthroughs. IMPLICATIONS The focus of PL on additional pediatric measures for predominantly adult new drugs reflects a tunnel view. Similar to the introduction of modern pharmaceutical legislation that triggered comparable laws in most countries worldwide after 1962, we currently need new worldwide steps to reward innovative treatment concepts for rare diseases-not against, but through the market. Created by philanthropy, parents, and other supporters, new therapeutic concepts should be rewarded upon meeting regulatory milestones. This market is limited today. It needs not only a boost by pioneers, but also acceptance, welcome, and re-thinking about drug development in academia, politics, and by the general public.
Collapse
Affiliation(s)
- Klaus Rose
- klausrose Consulting, Pediatric Drug Development & More, Riehen, Switzerland.
| |
Collapse
|
13
|
Yasinta M, Che RC, Hu CY, Du XH, Ding GX, Huang SM, Chen Y, Zhang AH. Use of off-label nephrology-related drugs in hospitalized pediatric patients: a retrospective study. World J Pediatr 2016; 12:236-42. [PMID: 26684307 DOI: 10.1007/s12519-015-0058-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 05/27/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The information about the use of off-label drugs in pediatric nephrology is still lacking, which leads to increased adverse reactions and medical disputes. We retrospectively analyzed the use of off-label drugs in the in-patient ward of the nephrology department of Nanjing Children's Hospital, China in order to provide more complete information about the use of drugs for children. METHODS Proportional stratified random sampling was applied to select patients with renal diseases aged 1 month to 18 years, who were admitted to the hospital from October 1, 2012 to September 30, 2013. All nephrology-related drugs prescribed in the hospitalization period and take-home drugs prescribed on discharge were recorded and evaluated as off-label drugs or not from three different perspectives: person-time, prescription, and drug category. RESULTS From 385 person-times of patients with 1424 prescriptions, according to the ratio between off-label drugs and person-times, drug prescriptions, and drug products, the rates of off-label drugs were 40.78%, 16.64%, and 31.43%, respectively. Low-molecular-weight heparin, alfacalcidol and diltiazem were the most commonly used off-label drugs. Infants and younger children were the high-risk population of off-label drug use. The high rate off-label nephrology-related drug use in children was mainly related to lacking clinical research into drugs in children and the pace of drug label's revision, which cannot follow the development of medical science. CONCLUSION Approximaely half of pediatric patients with renal diseases are usually prescribed with off-label nephrology-related drugs. Analyzing the off-label conditions from different perspectives may lead to various results. More clinical research into drugs for infants and younger children is needed so as to update drug descriptions.
Collapse
Affiliation(s)
- Marchella Yasinta
- Department of Nephrology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing, China
| | - Ruo-Chen Che
- Department of Nephrology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing, China
| | - Cai-Yu Hu
- Department of Nephrology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing, China
| | - Xiang-Hui Du
- Department of Nephrology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing, China
| | - Gui-Xia Ding
- Department of Nephrology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing, China
| | - Song-Ming Huang
- Department of Nephrology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing, China
| | - Ying Chen
- Department of Nephrology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China. .,Jiangsu Key Laboratory of Pediatrics, Nanjing, China. .,Department of Nephrology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210029, China.
| | - Ai-Hua Zhang
- Department of Nephrology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China.,Jiangsu Key Laboratory of Pediatrics, Nanjing, China
| |
Collapse
|
14
|
Meier-Girard D, Tibi A, Abdoul H, Prot-Labarthe S, Brion F, Bourdon O, Alberti C. Academic pediatric clinical research: factors associated with study implementation duration. BMC Med Res Methodol 2016; 16:36. [PMID: 27025840 PMCID: PMC4812626 DOI: 10.1186/s12874-016-0138-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 03/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ethical, methodological, and technical aspects of pediatric research, often results in complications and delays in implementation. Our objective was to identify factors associated with the implementation duration of hospital-based pediatric studies. METHODS All hospital-based pediatric studies sponsored by AP-HP between 2002 and 2008 were retrospectively identified. Association of the funding mechanism and methodological factors with the implementation duration was assessed using a multivariable mixed linear model. Pharmaceutical factors were explored as part of a subgroup analysis restricted to the studies involving drug therapy. Given that we took an exploratory approach, factors associated with implementation duration with p < 0.10 were kept in the final models. RESULTS A total of 139 studies were evaluated. The median implementation duration was 17.1 months (range: 0.9-55.3 months), and tended to increase over time (from 14.9 [25(th) percentile-75(th) percentile: 11.5-19.9] months in 2002 to 23.7 [15.2-31.0] months in 2008, p = 0.01). External (coefficient [95 % confidence interval]: -7.7 [-11.9;-3.5] months, p < 0.001) and internal funding (-5.3 95 % CI [-9.8;-0.8], p = 0.02) compared to governmental funding and number of centers (-0.1 95 % CI[-0.2;0.02] months for 1 center increase, p = 0.07) were associated with reduced duration, whereas interventional study (either involving drug therapy (6.0 95 % CI[0.7;11.3] months, p = 0.03 or not (3.5 95 % CI[-0.3;7.3] months, p = 0.06) was associated with increased duration compared to observational study. Regarding the 35 studies involving drug therapy, external funding decreased duration (-6.7 95 % CI[-13.2;-0.2] months, p = 0.05), whereas studies involving solely a pediatric population (7.8 95 % CI[1.1;14.5] months, p = 0.01) (compared to mixed adult-pediatric population), a placebo-controlled design (6.6 95 % CI[0.9;12.3] months, p = 0.01), and inappropriate drug formulation for at least one drug used in the study (6.9 95 % CI[-0.2;14.0] months, p = 0.06) were associated with increased duration. CONCLUSION Implementation of hospital-based pediatric studies primarily faced delays when they were interventional and, in particular, when they involved drug therapy. Regarding the latter, difficulties that resulted in delayed studies arose with respect to the supply of drugs and placebo in age-appropriate dosages and route of administration. Therefore, difficulties related to the use of pharmaceuticals need to be anticipated earlier in order to avoid implementation delays.
