1
|
Mathevula H, Schellack N, Orubu S, Godman B, Matlala M. Off-Label and Unlicenced Medicine Use among Hospitalised Children in South Africa: Practice and Policy Implications. PHARMACY 2023; 11:174. [PMID: 37987384 PMCID: PMC10661306 DOI: 10.3390/pharmacy11060174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/25/2023] [Accepted: 11/05/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Information regarding off-label and unlicensed medicine use among South African children is limited. This is a concern as the prescribing of off-label and unlicensed medicines can lead to issues of effectiveness and safety as well as raise liability issues in the event of adverse events. This potentially exposes physicians to legal penalties. Consequently, we sought to determine the prevalence of off-label and unlicensed medicine use among paediatric patients in South Africa to provide future direction. METHODS This study retrospectively examined the use of medicine in a point-prevalence survey study (PPS) involving paediatric patients aged (0-2 years) admitted to selected public hospitals in Gauteng Province, South Africa. Data were collected per hospital over two days between February 2022 and July 2022. Demographics, duration of treatment, diagnosis, and medicines prescribed were collected from patient medical records using a mobile application. Prescribed medicines were reviewed against the medicine formularies and other databases to assess their appropriateness. RESULTS From three academic hospitals, 184 patient records were reviewed. A total of 592 medicines were dispensed, of which 379 (64.0%) were licensed and 213 (36.0%) were used off-label/unlicensed for paediatric patients 0-2 years of age. The most prevalent off-label and unlicensed medicines were multivitamins (n = 32, 15.0%) and ampicillin injections (n = 15, 7.0%). CONCLUSION The frequency of unlicensed and off-label medicine prescribing shown in this study is consistent with the literature and can be considered high. This practice can pose a risk because it adversely affects patients if not properly regulated. Attention is needed to ensure future high-quality, safe, and effective use of medicines.
Collapse
Affiliation(s)
- Hlayiseka Mathevula
- School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria 0204, South Africa; (B.G.); (M.M.)
| | - Natalie Schellack
- Department of Pharmacology, University of Pretoria, Pretoria 0084, South Africa;
| | - Samuel Orubu
- Pharmacy Department, Niger Delta University, Yenagoa P.O. BOX 72, Nigeria;
- Global Strategy Lab, York University, Toronto, ON 4700, Canada
| | - Brian Godman
- School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria 0204, South Africa; (B.G.); (M.M.)
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Science (SIPBS), University of Strathclyde, Glasgow G4 0RE, UK
| | - Moliehi Matlala
- School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria 0204, South Africa; (B.G.); (M.M.)
| |
Collapse
|
2
|
Scholefield BR, Menzies JC, McAnuff J, Thompson JY, Manning JC, Feltbower RG, Geary M, Lockley S, Morris KP, Moore D, Pathan N, Kirkham F, Forsyth R, Rapley T. Implementing early rehabilitation and mobilisation for children in UK paediatric intensive care units: the PERMIT feasibility study. Health Technol Assess 2023; 27:1-155. [PMID: 38063184 PMCID: PMC11017141 DOI: 10.3310/hyrw5688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
Background Early rehabilitation and mobilisation encompass patient-tailored interventions, delivered within intensive care, but there are few studies in children and young people within paediatric intensive care units. Objectives To explore how healthcare professionals currently practise early rehabilitation and mobilisation using qualitative and quantitative approaches; co-design the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual of early rehabilitation and mobilisation interventions, with primary and secondary patient-centred outcomes; explore feasibility and acceptability of implementing the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual within three paediatric intensive care units. Design Mixed-methods feasibility with five interlinked studies (scoping review, survey, observational study, codesign workshops, feasibility study) in three phases. Setting United Kingdom paediatric intensive care units. Participants Children and young people aged 0-16 years remaining within paediatric intensive care on day 3, their parents/guardians and healthcare professionals. Interventions In Phase 3, unit-wide implementation of manualised early rehabilitation and mobilisation. Main outcome measures Phase 1 observational study: prevalence of any early rehabilitation and mobilisation on day 3. Phase 3 feasibility study: acceptability of early rehabilitation and mobilisation intervention; adverse events; acceptability of study design; acceptability of outcome measures. Data sources Searched Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PEDro, Open grey and Cochrane CENTRAL databases. Review methods Narrative synthesis. Results In the scoping review we identified 36 full-text reports evaluating rehabilitation initiated within 7 days of paediatric intensive care unit admission, outlining non-mobility and mobility early rehabilitation and mobilisation interventions from 24 to 72 hours and delivered twice daily. With the survey, 124/191 (65%) responded from 26/29 (90%) United Kingdom paediatric intensive care units; the majority considered early rehabilitation and mobilisation a priority. The observational study followed 169 patients from 15 units; prevalence of any early rehabilitation and mobilisation on day 3 was 95.3%. We then developed a manualised early rehabilitation and mobilisation intervention informed by current evidence, experience and theory. All three sites implemented the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual successfully, recruited to target (30 patients recruited) and followed up the patients until day 30 or discharge; 21/30 parents consented to complete additional outcome measures. Limitations The findings represent the views of National Health Service staff but may not be generalisable. We were unable to conduct workshops and interviews with children, young people and parents to support the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual development due to pandemic restrictions. Conclusions A randomised controlled trial is recommended to assess the effectiveness of the manualised early rehabilitation and mobilisation intervention. Future work A definitive cluster randomised trial of early rehabilitation and mobilisation in paediatric intensive care requires selection of outcome measure and health economic evaluation. Study registration The study is registered as PROSPERO CRD42019151050. The Phase 1 observational study is registered Clinicaltrials.gov NCT04110938 (Phase 1) (registered 1 October 2019) and the Phase 3 feasibility study is registered NCT04909762 (Phase 3) (registered 2 June 2021). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/21/06) and is published in full in Health Technology Assessment; Vol. 27, No. 27. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Barnaby R Scholefield
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Paediatric Intensive Care, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Julie C Menzies
- Paediatric Intensive Care, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Jennifer McAnuff
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle, UK
| | - Jacqueline Y Thompson
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Joseph C Manning
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Children and Young People Health Research, School of Health Sciences, The University of Nottingham, Nottingham, UK
| | - Richard G Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, UK
| | - Michelle Geary
- Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sophie Lockley
- PPIE Representative, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Kevin P Morris
- Paediatric Intensive Care, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - David Moore
- Institute of Applied Health, University of Birmingham, Birmingham, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Fenella Kirkham
- Child Health, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Robert Forsyth
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Tim Rapley
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle, UK
| |
Collapse
|
3
|
Abstract
Deferred consent has gained traction in some countries as a possible adjunct to prospective consent for evaluating emergency therapies in the neonatal population. This form of consent has been shown to increase recruitment of acutely and critically unwell patients, potentially reduce parent decision-making burden, and provide more robust evidence for clinical treatments where equipoise exists. However, deferred consent raises complex ethical concerns and guidelines for its use vary across different jurisdictions. The views of all stakeholders, including neonatal providers and parents, are important in determining the appropriateness of deferred consent in high-risk patients. Deferred consent may be ethically justifiable for assessing various treatments, particularly those used in emergency medical management. We present a framework based on neonatal deferred consent trials that assess both non-drug and drug interventions, our experience conducting deferred consent neonatal studies in Australia, and the views of providers and parents on how to best implement deferred consent in the neonatal research setting.
Collapse
|
4
|
Kleiber N, Gariépy-Assal L, Coulombe J, Marcoux S, Essouri S, McCuaig C, Powell J, Soulez G, Dubois J. Off-Label Use and Safety of Drug Use in Vascular Anomalies. Dermatology 2021; 237:649-657. [PMID: 33823514 DOI: 10.1159/000515980] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Off-label drug use is associated with an increased risk of adverse drug reactions. It is common in pediatrics and in rare diseases, which are two characteristics applying to vascular anomalies (VA). OBJECTIVES The aim of this work was to quantify off-label drug use in VA and assess its safety. METHODS A review was conducted to extract a list of drugs used in VA management. A drug was considered to have significant safety concerns if a black box warning was present or if a serious adverse drug reaction (SADR) was reported in at least 1% of the patients (SADR is defined as a noxious and unintended response to a drug that occurs at any dose and results in hospitalization, prolongation of existing hospitalization, congenital malformation, persistent or significant disability or incapacity, life-threatening condition, or death). The labelling status and safety of each drug was assessed based on the product monograph, Micromedex, and the FDA data. RESULTS We found that 98.9% of the inventoried drugs were used off-label or unlicensed for VA management. Only the oral solution of propranolol hydrochloride (Hemangeol®) for the treatment of infantile hemangiomas is approved. Significant safety issues concerned 73% of the drugs and were more frequent among systemic than locally delivered drugs. CONCLUSIONS Off-label drug use in VA is the rule and not the exception. Significant safety concerns are common. It is necessary to carefully weigh risk and benefits for every patient when using systemic and local treatments carrying safety concerns. Patients should be openly informed and involved in the decision-making process.