Collapse
Affiliation(s)
- Delphine Meier-Girard
- />Université Paris Diderot, Sorbonne Paris Cité, UMR-1123 ECEVE, F-75019 Paris, France
- />AP-HP, Hôpital Robert Debré, Unité d’Epidémiologie Clinique, F-75019 Paris, France
- />Inserm, U1123 and CICEC 1426, F-75019 Paris, France
- />University of Basel, University Children’s Hospital (UKBB), Basel, Switzerland
- />Department of Paediatric Pulmonology, University Children`s Hospital Basel (UKBB), Spitalstrasse 33, 4056 Basel, Switzerland
| | - Annick Tibi
- />Université Paris Descartes, Sorbonne Paris Cité, F-75270 Paris, France
- />Département d’Essais Cliniques, AP-HP, Agence Générale des Equipements et Produits de Santé, F-75013 Paris, France
| | - Hendy Abdoul
- />Université Paris Diderot, Sorbonne Paris Cité, UMR-1123 ECEVE, F-75019 Paris, France
- />AP-HP, Hôpital Robert Debré, Unité d’Epidémiologie Clinique, F-75019 Paris, France
- />Inserm, U1123 and CICEC 1426, F-75019 Paris, France
| | - Sonia Prot-Labarthe
- />Université Paris Diderot, Sorbonne Paris Cité, UMR-1123 ECEVE, F-75019 Paris, France
- />Inserm, U1123 and CICEC 1426, F-75019 Paris, France
- />AP-HP, Hôpital Robert Debré, Pharmacie à Usage Intérieur, F-75019 Paris, France
| | - Françoise Brion
- />Université Paris Descartes, Sorbonne Paris Cité, F-75270 Paris, France
- />AP-HP, Hôpital Robert Debré, Pharmacie à Usage Intérieur, F-75019 Paris, France
| | - Olivier Bourdon
- />Université Paris Descartes, Sorbonne Paris Cité, F-75270 Paris, France
- />AP-HP, Hôpital Robert Debré, Pharmacie à Usage Intérieur, F-75019 Paris, France
| | - Corinne Alberti
- />Université Paris Diderot, Sorbonne Paris Cité, UMR-1123 ECEVE, F-75019 Paris, France
- />AP-HP, Hôpital Robert Debré, Unité d’Epidémiologie Clinique, F-75019 Paris, France
- />Inserm, U1123 and CICEC 1426, F-75019 Paris, France
| |
Collapse
|
15
|
Sinha YK, Craig JC, Brien JAE. Paediatric drug policy in Australia. J Paediatr Child Health 2015; 51:259-62. [PMID: 24909989 DOI: 10.1111/jpc.12629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Yashwant K Sinha
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia; Faculty of Pharmacy, University of Sydney, Sydney, Australia
| | | | | |
Collapse
|
16
|
Westra AE, de Beaufort I. Improving the Helsinki Declaration's guidance on research in incompetent subjects. JOURNAL OF MEDICAL ETHICS 2015; 41:278-280. [PMID: 24014633 DOI: 10.1136/medethics-2013-101496] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Research involving children or other incompetent subjects who are deemed unable to provide informed consent is complex, particularly in the case of research that does not directly benefit the research subjects themselves. The Helsinki Declaration, the World Medical Association's landmark document for research ethics, therefore states that incompetent research subjects must not be included in such research unless it entails only minimal risk and minimal burden. In this paper, we argue that now that research in these groups is expected to expand, this undifferentiated minimal risk and burden requirement does not suffice any more. In the upcoming revision of the Declaration, the paragraph at stake should be refined in such a way that it is not unnecessarily restrictive or more permissive than can be ethically justified. Our first recommendation is to stimulate research ethics committees to identify more accurately those risks and burdens that the research subjects must undergo solely for research purposes by distinguishing between two types of study procedures instead of between two types of studies. Our second recommendation is to allow for exceptions to the minimal risk and burden requirement in cases of exceptionally valuable studies that involve subjects who can give their assent to participate in the study and that involve at most a minor increase over minimal risk and/or burden.
Collapse
Affiliation(s)
- Anna Eva Westra
- Department of Medical Ethics and Philosophy of Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Inez de Beaufort
- Department of Medical Ethics and Philosophy of Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| |
Collapse
|
17
|
Joseph PD, Craig JC, Caldwell PHY. Clinical trials in children. Br J Clin Pharmacol 2015; 79:357-69. [PMID: 24325152 PMCID: PMC4345947 DOI: 10.1111/bcp.12305] [Citation(s) in RCA: 222] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/28/2013] [Indexed: 12/31/2022] Open
Abstract
Safety and efficacy data on many medicines used in children are surprisingly scarce. As a result children are sometimes given ineffective medicines or medicines with unknown harmful side effects. Better and more relevant clinical trials in children are needed to increase our knowledge of the effects of medicines and to prevent the delayed or non-use of beneficial therapies. Clinical trials provide reliable evidence of treatment effects by rigorous controlled testing of interventions on human subjects. Paediatric trials are more challenging to conduct than trials in adults because of the paucity of funding, uniqueness of children and particular ethical concerns. Although current regulations and initiatives are improving the scope, quantity and quality of trials in children, there are still deficiencies that need to be addressed to accelerate radically equitable access to evidence-based therapies in children.
Collapse
Affiliation(s)
- Pathma D Joseph
- The Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
| | - Jonathan C Craig
- School of Public Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
| | - Patrina HY Caldwell
- The Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
| |
Collapse
|
18
|
Di Pietro ML, Cutrera R, Teleman AA, Barbaccia ML. Placebo-controlled trials in pediatrics and the child's best interest. Ital J Pediatr 2015; 41:11. [PMID: 25887736 PMCID: PMC4346103 DOI: 10.1186/s13052-015-0118-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 02/05/2015] [Indexed: 11/15/2022] Open
Abstract
For too long children have received medicines not sufficiently studied for their needs and, in fact, being considered as small replicas of adults, it was deemed sufficient to adjust the dosage of a drug approved for adults. Together with the limited availability of appropriate drug formulations, especially for neonates and toddlers, this approach has caused increased iatrogenic risk and/or suboptimal adherence to treatment. With the aim of encouraging the development of more efficacious and safer medicines for children, the Regulatory Agencies in Europe and U.S.A. commendably issued directives to promote adequate and well controlled pediatric clinical trials. In compliance with the agenda of the Pediatric Regulation, in the past decade the number of pediatric patients enrolled in double-blind randomized clinical trials (RCTs) is markedly increased. In order to establish the efficacy of new medicines, RCTs frequently include a placebo-control group that carries the burden of additional, and to some extent underestimated, ethical concerns with respect to trials in adults. Six years into the Pediatric Regulation implementation, off-patent drugs, most of which at present are extensively used off-label, are underrepresented in ongoing/proposed pediatric RCTs. We debate this status quo to assess what might be the child’s best interest. In fact, we argue that well-designed studies, in which efficacy and safety of new drugs are compared to off-patent drugs that are currently prescribed off-label, would achieve the aim of the Pediatric Regulation better and more ethically than placebo controlled RCTs.
Collapse
Affiliation(s)
- Maria Luisa Di Pietro
- Institute of Public Health, School of Medicine "A. Gemelli", Catholic University of Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy. .,Ethics Committee, Bambino Gesù Children's Research Hospital, Rome, Italy.
| | - Renato Cutrera
- Respiratory Unit, Pediatric Department, Bambino Gesù Children's Research Hospital, Rome, Italy.
| | - Adele Anna Teleman
- Institute of Public Health, School of Medicine "A. Gemelli", Catholic University of Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy.
| | - Maria Luisa Barbaccia
- Ethics Committee, Bambino Gesù Children's Research Hospital, Rome, Italy. .,Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
| |
Collapse
|
19
|
Abstract
Paediatric clinical pharmacology is the scientific study of medicines in children and is a relatively new subspecialty in paediatrics in the UK. Training encompasses both the study of the effectiveness of drugs in children (clinical trials) and aspects of drug toxicity (pharmacovigilance). Ethical issues in relation to clinical trials and also studies of the pharmacokinetics and drug metabolism in children are crucial. Paediatric patients require formulations that young children in particular are able to take. The scientific evidence generated from clinical trials, pharmacokinetic studies and studies of drug toxicity all need to be applied in order to ensure that medicines are used rationally in children.
Collapse
Affiliation(s)
- Imti Choonara
- Academic Unit of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Helen Sammons
- Academic Unit of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| |
Collapse
|
20
|
Liu X, Kruger P, Maibach H, Colditz PB, Roberts MS. Using skin for drug delivery and diagnosis in the critically ill. Adv Drug Deliv Rev 2014; 77:40-9. [PMID: 25305335 DOI: 10.1016/j.addr.2014.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 09/09/2014] [Accepted: 10/01/2014] [Indexed: 02/08/2023]
Abstract
Skin offers easy access, convenience and non-invasiveness for drug delivery and diagnosis. In principle, these advantages of skin appear to be attractive for critically ill patients given potential difficulties that may be associated with oral and parenteral access in these patients. However, the profound changes in skin physiology that can be seen in these patients provide a challenge to reliably deliver drugs or provide diagnostic information. Drug delivery through skin may be used to manage burn injury, wounds, infection, trauma and the multisystem complications that rise from these conditions. Local anaesthetics and analgesics can be delivered through skin and may have wide application in critically ill patients. To ensure accurate information, diagnostic tools require validation in the critically ill patient population as information from other patient populations may not be applicable.