Collapse
Affiliation(s)
- Niina Kleiber
- Department of Pharmacology and Physiology, Université de Montréal, Montreal, Québec, Canada.,Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada.,Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada.,Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada.,Clinical Pharmacology Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Laurence Gariépy-Assal
- Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Jérôme Coulombe
- Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada.,Division of Dermatology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Simon Marcoux
- Clinical Pharmacology Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada.,Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Sandrine Essouri
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada.,Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada.,Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Catherine McCuaig
- Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada.,Division of Dermatology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Julie Powell
- Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada.,Division of Dermatology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Gilles Soulez
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Québec, Canada
| | - Josée Dubois
- Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada.,Department of Radiology, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada
| |
Collapse
|
5
|
An evidence-based review of the use of vasoactive and inotropic medications in post-operative paediatric patients after cardiac surgery with cardiopulmonary bypass from 2000 to 2020. Cardiol Young 2020; 30:1757-1771. [PMID: 33213604 DOI: 10.1017/s1047951120004151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Infants with moderate-to-severe CHD frequently undergo cardiopulmonary bypass surgery in childhood. Morbidity and mortality are highest in those who develop post-operative low cardiac output syndrome. Vasoactive and inotropic medications are mainstays of treatment for these children, despite limited evidence supporting their use. METHODS To help inform clinical practice, as well as the conduct of future trials, we performed a systematic review of existing literature on inotropes and vasoactives in children after cardiac surgery using the PubMed and EMBASE databases. We included studies from 2000 to 2020, and the patient population was defined as birth - 18 years of age. Two reviewers independently reviewed studies to determine final eligibility. RESULTS The final analysis included 37 papers. Collectively, selected studies reported on 12 different vasoactive and inotropic medications in 2856 children. Overall evidence supporting the use of these drugs in children after cardiopulmonary bypass was limited. The majority of studies were small with 30/37 (81%) enrolling less than 100 patients, 29/37 (78%) were not randomised, and safety and efficacy endpoints differed widely, limiting the ability to combine data for meta-analyses. CONCLUSION Vasoactive and inotropic support remain critical parts of post-operative care for children after cardiopulmonary bypass surgery. There is a paucity of data for the selection and dosing of vasoactives and inotropes for these patients. Despite the knowledge gaps that remain, numerous recent innovations create opportunities to rethink the conduct of clinical trials in this high-risk population.
Collapse
|
6
|
Drug Utilisation and Off-Label Use on a German Neonatal Intensive Care Unit: A Retrospective Cohort Study and 10-Year Comparison. PHARMACY 2020; 8:pharmacy8030173. [PMID: 32957455 PMCID: PMC7559028 DOI: 10.3390/pharmacy8030173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/17/2022] Open
Abstract
Pharmacotherapy of neonates is complex and marked to a large extent of off-label use. The implementation of the Paediatric Regulation (2007) gave hope for a change in the safety and efficacy for drugs used in neonatal intensive care units (NICU). This study investigates drug utilisation patterns and off-label use in a German neonatal intensive care unit (NICU) in 2014. A 12-months retrospective, observational cohort study was performed at the NICU of the University Children's Hospital Erlangen, Germany. Licensing status was determined using the Summary of Product Characteristics (SmPC). Results are compared with a similar study conducted 10 years earlier. The study included 204 patients (57.8% male) (2004: 183) and 2274 drug prescriptions were recorded (2004: 1978). The drugs that were mostly prescribed were drugs for the nervous system (2004: 22.6%; 2014: 26.9%) and anti-infectives for systemic use (2004: 26.0%; 2014: 24.9%);34.3% (2004) and 39.2% (2014) of all prescriptions were off-label;62.7% of all patients received at least one off-label or unlicensed drug (2004: 70%). For 13 drugs, the licensing status changed either from off-label to label (n = 9) or vice versa (n = 4). Overall, there was no significant change neither in terms of the drugs used nor regarding their licensing status. Further studies are needed to validate these findings in a European context.