Collapse
|
21
|
Magalhães J, Rodrigues AT, Roque F, Figueiras A, Falcão A, Herdeiro MT. Use of off-label and unlicenced drugs in hospitalised paediatric patients: a systematic review. Eur J Clin Pharmacol 2014; 71:1-13. [DOI: 10.1007/s00228-014-1768-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 10/06/2014] [Indexed: 11/29/2022]
|
22
|
Wimmer S, Rascher W, McCarthy S, Neubert A. The EU paediatric regulation: still a large discrepancy between therapeutic needs and approved paediatric investigation plans. Paediatr Drugs 2014; 16:397-406. [PMID: 25056717 DOI: 10.1007/s40272-014-0082-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Prior to the implementation of the EU Paediatric Regulation, the European Medicines Agency (EMA) defined unmet paediatric needs for active substances already available on the market. Seven years after the Paediatric Regulation came into force, we investigated the extent to which previously identified needs have led to programmes for generating evidence necessary for the regulatory approval of medicines for managing childhood conditions. METHODS The websites of the EMA and the European Commission Community Research and Development Information Service (CORDIS) were systematically screened to identify active substances from the assessment of paediatric needs, off-patent priority list, agreed Paediatric Investigation Plans (PIP) and 7th Framework Programme (FP7) projects related to paediatric medicines. RESULTS A total of 357 active substances with paediatric needs were identified by June 2013. 511 PIPs were agreed by the Paediatric Committee at the EMA (PDCO), including 51 (14.3 %) PIPs for a previously identified need. Amongst those, 21 were off-patent at the time of the PIP approval, 15 of which received funding from the European Commission's FP7. According to the assessment of paediatric needs, evidence is particularly needed for active substances treating cardiovascular diseases (n = 61), cancer (n = 40) and in the field of anaesthesiology (n = 38). Whereas oncology drugs (n = 66) were frequently represented in PIPs, drugs for cardiovascular diseases (n = 39) and anaesthesiology (n = 3) rarely were. CONCLUSIONS Most PIPs are attributable to marketing authorisations of new active substances, whereas off-patent drugs which are commonly used off-label remain unstudied to a large extent. More effort including ongoing research funding is essential to further regularise and standardise paediatric pharmacotherapy.
Collapse
Affiliation(s)
- Stefan Wimmer
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Loschgestraße 15, 91054, Erlangen, Germany
| | | | | | | |
Collapse
|
23
|
Pansieri C, Bonati M, Choonara I, Jacqz-Aigrain E. Neonatal drug trials: impact of EU and US paediatric regulations. Arch Dis Child Fetal Neonatal Ed 2014; 99:F438. [PMID: 24792777 DOI: 10.1136/archdischild-2013-305900] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Claudia Pansieri
- Service de Pharmacologie Pédiatrique, AP-HP, Hôpital Robert Debré, Paris, France Laboratory for Mother and Child Health, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - Maurizio Bonati
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - Imti Choonara
- Academic Division of Child Health, Derbyshire Children's Hospital, University of Nottingham, Derby, UK
| | - Evelyne Jacqz-Aigrain
- Service de Pharmacologie Pédiatrique, AP-HP, Hôpital Robert Debré, Paris, France Université Paris Diderot, Sorbonne Paris Cité, Paris, France INSERM, CIC1426, Hôpital Robert Debré, Paris, France
| |
Collapse
|
24
|
Ivanovska V, Rademaker CMA, van Dijk L, Mantel-Teeuwisse AK. Pediatric drug formulations: a review of challenges and progress. Pediatrics 2014; 134:361-72. [PMID: 25022739 DOI: 10.1542/peds.2013-3225] [Citation(s) in RCA: 182] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Children differ from adults in many aspects of pharmacotherapy, including capabilities for drug administration, medicine-related toxicity, and taste preferences. It is essential that pediatric medicines are formulated to best suit a child's age, size, physiologic condition, and treatment requirements. To ensure adequate treatment of all children, different routes of administration, dosage forms, and strengths may be required. Many existing formulations are not suitable for children, which often leads to off-label and unlicensed use of adult medicines. New regulations, additional funding opportunities, and innovative collaborative research initiatives have resulted in some recent progress in the development of pediatric formulations. These advances include a paradigm shift toward oral solid formulations and a focus on novel preparations, including flexible, dispersible, and multiparticulate oral solid dosage forms. Such developments have enabled greater dose flexibility, easier administration, and better acceptance of drug formulations in children. However, new pediatric formulations address only a small part of all therapeutic needs in children; moreover, they are not always available. Five key issues need to be addressed to stimulate the further development of better medicines for children: (1) the continued prioritization of unmet formulation needs, particularly drug delivery in neonates and treatment gaps in pediatric cancers and childhood diseases in developing countries; (2) a better use of existing data to facilitate pediatric formulation development; (3) innovative technologies in adults that can be used to develop new pediatric formulations; (4) clinical feedback and practice-based evidence on the impact of novel formulations; and (5) improved access to new pediatric formulations.
Collapse
Affiliation(s)
- Verica Ivanovska
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands;Faculty of Medical Sciences, University Goce Delcev, Republic of Macedonia;
| | - Carin M A Rademaker
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, Netherlands; and
| | - Liset van Dijk
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, Netherlands
| | | |
Collapse
|
25
|
Sosnik A, Carcaboso AM. Nanomedicines in the future of pediatric therapy. Adv Drug Deliv Rev 2014; 73:140-61. [PMID: 24819219 DOI: 10.1016/j.addr.2014.05.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Revised: 04/16/2014] [Accepted: 05/01/2014] [Indexed: 01/02/2023]
Abstract
Nanotechnology has become a key tool to overcome the main (bio)pharmaceutical drawbacks of drugs and to enable their passive or active targeting to specific cells and tissues. Pediatric therapies usually rely on the previous clinical experience in adults. However, there exists scientific evidence that drug pharmacokinetics and pharmacodynamics in children differ from those in adults. For example, the interaction of specific drugs with their target receptors undergoes changes over the maturation of the different organs and systems. A similar phenomenon is observed for toxicity and adverse effects. Thus, it is clear that the treatment of disease in children cannot be simplified to the direct adjustment of the dose to the body weight/surface. In this context, the implementation of innovative technologies (e.g., nanotechnology) in the pediatric population becomes extremely challenging. The present article overviews the different attempts to use nanotechnology to treat diseases in the pediatric population. Due to the relevance, though limited available literature on the matter, we initially describe from preliminary in vitro studies to preclinical and clinical trials aiming to treat pediatric infectious diseases and pediatric solid tumors by means of nanotechnology. Then, the perspectives of pediatric nanomedicine are discussed.
Collapse
Affiliation(s)
- Alejandro Sosnik
- Department of Materials Science and Engineering, Technion-Israel Institute of Technology, Technion City, Haifa 32000, Israel.
| | - Angel M Carcaboso
- Preclinical Therapeutics and Drug Delivery Research Program, Department of Oncology, Hospital Sant Joan de Déu Barcelona, Esplugues de Llobregat, Barcelona 08950, Spain
| |
Collapse
|
26
|
Affiliation(s)
- Roderik F Viergever
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | | |
Collapse
|
27
|
Lathyris D, Panagiotou OA, Baltogianni M, Ioannidis JP, Contopoulos-Ioannidis DG. Safety of medical interventions in children versus adults. Pediatrics 2014; 133:e666-73. [PMID: 24567023 PMCID: PMC9923602 DOI: 10.1542/peds.2013-3128] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Compare the risk of harm from pharmacologic interventions in pediatric versus adult randomized controlled trials (RCTs). METHODS We used systematic reviews from the Cochrane Database of Systematic Reviews. We considered separately 7 categories of harms/harm-related end points: severe harms, withdrawals due to harms, any harm, organ system-level harms, specific harms, withdrawals for any reason, and mortality. Systematic reviews with quantitative synthesis from at least 1 adult and 1 pediatric RCT for any of those end points were eligible. We calculated the summary odds ratio (experimental versus control intervention) in adult and pediatric trials/meta-analysis; the relative odds ratio (ROR) in adults versus children per meta-analysis; and the summary ROR (sROR) across all meta-analyses for each end point. ROR <1 means that the experimental intervention fared worse in children than adults. RESULTS We identified 176 meta-analyses for 52 types of harms/harm-related end points with 669 adult and 184 pediatric RCTs. Of those, 165 had sufficient data for ROR estimation. sRORs showed statistically significant discrepancy between adults and children only for headache (sROR 0.82; 95% confidence interval 0.70-0.96). Nominally significant discrepancies for specific harms were identified in 12 of 165 meta-analyses (RORs <1 in 7, ROR >1 in 5). In 36% of meta-analyses, the ROR estimates suggested twofold or greater differences between children and adults, and the 95% confidence intervals could exclude twofold differences only in 18% of meta-analyses. CONCLUSIONS Available evidence on harms/harm-related end points from pharmacologic interventions has large uncertainty. Extrapolation of evidence from adults to children may be tenuous. Some clinically important discrepancies were identified.
Collapse
Affiliation(s)
- Dimitrios Lathyris
- Intensive Care Unit, General Hospital G. Gennimatas, Thessaloniki, Greece
| | - Orestis A. Panagiotou
- Clinical Trials and Evidence-Based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Maria Baltogianni
- Neonatal Intensive Care Unit, University Hospital of Ioannina, Ioannina, Greece
| | - John P.A. Ioannidis
- Stanford Prevention Research Center, Department of Medicine,,Department of Health Research and Policy, and
| | - Despina G. Contopoulos-Ioannidis
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California; and,Palo Alto Medical Foundation Research Institute, Palo Alto, California,Address correspondence to Despina G. Contopoulos-Ioannidis, MD, Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, Room G312, 300 Pasteur Dr, Stanford, CA 94305. E-mail:
| |
Collapse
|
28
|
Silva D, Ansotegui I, Morais-Almeida M. Off-label prescribing for allergic diseases in children. World Allergy Organ J 2014; 7:4. [PMID: 24528848 PMCID: PMC3928583 DOI: 10.1186/1939-4551-7-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 01/22/2014] [Indexed: 01/10/2023] Open
Abstract
The majority of drugs prescribed have not been tested in children and safety and efficacy of children's medicines are frequently supported by low quality of evidence. Therefore, a large percentage of prescriptions for children in the clinical daily practice are used off label. Despite the several recent legislation and regulatory efforts performed worldwide, they have not been successful in increasing availability of medicines adapted to children. Moreover, if we consider that 30% of the prescribed drugs for children are for the respiratory field and only 4% of new investigation projects for children research were proposed to access drugs for respiratory and allergy treatment, there is a clear imbalance of the children needs in this therapeutic area. This narrative review aimed to describe and discuss the off-label use of medicines in the treatment and control of respiratory and allergic diseases in children. It was recognized that a large percentage of prescriptions performed for allergy treatment in daily clinical practice are off label. The clinicians struggle on a daily basis with the responsibility to balance risk-benefits of an off-label prescription while involving the patients and their families in this decision. It is crucial to increase awareness of this reality not only for the clinician, but also to the global organizations and competent authorities. New measures for surveillance of off-label use should be established, namely through population databases implementation. There is a need for new proposal to correct the inconsistency between the priorities for pediatric drug research, frequently dependent on commercial motivations, in order to comply to the true needs of the children, especially on the respiratory and allergy fields.
Collapse
Affiliation(s)
- Diana Silva
- Immunoallergology Department, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, 4200-309 Porto, Portugal
- Immunoallergology Department, CUF Descobertas Hospital, R. Mário Botas, 1998-018 Lisboa, Portugal
| | - Ignacio Ansotegui
- Department of Allergy and Immunology, Hospital Quirón Bizkaia, Carretera de Leioa-Unbe, 33 Bis., 48950 Erandio, Spain
| | - Mário Morais-Almeida
- Immunoallergology Department, CUF Descobertas Hospital, R. Mário Botas, 1998-018 Lisboa, Portugal
- Center for Research in Health Technologies and Information Systems, University of Porto, Porto, Portugal
| |
Collapse
|
29
|
Kern SE. Challenges in conducting clinical trials in children: approaches for improving performance. Expert Rev Clin Pharmacol 2014; 2:609-617. [PMID: 20228942 DOI: 10.1586/ecp.09.40] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Recent legislative changes in both Europe and the USA have increased the responsibility of drug developers to purposefully study the agents they market in children so that specific dosing recommendations can be made to assist clinicians in their use. Typically, clinicians use empiricalor experiential-based rationales for selecting the dose to use in children, generally in a manner that attempts to achieve the same dose-exposure or pharmacokinetic profile in children as in adults. However, whether this approach achieves the necessary dose exposure or exposure effect needed may not be systematically explored during off-label use. This creates the opportunity for under- or over-exposure in children, particularly in very young children (i.e., less than 2 years old) where a combination of factors during development can effect both pharmacokinetics and pharmacodynamics. The ethical, physiological and statistical differences of studying new therapeutic agents in children present economic challenges that may create unintended incentives - both positive and negative - for any individual developer who tries to meet the requirements of new legislation to study pharmaceutical agents in children. There should be a continued emphasis in academic clinical pharmacology programs towards creative methods and approaches to better understand these differences in children compared with adults. The ability to use information from knowledge obtained from adult studies, from preclinical studies, from studies of compounds with similar chemistry or pharmacology, or from known physiological differences between children and adults is essential to choosing a suitable dose for children and achieving these regulatory aims.
Collapse
Affiliation(s)
- Steven E Kern
- Associate Professor of Pharmaceutics and Pharmaceutical Chemistry, Adjunct Associate Professor of Pediatrics and Anesthesiology, Research Associate Professor of Bioengineering, University of Utah, Salt Lake City, UT, USA, Tel.: +1 801 585 5958, ,
| |
Collapse
|
30
|
Xavier AFC, Moura EFF, Azevedo WF, Vieira FF, Abreu MHNG, Cavalcanti AL. Erosive and cariogenicity potential of pediatric drugs: study of physicochemical parameters. BMC Oral Health 2013; 13:71. [PMID: 24325544 PMCID: PMC4029480 DOI: 10.1186/1472-6831-13-71] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 12/05/2013] [Indexed: 11/28/2022] Open
Abstract
Background Pediatric medications may possess a high erosive potential to dental tissues due to the existence of acid components in their formulations. The purpose was to determine the erosive and cariogenic potential of pediatric oral liquid medications through the analysis of their physicochemical properties in vitro. Methods A total of 59 substances were selected from the drug reference list of the National Health Surveillance Agency (ANVISA), which belong to 11 therapeutic classes, as follows: analgesics, non-steroidal anti-inflammatory, corticosteroids, antihistamines, antitussives, bronchodilators, antibacterials, antiparasitics, antiemetics, anticonvulsants and antipsychotics. Measurement of pH was performed by potentiometry, using a digital pH meter. For the Total Titratable Acidity (TTA) chemical assay, a 0.1 N NaOH standard solution was used, which was titrated until drug pH was neutralized. The Total Soluble Solids Contents (TSSC) quantification was carried out by refractometry using Brix scale and the analysis of Total Sugar Content was performed according to Fehling’s method. In addition, it was analyzed the information contained in the drug inserts with regard to the presence of sucrose and type of acid and sweetener added to the formulations. Results All drug classes showed acidic pH, and the lowest mean was found for antipsychotics (2.61 ± 0.08). There was a large variation in the TTA (0.1% - 1.18%) and SST (10.44% - 57.08%) values. High total sugar contents were identified in the antitussives (53.25%) and anticonvulsants (51.75%). As described in the drug inserts, sucrose was added in 47.5% of the formulations, as well as citric acid (39.0%), sodium saccharin (36.4%) and sorbitol (34.8%). Conclusion The drugs analyzed herein showed physicochemical characteristics indicative of a cariogenic and erosive potential on dental tissues. Competent bodies’ strategies should be implemented in order to broaden the knowledge of health professionals, drug manufacturers and general consuming public about the risks from the consumption of medicines potentially harmful to dental tissues.