Collapse
|
7
|
Enteral Acetaminophen Bioavailability in Pediatric Intensive Care Patients Determined With an Oral Microtracer and Pharmacokinetic Modeling to Optimize Dosing. Crit Care Med 2020; 47:e975-e983. [PMID: 31609773 DOI: 10.1097/ccm.0000000000004032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Decreasing morbidity and mortality by rationalizing drug treatment in the critically ill is of paramount importance but challenging as the underlying clinical condition may lead to large variation in drug disposition and response. New microtracer methodology is now available to gain knowledge on drug disposition in the intensive care. On the basis of studies in healthy adults, physicians tend to assume that oral doses of acetaminophen will be completely absorbed and therefore prescribe the same dose per kilogram for oral and IV administration. As the oral bioavailability of acetaminophen in critically ill children is unknown, we designed a microtracer study to shed a light on this issue. DESIGN An innovative microtracer study design with population pharmacokinetics. SETTING A tertiary referral PICU. PATIENTS Stable critically ill children, 0-6 years old, and already receiving IV acetaminophen. INTERVENTIONS Concomitant administration of an oral C radiolabeled acetaminophen microtracer (3 ng/kg) with IV acetaminophen treatment (15 mg/kg every 6 hr). MEASUREMENTS Blood was drawn from an indwelling arterial or central venous catheter up to 24 hours after C acetaminophen microtracer administration. Acetaminophen concentrations were measured by liquid chromatography-mass spectrometry and C concentrations by accelerated mass spectrometry. MAIN RESULTS In 47 patients (median age of 6.1 mo; Q1-Q3, 1.8-20 mo) the mean enteral bioavailability was 72% (range, 11-91%). With a standard dose (15 mg/kg 4 times daily), therapeutic steady-state concentrations were 2.5 times more likely to be reached with IV than with oral administration. CONCLUSIONS Microtracer studies present a new opportunity to gain knowledge on drug disposition in the intensive care. Using this modality in children in the pediatric intensive care, we showed that enteral administration of acetaminophen results in less predictable exposure and higher likelihood of subtherapeutic blood concentration than does IV administration. IV dosing may be preferable to ensure adequate pain relief.
Collapse
|
8
|
Germovsek E, Barker CIS, Sharland M, Standing JF. Pharmacokinetic-Pharmacodynamic Modeling in Pediatric Drug Development, and the Importance of Standardized Scaling of Clearance. Clin Pharmacokinet 2020; 58:39-52. [PMID: 29675639 PMCID: PMC6325987 DOI: 10.1007/s40262-018-0659-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Pharmacokinetic/pharmacodynamic (PKPD) modeling is important in the design and conduct of clinical pharmacology research in children. During drug development, PKPD modeling and simulation should underpin rational trial design and facilitate extrapolation to investigate efficacy and safety. The application of PKPD modeling to optimize dosing recommendations and therapeutic drug monitoring is also increasing, and PKPD model-based dose individualization will become a core feature of personalized medicine. Following extensive progress on pediatric PK modeling, a greater emphasis now needs to be placed on PD modeling to understand age-related changes in drug effects. This paper discusses the principles of PKPD modeling in the context of pediatric drug development, summarizing how important PK parameters, such as clearance (CL), are scaled with size and age, and highlights a standardized method for CL scaling in children. One standard scaling method would facilitate comparison of PK parameters across multiple studies, thus increasing the utility of existing PK models and facilitating optimal design of new studies.
Collapse
Affiliation(s)
- Eva Germovsek
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute of Child Heath, University College London, London, UK. .,Pharmacometrics Research Group, Department of Pharmaceutical Biosciences, Uppsala University, PO Box 591, 751 24, Uppsala, Sweden.
| | - Charlotte I S Barker
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute of Child Heath, University College London, London, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute of Child Heath, University College London, London, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| |
Collapse
|
9
|
Mooij MG, van Duijn E, Knibbe CAJ, Allegaert K, Windhorst AD, van Rosmalen J, Hendrikse NH, Tibboel D, Vaes WHJ, de Wildt SN. Successful Use of [ 14C]Paracetamol Microdosing to Elucidate Developmental Changes in Drug Metabolism. Clin Pharmacokinet 2018; 56:1185-1195. [PMID: 28155137 PMCID: PMC5591809 DOI: 10.1007/s40262-017-0508-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background We previously showed the practical and ethical feasibility of using [14C]-microdosing for pharmacokinetic studies in children. We now aimed to show that this approach can be used to elucidate developmental changes in drug metabolism, more specifically, glucuronidation and sulfation, using [14C]paracetamol (AAP). Methods Infants admitted to the intensive care unit received a single oral [14C]AAP microdose while receiving intravenous therapeutic AAP every 6 h. [14C]AAP pharmacokinetic parameters were estimated. [14C]AAP and metabolites were measured with accelerator mass spectrometry. The plasma area under the concentration-time curve from time zero to infinity and urinary recovery ratios were related to age as surrogate markers of metabolism. Results Fifty children [median age 6 months (range 3 days–6.9 years)] received a microdose (3.3 [2.0–3.5] ng/kg; 64 [41–71] Bq/kg). Plasma [14C]AAP apparent total clearance was 0.4 (0.1–2.6) L/h/kg, apparent volume of distribution was 1.7 (0.9–8.2) L/kg, and the half-life was 2.8 (1–7) h. With increasing age, plasma and urinary AAP-glu/AAP and AAP-glu/AAP-sul ratios significantly increased by four fold, while the AAP-sul/AAP ratio significantly decreased. Conclusion Using [14C]labeled microdosing, the effect of age on orally administered AAP metabolism was successfully elucidated in both plasma and urine. With minimal burden and risk, microdosing is attractive to study developmental changes in drug disposition in children.
Collapse
Affiliation(s)
- Miriam G Mooij
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Catherijne A J Knibbe
- Division of Pharmacology, Faculty of Science, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Development and Regeneration, KU Leuven, Louvain, Belgium
| | - Albert D Windhorst
- Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | | | - N Harry Hendrikse
- Department of Pharmacy and Clinical Pharmacology, VU University Medical Center, Amsterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
- Department of Pharmacology and Toxicology, Radboud University, PO box 9101, Geert Grooteplein 21, Nijmegen, 6500 HB, The Netherlands.
| |
Collapse
|
10
|
Menzies JC, Morris KP, Duncan HP, Marriott JF. Patient and public involvement in Paediatric Intensive Care research: considerations, challenges and facilitating factors. RESEARCH INVOLVEMENT AND ENGAGEMENT 2016; 2:32. [PMID: 29507766 PMCID: PMC5831882 DOI: 10.1186/s40900-016-0046-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 10/25/2016] [Indexed: 06/08/2023]
Abstract
PLAIN ENGLISH SUMMARY Paediatric Intensive Care (PIC) provides care to extremely ill children. Research in this area can be difficult because children are often too sick to discuss being involved in a study and parents are too upset about their child to think about taking part. This makes it even more important that research is well designed. We conducted a review of the literature about involving patients and the public (PPI) in PIC research. We wanted to know what PPI has taken place, who had been consulted and how this was undertaken. We reviewed the titles and abstracts of 4717 papers but found only 4 relevant papers. Three of the papers had consulted with parents of children who had been on PIC but only one study had spoken directly to a child themselves. The studies had used a number of different methods to invite people to take part but there did not appear to be one solution. All of the studies thought PPI was good for the development of their research but none of them had tried to measure what had changed as a result. There are difficulties associated with carrying out PPI in the PIC setting. Researchers need to share more of their experiences, positive and negative, so we can try to identify the best ways of carrying out PPI in PIC studies. This will help ensure that research studies are designed which address the needs and concerns of children and their parents. ABSTRACT Introduction Involving the public in health care research is reported to enhance the quality, appropriateness, acceptability and relevance to patients and the public (INVOLVE, Briefing notes for researchers, 2012; Staniszewska et al., Int J Technol Assess Health Care 274:391-9, 2011). Conducting research with children and young people is regarded as challenging and this makes it even more important that the research is well designed and understands the perspective of the child and family. We conducted a narrative literature review of the Patient and Public Involvement (PPI) literature, in the context of Paediatric Intensive Care (PIC). Our aims were to identify what PPI activity has taken place, with whom researchers engaged and what outcomes they reported. Method Electronic databases Medline, CINAHL and Embase (January 2000- June 2016) were searched using the search terms patient and public involvement and consultation. Participants were defined as child, parent, paediatric or pediatric and the context as intensive or critical care. Papers were excluded where activity reflected 'participants' as research subjects. Included papers were reviewed using the GRIPP checklist to appraise the quality of reporting. Results The search strategy identified 4717 abstracts. Seventeen papers were reviewed in full and four papers were included, all of which are case studies, describing a consultation approach. None of the papers described PPI as a multi-stage process. Only one study engaged with a former PIC patient and the majority of those consulted did not have any PIC experience. Activity was reported as being of benefit but there was no measurement of the impact of PPI. Conclusion There are numerous challenges associated with the conduct of research in PIC. It is therefore essential that the perspective of children, young people and their parents have been considered in the design of trials. However, there are few published accounts of PPI within the PIC context and the accounts that exist highlight issues about who to approach and when, and a lack of clarity about the best ways to engage with them. Research Ethics Committees and funding bodies expect to see evidence of PPI in research applications and we need to develop our understanding of what contributes towards successful PPI in this context.