Collapse
Affiliation(s)
- Alidianne Fábia C Xavier
- Department of Preventive Dentistry, School of Dentistry, State University of Paraiba, Avenida das Baraunas, S/N, Bodocongo, Campina Grande, PB 58109-970, Brazil.
| | | | | | | | | | | |
Collapse
|
31
|
Viergever RF. The mismatch between the health research and development (R&D) that is needed and the R&D that is undertaken: an overview of the problem, the causes, and solutions. Glob Health Action 2013; 6:22450. [PMID: 24119660 PMCID: PMC3796018 DOI: 10.3402/gha.v6i0.22450] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 09/10/2013] [Accepted: 09/16/2013] [Indexed: 01/21/2023] Open
Abstract
One of the most pressing global health problems is that there is a mismatch between the health research and development (R&D) that is needed and that which is undertaken. The dependence of health R&D on market incentives in the for-profit private sector and the lack of coordination by public and philanthropic funders on global R&D priorities have resulted in a global health R&D landscape that neglects certain products and populations and is characterised, more generally, by a distribution that is not 'needs-driven'. This article provides an overview of the mismatch, its causes, and solutions.
Collapse
Affiliation(s)
- Roderik F Viergever
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands; Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK;
| |
Collapse
|
32
|
Murthy S, Mandl KD, Bourgeois F. Analysis of pediatric clinical drug trials for neuropsychiatric conditions. Pediatrics 2013; 131:1125-31. [PMID: 23650305 PMCID: PMC4074660 DOI: 10.1542/peds.2012-2694] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Neuropsychiatric conditions represent a large and increasing disease burden in children. A number of drugs are available for the treatment of these conditions, but most drugs have not been adequately tested in children, and off-label drug use remains widespread. We sought to define and quantify recent and ongoing clinical research on the use of neuropsychiatric drugs in children. METHODS Drug trials registered in ClinicalTrials.gov between 2006 and 2011 and studying neuropsychiatric conditions were selected and classified based on the drug's Food and Drug Administration (FDA) approval status in children. We measured the proportion of trials seeking to expand the use of a drug to pediatric patients and the proportion of available drugs studied in children. RESULTS Only 10% of neuropsychiatric trials focused on children. Of 303 drugs studied in both pediatric and adult populations, 90% lacked FDA approval in children and 97% were not approved in children for the indication studied. However, only 19% of all neuropsychiatric drugs were under study in pediatric populations, with as few as 8% of either antidepressant or antipsychotic drugs. Overall, 76% of pediatric drug trials examined a drug previously unapproved in children and 26% explored the use of a drug for a new indication. CONCLUSIONS Despite the rising prevalence of neuropsychiatric disease and the paucity of FDA-approved pediatric drugs, only a small proportion of trials focus on pediatric populations and these trials cover only a fraction of available drugs. This deficiency is most pronounced for depression and schizophrenia.
Collapse
Affiliation(s)
- Srinivas Murthy
- Department of Critical Care, Hospital for Sick Children, Toronto, ON, Canada.
| | - Kenneth D. Mandl
- Division of Emergency Medicine, and,Children’s Hospital Informatics Program at the Harvard-MIT Division of Health Sciences and Technology, Boston Children’s Hospital, Boston, Massachusetts; and,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Florence Bourgeois
- Division of Emergency Medicine, and,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
33
|
How to improve the implementation of academic clinical pediatric trials involving drug therapy? A qualitative study of multiple stakeholders. PLoS One 2013; 8:e64516. [PMID: 23724056 PMCID: PMC3665797 DOI: 10.1371/journal.pone.0064516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 04/15/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The need for encouraging pediatric drug research is widely recognized. However, hospital-based clinical trials of drug treatments are extremely time-consuming, and delays in trial implementation are common. The objective of this qualitative study was to collect information on the perceptions and experience of health professionals involved in hospital-based pediatric drug trials. METHODS Two independent researchers conducted in-depth semi-structured interviews with principal investigators (n = 17), pharmacists (n = 7), sponsor representatives (n = 4), and drug regulatory agency representatives (n = 3) who participated in institutionally sponsored clinical trials of experimental drugs in pediatric patients between 2002 and 2008. RESULTS Dissatisfaction was reported by 67% (16/24) of principal investigators and pharmacists: all 7 pharmacists felt they were involved too late in the trial implementation process, whereas 11 (65%) principal investigators complained of an excessive regulatory burden and felt they were insufficiently involved in the basic research questions. Both groups perceived clinical trial implementation as burdensome and time-consuming. The sponsor and regulatory agency representatives reported a number of difficulties but were not dissatisfied. CONCLUSIONS The heavy burden related to regulatory requirements, and suboptimal communication across disciplines involved, seem to be the main reasons for the major delays in pediatric drug trial implementation. The pharmaceutical aspects are intrinsically tied to trial methodology and implementation and must therefore be examined, in particular by involving Clinical Research Pharmacists at early stages of study conception.
Collapse
|
34
|
Dickey M, Clark P. Changing the outcomes of pediatric drug trials: APNs making a difference. J Pediatr Health Care 2013; 27:222-5. [PMID: 23434364 DOI: 10.1016/j.pedhc.2013.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 01/21/2013] [Accepted: 01/21/2013] [Indexed: 11/25/2022]
Affiliation(s)
- Michelle Dickey
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | |
Collapse
|
35
|
Tramontina MY, Heineck I, Dos Santos L. Use of non-formulary drugs in children at a Brazilian teaching hospital: a descriptive study. Pharm Pract (Granada) 2013; 11:17-23. [PMID: 24155845 PMCID: PMC3780509 DOI: 10.4321/s1886-36552013000100004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 02/01/2013] [Indexed: 12/04/2022] Open
Abstract
Objective To characterise the prescription of non-formulary drugs to children and neonates at a Brazilian teaching hospital and identify adverse drug reactions (ADRs), drug interactions, and prescription of potentially hazardous medicines. Methods A prospective exploratory study was carried out between January and May 2011 at the general paediatric wards and paediatric oncology, paediatric intensive care, and neonatal care units of the study hospital. Non-formulary drugs were categorised as approved, off-label, or not approved for use in children according to Brazilian compendia. Electronic health records were actively searched for ADRs and the possibility of moderate to severe interactions between non-formulary drugs and other medicines was determined with the Micromedex® database. Results Overall, 109 children or neonates received non-formulary drugs. Of these drugs, 54% were approved for use in children, 12.2% were used off-label, and 33.8% were not approved for use in children. Non-formulary drugs accounted for 13.4% of total prescriptions; 5.3% of drugs had a potential for interactions and five were possibly associated with ADRs. Conclusions Prescription of non-formulary drugs not approved for use in children was common at the study hospital. Studies such as this provide information on the use of medicines for special indications and permit assessment of the relevance of hospital formularies for the paediatric population.
Collapse
Affiliation(s)
- Mariana Y Tramontina
- Universidade Federal do Rio Grande do Sul; and Clinical Pharmacy Service, Hospital de Clínicas de Porto Alegre - HCPA. Porto Alegre (Brazil)
| | | | | |
Collapse
|
36
|
Modi N, Clark H, Wolfe I, Costello A, Budge H, Goodier R, Hyde MJ, Lumsden D, Prayle A, Roland D. A healthy nation: strengthening child health research in the UK. Lancet 2013. [PMID: 23176802 DOI: 10.1016/s0140-6736(12)61818-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Despite a general acknowledgment that research in children is necessary and ethical, the evidence base for child-specific treatments is still sparse. We investigated children's biomedical and health services research in the UK in relation to training, infrastructure and activity, research evidence, and visibility. We show that excellent opportunities for career researchers exist through a competitive, national integrated academic training programme, but that the number of academic paediatricians has decreased by 18% between 2000 and 2011, falling from 11·3% to 5·9% of the consultant workforce. The potential for rapid delivery of studies in children through the National Health Service (NHS) is not being realised: clinical trainees are poorly equipped with core research skills; most newly appointed consultant paediatricians have little or no research experience; less than 5% of contracted consultant time supports research; less than 2·5% of the 2 million children seen in the NHS every year are recruited to studies; and ten of the 20 UK children's hospitals do not have a clinical research facility. Support through National Institute for Health Research networks is good for studies into drugs, but inconsistent for non-drug research; less than 5% of registered studies involve children and only one children's biomedical research centre has been allocated funding from 2012. Of the UK annual public and charitable biomedical research expenditure of roughly £2·2 billion, about 5% is directed at child health research. The scant evidence base is impeding the development of clinical guidance and policy-less than 20% of the outputs of the National Institute for Health and Clinical Excellence are applicable to children. Paediatric representation on major research boards is weak. Parent and young people's advocacy is fragmented, and their views are insufficiently heeded by regulatory bodies. The strong UK Government commitment to biomedical research has not been translated fully to research for children. The power of research in children to turn the tide of the growing burden of non-communicable, chronic, adult diseases that have their origins in early life, to benefit the health of an ageing population and future generations, and to reduce health-care costs is inadequately recognised. On the basis of our findings, we make several recommendations to improve early-years research, including the formation of multidisciplinary, cross-institutional groups of clinical and non-clinical child health researchers and their access to diagnostic and laboratory facilities suitable for children; a unified Children's Research Network for drug studies and non-drug studies; regulatory assessment of research that is proportionate and based on consistent national criteria; an expansion of research posts; support for parents' and young people's advocacy; collaboration between children's research charities; improved research training for paediatric trainees; and closer integration of child health research with core NHS activities.
Collapse
Affiliation(s)
- Neena Modi
- Imperial College London, Chelsea and Westminster Hospital, London, UK.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Pasquali SK, Lam WK, Chiswell K, Kemper AR, Li JS. Status of the pediatric clinical trials enterprise: an analysis of the US ClinicalTrials.gov registry. Pediatrics 2012; 130:e1269-77. [PMID: 23027172 PMCID: PMC4074644 DOI: 10.1542/peds.2011-3565] [Citation(s) in RCA: 71] [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 AND OBJECTIVES Clinical trials are the gold standard for generating evidence-based knowledge in medicine. Recent legislation requiring trials to be registered at ClinicalTrials.gov has enabled evaluation of the clinical trial enterprise as a whole, which was previously not possible. The purpose of this study was to create a snapshot of the pediatric clinical trial portfolio. METHODS All interventional trials registered at ClinicalTrials.gov from July 2005 to September 2010 were included. Pediatric (ie, enrolling patients aged 0-18 years) trial characteristics, therapeutic area, location, and funding were described. Secondary objectives included describing pediatric trials over time and comparison with nonpediatric trials. RESULTS During this time, 5035 pediatric trials were registered compared with >10 times as many nonpediatric trials. Neonates/infants were eligible for enrollment in 46.6% of trials versus children (77.9%) and adolescents (45.2%). Nearly one-half of pediatric trials enrolled <100 subjects, and more pediatric trials versus nonpediatric trials evaluated preventive therapies. The proportion of pediatric trials evaluating a drug intervention declined over time, and there were fewer Phase 0 to II versus Phase III to IV trials. Infectious disease/vaccine studies (23%) were the most common, followed by psychiatric/mental health (13%) studies. Many trials enrolled patients outside the United States, and <15% of trials were sponsored by the National Institutes of Health or other US federal agencies. CONCLUSIONS Analysis of the ClinicalTrials.gov data set allows description of the current scope of pediatric trials. These data may be useful to stakeholders in informing decisions regarding the conduct of trials in children and provide insight into mechanisms to advance pediatric trial infrastructure and methodology toward improving child health.
Collapse
Affiliation(s)
- Sara K. Pasquali
- Department of Pediatrics, Duke University School of Medicine,,Duke Clinical Research Institute, and
| | - Wendy K. Lam
- Duke Translational Medicine Institute, Duke University Medical Center, Durham, North Carolina
| | | | - Alex R. Kemper
- Department of Pediatrics, Duke University School of Medicine,,Duke Clinical Research Institute, and
| | - Jennifer S. Li
- Department of Pediatrics, Duke University School of Medicine,,Duke Clinical Research Institute, and
| |
Collapse
|
38
|
Methods in pharmacoepidemiology: a review of statistical analyses and data reporting in pediatric drug utilization studies. Eur J Clin Pharmacol 2012; 69:599-604. [PMID: 22832725 DOI: 10.1007/s00228-012-1354-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 07/10/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To evaluate the quality of data reporting and statistical methods performed in drug utilization studies in the pediatric population. METHODS Drug utilization studies evaluating all drug prescriptions to children and adolescents published between January 1994 and December 2011 were retrieved and analyzed. For each study, information on measures of exposure/consumption, the covariates considered, descriptive and inferential analyses, statistical tests, and methods of data reporting was extracted. An overall quality score was created for each study using a 12-item checklist that took into account the presence of outcome measures, covariates of measures, descriptive measures, statistical tests, and graphical representation. RESULTS A total of 22 studies were reviewed and analyzed. Of these, 20 studies reported at least one descriptive measure. The mean was the most commonly used measure (18 studies), but only five of these also reported the standard deviation. Statistical analyses were performed in 12 studies, with the chi-square test being the most commonly performed test. Graphs were presented in 14 papers. Sixteen papers reported the number of drug prescriptions and/or packages, and ten reported the prevalence of the drug prescription. The mean quality score was 8 (median 9). Only seven of the 22 studies received a score of ≥10, while four studies received a score of <6. CONCLUSIONS Our findings document that only a few of the studies reviewed applied statistical methods and reported data in a satisfactory manner. We therefore conclude that the methodology of drug utilization studies needs to be improved.