Collapse
Affiliation(s)
- J. C. Menzies
- Paediatric Intensive Care Unit, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - K. P. Morris
- Paediatric Intensive Care Unit, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - H. P. Duncan
- Paediatric Intensive Care Unit, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - J. F. Marriott
- Institute of Clinical Sciences, College of Medical and Dental Sciences, Medical School Building, University of Birmingham, Edgbaston, Birmingham B15 2TT UK
| |
Collapse
|
11
|
Dorofaeff T, Bandini RM, Lipman J, Ballot DE, Roberts JA, Parker SL. Uncertainty in Antibiotic Dosing in Critically Ill Neonate and Pediatric Patients: Can Microsampling Provide the Answers? Clin Ther 2016; 38:1961-75. [PMID: 27544661 DOI: 10.1016/j.clinthera.2016.07.093] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/20/2016] [Accepted: 07/22/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE With a decreasing supply of antibiotics that are effective against the pathogens that cause sepsis, it is critical that we learn to use currently available antibiotics optimally. Pharmacokinetic studies provide an evidence base from which we can optimize antibiotic dosing. However, these studies are challenging in critically ill neonate and pediatric patients due to the small blood volumes and associated risks and burden to the patient from taking blood. We investigate whether microsampling, that is, obtaining a biologic sample of low volume (<50 μL), can improve opportunities to conduct pharmacokinetic studies. METHODS We performed a literature search to find relevant articles using the following search terms: sepsis, critically ill, severe infection, intensive care AND antibiotic, pharmacokinetic, p(a)ediatric, neonate. For microsampling, we performed a search using antibiotics AND dried blood spots OR dried plasma spots OR volumetric absorptive microsampling OR solid-phase microextraction OR capillary microsampling OR microsampling. Databases searched include Web of Knowledge, PubMed, and EMbase. FINDINGS Of the 32 antibiotic pharmacokinetic studies performed on critically ill neonate or pediatric patients in this review, most of the authors identified changes to the pharmacokinetic properties in their patient group and recommended either further investigations into this patient population or therapeutic drug monitoring to ensure antibiotic doses are suitable. There remain considerable gaps in knowledge regarding the pharmacokinetic properties of antibiotics in critically ill pediatric patients. Implementing microsampling in an antibiotic pharmacokinetic study is contingent on the properties of the antibiotic, the pathophysiology of the patient (and how this can affect the microsample), and the location of the patient. A validation of the sampling technique is required before implementation. IMPLICATIONS Current antibiotic regimens for critically ill neonate and pediatric patients are frequently suboptimal due to a poor understanding of altered pharmacokinetic properties. An assessment of the suitability of microsampling for pharmacokinetic studies in neonate and pediatric patients is recommended before wider use. The method of sampling, as well as the method of bioanalysis, also requires validation to ensure the data obtained reflect the true result.
Collapse
Affiliation(s)
- Tavey Dorofaeff
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia; Paediatric Intensive Care, Lady Cilento Children's Hospital, Brisbane, Australia
| | - Rossella M Bandini
- School of Physiology, University of the Witwatersrand, Johannesburg, South Africa; Wits UQ Critical Care Infection Collaboration, Johannesburg, South Africa
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia; Wits UQ Critical Care Infection Collaboration, Johannesburg, South Africa; Department of Intensive Care Medicine, Royal Brisbane Hospital, Brisbane, Australia; Faculty of Health, Brisbane, Queensland University of Technology, Brisbane, Australia
| | - Daynia E Ballot
- Wits UQ Critical Care Infection Collaboration, Johannesburg, South Africa; Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane Hospital, Brisbane, Australia; Department of Pharmacy, Royal Brisbane Hospital, Brisbane, Australia; School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Suzanne L Parker
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.
| |
Collapse
|
12
|
|
13
|
Vet NJ, de Wildt SN, Verlaat CWM, Knibbe CAJ, Mooij MG, van Woensel JBM, van Rosmalen J, Tibboel D, de Hoog M. A randomized controlled trial of daily sedation interruption in critically ill children. Intensive Care Med 2015; 42:233-44. [PMID: 26602782 PMCID: PMC4726735 DOI: 10.1007/s00134-015-4136-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [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: 11/01/2015] [Indexed: 11/25/2022]
Abstract
Purpose To compare daily sedation interruption plus protocolized sedation (DSI + PS) to protocolized sedation only (PS) in critically ill children. Methods In this multicenter randomized controlled trial in three pediatric intensive care units in the Netherlands, mechanically ventilated critically ill children with need for sedative drugs were included. They were randomly assigned to either DSI + PS or PS only. Children in both study arms received sedation adjusted on the basis of validated sedation scores. Provided a safety screen was passed, children in the DSI + PS group received daily blinded infusions of saline; children in the PS group received blinded infusions of the previous sedatives/analgesics. If a patient’s sedation score indicated distress, the blinded infusions were discontinued, a bolus dose of midazolam was given and the ‘open’ infusions were resumed: DSI + PS at half of infusion rate, PS at previous infusion rate. The primary endpoint was the number of ventilator-free days at day 28. Data were analyzed by intention to treat. Results From October 2009 to August 2014, 129 children were randomly assigned to DSI + PS (n = 66) or PS (n = 63). The study was terminated prematurely due to slow recruitment rates. Median number of ventilator-free days did not differ: DSI + PS 24.0 days (IQR 21.6–25.8) versus PS 24.0 days (IQR 20.6–26.0); median difference 0.02 days (95 % CI −0.91 to 1.09), p = 0.90. Median ICU and hospital length of stay were similar in both groups: DSI + PS 6.9 days (IQR 5.2–11.0) versus PS 7.4 days (IQR 5.3–12.8), p = 0.47, and DSI + PS 13.3 days (IQR 8.6–26.7) versus PS 15.7 days (IQR 9.3–33.2), p = 0.19, respectively. Mortality at 30 days was higher in the DSI + PS group than in the PS group (6/66 versus 0/63, p = 0.03), though no causal relationship to the intervention could be established. Median cumulative midazolam dose did not differ: DSI + PS 14.1 mg/kg (IQR 7.6–22.6) versus PS 17.0 mg/kg (IQR 8.2–39.8), p = 0.11. Conclusion In critically ill children, daily sedation interruption in addition to protocolized sedation did not improve clinical outcome and was associated with increased mortality compared with protocolized sedation only.
Collapse
Affiliation(s)
- Nienke J Vet
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands.
- Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Saskia N de Wildt
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Carin W M Verlaat
- Intensive Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Catherijne A J Knibbe
- Divison of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
- Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Miriam G Mooij
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | | | - Dick Tibboel
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Matthijs de Hoog
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
- Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
14
|
Brouwer KLR, Aleksunes LM, Brandys B, Giacoia GP, Knipp G, Lukacova V, Meibohm B, Nigam SK, Rieder M, de Wildt SN. Human Ontogeny of Drug Transporters: Review and Recommendations of the Pediatric Transporter Working Group. Clin Pharmacol Ther 2015; 98:266-87. [PMID: 26088472 DOI: 10.1002/cpt.176] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/15/2015] [Accepted: 06/15/2015] [Indexed: 12/19/2022]
Abstract
The critical importance of membrane-bound transporters in pharmacotherapy is widely recognized, but little is known about drug transporter activity in children. In this white paper, the Pediatric Transporter Working Group presents a systematic review of the ontogeny of clinically relevant membrane transporters (e.g., SLC, ABC superfamilies) in intestine, liver, and kidney. Different developmental patterns for individual transporters emerge, but much remains unknown. Recommendations to increase our understanding of membrane transporters in pediatric pharmacotherapy are presented.