Collapse
|
39
|
Needle MN. A proposed modification to the Best Pharmaceuticals for Children Act to benefit pediatric oncology. Pediatr Blood Cancer 2012; 59:3-4. [PMID: 22378597 DOI: 10.1002/pbc.24115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/31/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Michael N Needle
- Columbia University Medical Center, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, New York 10032, USA.
| |
Collapse
|
40
|
Dos Santos L, Heineck I. Drug utilization study in pediatric prescriptions of a university hospital in southern brazil: off-label, unlicensed and high-alert medications. FARMACIA HOSPITALARIA 2012; 36:180-6. [DOI: 10.1016/j.farma.2010.12.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 12/23/2010] [Accepted: 12/29/2010] [Indexed: 11/25/2022] Open
|
41
|
van Riet-Nales DA, de Jager KE, Schobben AFAM, Egberts TCG, Rademaker CMA. The availability and age-appropriateness of medicines authorized for children in The Netherlands. Br J Clin Pharmacol 2011; 72:465-73. [PMID: 21477143 DOI: 10.1111/j.1365-2125.2011.03982.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIM To study the number of medicines and active chemical entities that are authorized and commercially available for children in the Netherlands and to evaluate the age-appropriateness of the available paediatric medicines. METHODS The availability of paediatric medicines and active chemical entities was studied with the help of a Dutch medicines database and the Summary of Product Characteristics. Medicines were categorized with respect to their route of administration, type of oral dosage form and therapeutic category. The age-appropriateness was assessed on three aspects: dose capability, suitability of the dosage form and inclusion of potentially harmful excipients. RESULTS Three thousand five hundred and forty-two paediatric medicines containing 703 different active chemical entities were identified. This equalled half of all the medicines and chemical entities available for human use. The percentage of paediatric medicines increased with age and varied for the route of administration from 22% (dermal) to 81% (inhalation) and for the therapeutic category from 11% (uro-genital, sex hormones) to 89% (anti-parasites). The appropriateness of the paediatric medicines with respect to their authorization status, dose capability and dosage form increased with age from 27-88%. Fifty-two percent of all oral paediatric liquid formulations contained a potentially harmful excipient. CONCLUSION This study confirms the limited availability of paediatric medicines for a broad range of therapeutic areas and shows that paediatric medicines may not be age-appropriate, even if authorized. While confirming the need for a legislative incentive, the results also provide baseline information for an estimation of the effect of the European Paediatric Regulation in the near future.
Collapse
Affiliation(s)
- Diana A van Riet-Nales
- National Institute for Public Health and the Environment, Centre for Quality of Chemical Pharmaceutical Products, Bilthoven, The Netherlands.
| | | | | | | | | |
Collapse
|
42
|
Kesselheim AS. An empirical review of major legislation affecting drug development: past experiences, effects, and unintended consequences. Milbank Q 2011; 89:450-502. [PMID: 21933276 PMCID: PMC3214718 DOI: 10.1111/j.1468-0009.2011.00636.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
CONTEXT With the development of transformative drugs at a low point, numerous commentators have recommended new legislation that uses supplementary market exclusivity as an incentive to promote innovation in the pharmaceutical market. METHODS This report provides an historical perspective on proposals for encouraging drug research. Four legislative programs have been primarily designed to offer market exclusivity to promote public health goals in the pharmaceutical or biomedical sciences: the Bayh-Dole Act of 1980, the Orphan Drug Act of 1983, the Hatch-Waxman Act of 1984, and the pediatric exclusivity provisions of the FDA Modernization Act of 1997. I reviewed quantitative and qualitative studies that reported on the outcomes from these programs and evaluated the quality of evidence generated. FINDINGS All four legislative programs generally have been regarded as successful, although such conclusions are largely based on straightforward descriptive reports rather than on more rigorous comparative data or analyses that sufficiently account for confounding. Overall, solid data demonstrate that market exclusivity incentives can attract interest from parties involved in drug development. However, using market exclusivity to promote innovation in the pharmaceutical market can be prone to misuse, leading to improper gains. In addition, important collateral effects have emerged with substantial negative public health implications. CONCLUSIONS Using market exclusivity to promote pharmaceutical innovation can lead to positive outcomes, but the practice is also characterized by waste and collateral effects. Certain practices, such as mechanisms for reevaluation and closer ties of incentives programs to public health outcomes, can help address these problems.
Collapse
Affiliation(s)
- Aaron S Kesselheim
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA.
| |
Collapse
|
43
|
Viergever RF, Rademaker CMA, Ghersi D. Pharmacokinetic research in children: an analysis of registered records of clinical trials. BMJ Open 2011; 1:e000221. [PMID: 22021789 PMCID: PMC3191584 DOI: 10.1136/bmjopen-2011-000221] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Reported off-label/unlicensed prescribing rates in children range from 11% to 80%. Research into pharmacokinetic profiles of children's medicines is essential in the creation of more knowledge on the safety and efficacy of medicines in children. This study investigated how often pharmacokinetic data are collected in clinical trials of medicines in children by analysing registered records of clinical trials. METHODS The registered records of all clinical trials in children that were recruiting on 22 May 2009 were identified on the International Clinical Trials Registry Platform using a Clinical Trials in Children search filter. The records of trials in children below 12 years of age, in which the intervention was one or more medicines, were assessed for evidence that pharmacokinetic data would be collected. RESULTS Of 1081 eligible trial records, 257 (24%) declared that pharmacokinetic data would be collected. Of these trials, 199 (77%) recruited in Northern America; recruitment in all other regions was below 20%. Trials recruited most often in children over 2 years of age (74%), and least often in newborn infants (32%). Most trials researched medicines in the field of cancer (29%). Trials investigated one-third of the medicines that were indicated as a priority for pharmacokinetic research by the European Medicines Agency. CONCLUSIONS There is a need for increased knowledge of the pharmacokinetic profiles of children's medicines. The amount of currently ongoing pharmacokinetic research does not seem to address adequately the lack of knowledge in this area. This study sets a baseline for monitoring of future progress on the amount of ongoing pharmacokinetic research in children.
Collapse
Affiliation(s)
- Roderik F Viergever
- International Clinical Trials Registry Platform, Department of Research Policy and Cooperation, World Health Organization, Geneva, Switzerland.
| | | | | |
Collapse
|
44
|
Hoppu K, Anabwani G, Garcia-Bournissen F, Gazarian M, Kearns GL, Nakamura H, Peterson RG, Sri Ranganathan S, de Wildt SN. The status of paediatric medicines initiatives around the world--What has happened and what has not? Eur J Clin Pharmacol 2011; 68:1-10. [PMID: 21732178 DOI: 10.1007/s00228-011-1089-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 06/09/2011] [Indexed: 01/07/2023]
Abstract
PURPOSE This review was conducted to examine the current status of paediatric medicines initiatives across the globe. METHODS The authors made a non-systematic descriptive review of current world situation. RESULTS Two regions, the United States (US) and the European Union (EU), and the World Health Organization (WHO) have introduced strong paediatric initiatives to improve children's health through improving access to better paediatric medicines. The experience from the US initiative indicates that it is possible to stimulate development and study of paediatric medicines and provide important new information for improvement of paediatric therapy. The early results from the EU initiative are similarly encouraging. In Canada, Japan, Australia and other developed countries, specific paediatric medicines initiatives have been less extensive and weaker, with modest results. Disappointingly, current evidence suggests that results from clinical trials outside the US often do not benefit children in the country in which the trials were largely conducted. Pharmaceutical companies that have derived a financial benefit commensurate with the cost of doing the paediatric trials in one country do not seem to be making the results of these trials available to all countries if there is no financial incentive to the company. The WHO campaign 'make medicines child size' has produced substantive accomplishments in building improved foundations to improve mechanisms that will enhance children's access to critical medicines in resource-limited settings. However, practically all of this work has been performed using an amalgamation of short-term funding from a variety of sources as opposed to a sustained, programmatic commitment. CONCLUSIONS Although much still needs to be done, it's clear that with concerted efforts and appropriate resources, change is possible but slow. Retaining and fostering public and political interest in paediatric medicines is challenging, but pivotal for success.
Collapse
Affiliation(s)
- Kalle Hoppu
- Hospital for Children and Adolescents and Dept. of Clinical Pharmacology, University of Helsinki and Poison Information Centre, Helsinki University Central Hospital, P.O. Box 790, 00029, Helsinki, Finland.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Westra AE, Wit JM, Sukhai RN, de Beaufort ID. Regulating "higher risk, no direct benefit" studies in minors. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2011; 11:29-31. [PMID: 21678214 DOI: 10.1080/15265161.2011.566669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Anna E Westra
- Department of Pediatrics, Leiden University Medical Center, PO Box 9600 2300, RC, Leiden, The Netherlands.
| | | | | | | |
Collapse
|
46
|
Kemper EM, Merkus M, Wierenga PC, Van Rijn PC, Van der Werff D, Lie-A-Huen L, Offringa M. Towards evidence-based pharmacotherapy in children. Paediatr Anaesth 2011; 21:183-9. [PMID: 21199133 DOI: 10.1111/j.1460-9592.2010.03493.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In daily practice, it is difficult to find a registered drug for children, because about 70% of the drugs prescribed in children are not studied, off-label or unlicensed in this age group. Clinical trials have usually been performed in adults, and then in daily practice dosages are adjusted for children without proper studies in that age group. In some countries, national formularies are being established to overcome the existing variance in prescribing between physicians. Complicating factors in finding the correct dosage for children include the heterogeneity between different age groups in the developmental stages of the organs influencing the absorption, distribution, metabolism, and excretion as well as differences in body composition during growth. Growth may also influence the effects and adverse effects of a drug used in a child. For oral administration of drugs in children, the bioavailability, the taste, the composition, and the absence of toxic ingredients for that age group are additional important factors. The EU has recently introduced legislation to stimulate the pharmaceutical industry to investigate the pharmacological effect and safety of new medicines in children. In response to this legislation, research networks are being established to provide the optimal infrastructure for pediatric drug investigation. The goals of this paper are to review the current problems in daily practice and to address the needs for evidence based pharmacotherapy in children.
Collapse
Affiliation(s)
- Elles Marleen Kemper
- Department of Pharmacy, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
47
|
Antiparasitic drugs for paediatrics: systematic review, formulations, pharmacokinetics, safety, efficacy and implications for control. Parasitology 2011; 138:1620-32. [PMID: 21349223 DOI: 10.1017/s0031182011000023] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Drug development for paediatric applications entails a number of challenges, such as the wide age spectrum covered - from birth to adolescence - and developmental changes in physiology during biological maturation that influence the efficacy and toxicity of drugs. Safe and efficacious antiparasitic drugs for children are of pivotal importance given the large proportion of burden attributable to parasitic diseases in this age group, and growing efforts to administer, as widely as possible, antiparasitic drugs to at-risk populations, such as infants and school-aged children, often without prior diagnosis. The purpose of this review is to investigate whether antiparasitic drugs have been adequately studied for use in paediatrics. We approached this issue through a systematic review using PubMed and the Cochrane Central Register of Trials covering a period of 10 years and 8 months until the end of August 2010 to identify trials that investigated efficacy, safety and pharmacokinetic (PK) parameters of antiparasitic drugs for paediatrics. Overall, 269 clinical drug trials and 17 PK studies met our inclusion criteria. Antimalarial drugs were the most commonly studied medicines (82·6%). Most trials were carried out in Africa and children aged 2-11 years were the age group most often investigated. Additionally, we critically examined available drug formulations for anthelminthics and identified a number of shortcomings that are discussed. Finally, we shed new light on current proposals to expand 'preventive chemotherapy' to preschool-aged children and emphasise that new research, including risk-benefit analyses, are needed before such a strategy can be adopted more widely.
Collapse
|
48
|
Knellwolf AL, Bauzon S, Alberighi ODC, Lutsar I, Bácsy E, Alfarez D, Panei P. Framework conditions facilitating paediatric clinical research. Ital J Pediatr 2011; 37:12. [PMID: 21345195 PMCID: PMC3055809 DOI: 10.1186/1824-7288-37-12] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 02/23/2011] [Indexed: 12/05/2022] Open
Abstract
The use of unlicensed and "off-label" medicines in children is widespread. Between 50-80% of the medicines currently administered to children have neither been tested nor authorized for their use in the paediatric population which represents approximately 25% of the whole European population. On 26 January 2007, entered into force the European Regulation of Paediatric Medicines. It aims at the quality of research into medicines for children but without subjecting the paediatric population to unnecessary clinical trial. This article addresses ethical and legal issues arising from the regulation and makes recommendations for the framework conditions facilitating the development of clinical research with children.
Collapse
Affiliation(s)
- Anne-Laure Knellwolf
- Dept. of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Stéphane Bauzon
- Storia e Teoria del Diritto, Facoltà di Giurisprudenza, University of Rome "Tor Vergata", Rome, Italy
| | | | - Irja Lutsar
- Dept. of Microbiolgoy, University of Tartu, Tartu, Estonia
| | - Ernö Bácsy
- Medical Research Council of Hungary, Budapest, Hungary
| | - Deborah Alfarez
- ERA-NET Priority Medicines for Children Coordination, The Netherlands Organization for Health Research and Development, The Hague, The Netherlands
| | - Pietro Panei
- Dept. of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| |
Collapse
|
49
|
Lai WW, Vetter VL, Richmond M, Li JS, Saul JP, Mital S, Colan SD, Newburger JW, Sleeper LA, McCrindle BW, Minich LL, Goldmuntz E, Marino BS, Williams IA, Pearson GD, Evans F, Scott JD, Cohen MS. Clinical research careers: reports from a NHLBI pediatric heart network clinical research skills development conference. Am Heart J 2011; 161:13-67. [PMID: 21167335 DOI: 10.1016/j.ahj.2010.08.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Wyman W. Lai, MD, MPH, and Victoria L. Vetter, MD, MPH. The Pediatric Heart Network (PHN), funded under the U.S. National Institutes of Health-National Heart, Lung, and Blood Institute (NIH-NHLBI), includes two Clinical Research Skills Development (CRSD) Cores, which were awarded to The Children's Hospital of Philadelphia and to the Morgan Stanley Children's Hospital of New York-Presbyterian. To provide information on how to develop a clinical research career to a larger number of potential young investigators in pediatric cardiology, the directors of these two CRSD Cores jointly organized a one-day seminar for fellows and junior faculty from all of the PHN Core sites. The participants included faculty members from the PHN and the NHLBI. The day-long seminar was held on April 29, 2009, at the NHLBI site, immediately preceding the PHN Steering Committee meeting in Bethesda, MD. METHODS the goals of the seminar were 1) to provide fellows and early investigators with basic skills in clinical research 2) to provide a forum for discussion of important research career choices 3) to introduce attendees to each other and to established clinical researchers in pediatric cardiology, and 4) to publish a commentary on the future of clinical research in pediatric cardiology. RESULTS the following chapters are compilations of the talks given at the 2009 PHN Clinical Research Skills Development Seminar, published to share the information provided with a broader audience of those interested in learning how to develop a clinical research career in pediatric cardiology. The discussions of types of clinical research, research skills, career development strategies, funding, and career management are applicable to research careers in other areas of clinical medicine as well. CONCLUSIONS the aim of this compilation is to stimulate those who might be interested in the research career options available to investigators.
Collapse
Affiliation(s)
- Wyman W Lai
- Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Affiliation(s)
- Aaron S Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, USA.
| |
Collapse
|