Collapse
Affiliation(s)
- K L R Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - L M Aleksunes
- Department of Pharmacology and Toxicology, Rutgers, the State University of New Jersey, Ernest Mario School of Pharmacy, Piscataway, New Jersey, USA
| | - B Brandys
- NIH Library, National Institutes of Health, Bethesda, Maryland, USA
| | - G P Giacoia
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland, USA
| | - G Knipp
- College of Pharmacy, Department of Industrial and Physical Pharmacy, Purdue University, West Lafayette, Indiana, USA
| | - V Lukacova
- Simulations Plus, lnc., Lancaster, California, USA
| | - B Meibohm
- University of Tennessee Health Science Center, College of Pharmacy, Memphis, Tennessee, USA
| | - S K Nigam
- University of California San Diego, La Jolla, California, USA
| | - M Rieder
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada
| | - S N de Wildt
- Erasmus MC Sophia Children's Hospital, Intensive Care and Department of Pediatric Surgery, Rotterdam, the Netherlands
| | | |
Collapse
|
15
|
Valkenburg AJ, de Leeuw TG, van Dijk M, Tibboel D. Pain in Intellectually Disabled Children: Towards Evidence-Based Pharmacotherapy? Paediatr Drugs 2015; 17:339-48. [PMID: 26076801 PMCID: PMC4768233 DOI: 10.1007/s40272-015-0138-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This critical opinion article deals with the challenges of finding the most effective pharmacotherapeutic options for the management of pain in intellectually disabled children and provides recommendations for clinical practice and research. Intellectual disability can be caused by a wide variety of underlying diseases and may be associated with congenital anomalies such as cardiac defects, small-bowel obstructions or limb abnormalities as well as with comorbidities such as scoliosis, gastro-esophageal reflux disease, spasticity, and epilepsy. These conditions themselves or any necessary surgical interventions are sources of pain. Epilepsy often requires chronic pharmacological treatment with antiepileptic drugs. These antiepileptic drugs can potentially cause drug-drug interactions with analgesic drugs. It is unfortunate that children with intellectual disabilities often cannot communicate pain to caregivers. Although these children are at high risk of experiencing pain, researchers nevertheless often have to exclude them from trials on pain management because of ethical considerations. We therefore make a plea for prescribers, researchers, patient organizations, pharmaceutical companies, and policy makers to study evidence-based, safe and effective pharmacotherapy in these children through properly designed studies. In the meantime, parents and clinicians must resort to validated pain assessment tools such as the revised FLACC scale.
Collapse
Affiliation(s)
- Abraham J Valkenburg
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands.
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Tom G de Leeuw
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Anesthesiology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
- Division of Neonatology, Department of Pediatrics, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
16
|
Turner MA, Mooij MG, Vaes WHJ, Windhorst AD, Hendrikse NH, Knibbe CAJ, Kõrgvee LT, Maruszak W, Grynkiewicz G, Garner RC, Tibboel D, Park BK, de Wildt SN. Pediatric microdose and microtracer studies using 14C in Europe. Clin Pharmacol Ther 2015; 98:234-7. [PMID: 26095095 DOI: 10.1002/cpt.163] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Important information gaps remain on the efficacy and safety of drugs in children. Pediatric drug development encounters several ethical, practical, and scientific challenges. One barrier to the evaluation of medicines for children is a lack of innovative methodologies that have been adapted to the needs of children. This article presents our successful experience of pediatric microdose and microtracer studies using (14) C-labeled probes in Europe to illustrate the strengths and limitations of these approaches.
Collapse
Affiliation(s)
- M A Turner
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M G Mooij
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - A D Windhorst
- Department of Radiology & Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - N H Hendrikse
- Department of Clinical Pharmacology & Pharmacy, Department of Radiology & Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - C A J Knibbe
- Faculty of Science, Leiden Academic Centre for Research, Pharmacology, Leiden, The Netherlands.,Hospital Pharmacy and Clinical Pharmacology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - L T Kõrgvee
- Department of Clinical Pharmacology, University of Tartu, Tartu, Estonia
| | - W Maruszak
- R&D Analytical Chemistry Department, Pharmaceutical Research Institute, Warsaw, Poland
| | | | - R C Garner
- Garner Consulting and Hull York Medical School, University of York, York, UK
| | - D Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - B K Park
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - S N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
17
|
|
18
|
|
19
|
Tromp K, Vathorst SVD. Gatekeeping by Professionals in Recruitment of Pediatric Research Participants: Indeed an Undesirable Practice. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:30-32. [PMID: 26575811 DOI: 10.1080/15265161.2015.1088978] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
|