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Sychterz C, Shen H, Zhang Y, Sinz M, Rostami-Hodjegan A, Schmidt BJ, Gaohua L, Galetin A. A close examination of BCRP's role in lactation and methods for predicting drug distribution into milk. CPT Pharmacometrics Syst Pharmacol 2024. [PMID: 39292199 DOI: 10.1002/psp4.13243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 08/18/2024] [Accepted: 08/27/2024] [Indexed: 09/19/2024] Open
Abstract
Breastfeeding is the most complete nutritional method of feeding infants, but several impediments affect the decision to breastfeed, including questions of drug safety for medications needed during lactation. Despite recent FDA guidance, few labels provide clear dosing advice during lactation. Physiologically based pharmacokinetic modeling (PBPK) is well suited to mechanistically explore pharmacokinetics and dosing paradigms to fill gaps in the absence of extensive clinical studies and complement existing real-world data. For lactation-focused PBPK (Lact-PBPK) models, information on system parameters (e.g., expression of drug transporters in mammary epithelial cells) is sparse. The breast cancer resistance protein (BCRP) is expressed on the apical side of mammary epithelial cells where it actively transports drugs/substrates into milk (reported milk: plasma ratios range from 2 to 20). A critical review of BCRP and its role in lactation was conducted. Longitudinal changes in BCRP mRNA expression have been identified in women with a maximum reached around 5 months postpartum. Limited data are available on the ontogeny of BCRP in infant intestine; however, data indicate lower BCRP abundance in infants compared to adults. Current status of incorporation of drug transporter information in Lact-PBPK models to predict active secretion of drugs into breast milk and consequential exposure of breast-fed infants is discussed. In addition, this review highlights novel clinical tools for evaluation of BCRP activity, namely a potential non-invasive BCRP biomarker (riboflavin) and liquid biopsy that could be used to quantitatively elucidate the role of this transporter without the need for administration of drugs and to inform Lact-PBPK models.
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Affiliation(s)
- Caroline Sychterz
- Division of Pharmacy and Optometry, Centre for Applied Pharmacokinetic Research, School of Health Sciences, University of Manchester, Manchester, UK
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Hong Shen
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | | | - Michael Sinz
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Amin Rostami-Hodjegan
- Division of Pharmacy and Optometry, Centre for Applied Pharmacokinetic Research, School of Health Sciences, University of Manchester, Manchester, UK
- Certara Predictive Technologies, Certara UK, Sheffield, UK
| | | | - Lu Gaohua
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Aleksandra Galetin
- Division of Pharmacy and Optometry, Centre for Applied Pharmacokinetic Research, School of Health Sciences, University of Manchester, Manchester, UK
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2
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Koldeweij CJM, Dibbets AC, Ceulemans M, de Vries LC, Franklin BD, Scheepers HCJ, de Wildt SN. Willingness-to-use and preferences for model-informed antenatal doses: a cross-sectional study among European healthcare practitioners and pregnant women. Front Pharmacol 2024; 15:1403747. [PMID: 39211781 PMCID: PMC11358599 DOI: 10.3389/fphar.2024.1403747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
Background: Physiological changes in pregnancy may affect drug safety and efficacy, sometimes requiring dose adjustments. Pregnancy-adjusted doses, however, are missing for most medications. Increasingly, pharmacokinetic models can be used for antenatal dose finding. Given the novelty of this technique and questions regarding dose credibility, the acceptability of model-informed antenatal doses should be explored. Objective: We aimed to assess the willingness-to-use and preferred features for model-informed antenatal doses among healthcare practitioners (HCPs) and pregnant women in European countries. Methods: A cross-sectional, web-based study drawing on two open surveys was performed between 8 September and 30 November 2022. Each survey comprised statements drawn from prior focus groups, associated with Likert-scales. Themes included respondents' information needs, search behaviours along with their willingness-to-use and preferred features for model-informed antenatal doses. The surveys were disseminated through professional societies, pregnancy websites and social media. A descriptive analysis was performed. Results: In total, 608 HCPs from different specialties and 794 pregnant women across 15 countries participated, with 81% of respondents across both groups in the Netherlands or Belgium. Among pregnant women, 31% were medical professionals and 85% used medication during pregnancy. Eighty-three percent of HCPs found current antenatal pharmacotherapy suboptimal and 97% believed that model-informed antenatal doses would enhance the quality of antenatal care. Most HCPs (93%) and pregnant women (75%) would be willing to follow model-informed antenatal doses. Most HCPs desired access to the evidence (88%), including from pharmacokinetic modelling (62%). Most pregnant women (96%) wanted to understand antenatal dosing rationales and to be involved in dosing decisions (97%). Conclusion: The willingness-to-use model-informed antenatal doses is high among HCPs and pregnant women provided that certain information needs are met.
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Affiliation(s)
- C. J. M. Koldeweij
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - A. C. Dibbets
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - M. Ceulemans
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KULeuven, Belgium
- IQ Health, Radboud University Medical Center, Nijmegen, Netherlands
- L-C&Y, KU Leuven Child and Youth Institute, Leuven, Belgium
| | - L. C. de Vries
- Teratology Information Service, Netherlands Pharmacovigilance Centre Lareb, S’Hertogenbosch, Netherlands
| | - B. D. Franklin
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
| | - H. C. J. Scheepers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, Netherlands
- Grow, School for Oncology and Reproduction, Maastricht, Netherlands
| | - S. N. de Wildt
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Paediatric and Neonatal Intensive Care, Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands
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Wu YE, Zheng YY, Li QY, Yao BF, Cao J, Liu HX, Hao GX, van den Anker J, Zheng Y, Zhao W. Model-informed drug development in pediatric, pregnancy and geriatric drug development: States of the art and future. Adv Drug Deliv Rev 2024; 211:115364. [PMID: 38936664 DOI: 10.1016/j.addr.2024.115364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 06/09/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024]
Abstract
The challenges of drug development in pediatric, pregnant and geriatric populations are a worldwide concern shared by regulatory authorities, pharmaceutical companies, and healthcare professionals. Model-informed drug development (MIDD) can integrate and quantify real-world data of physiology, pharmacology, and disease processes by using modeling and simulation techniques to facilitate decision-making in drug development. In this article, we reviewed current MIDD policy updates, reflected on the integrity of physiological data used for MIDD and the effects of physiological changes on the drug PK, as well as summarized current MIDD strategies and applications, so as to present the state of the art of MIDD in pediatric, pregnant and geriatric populations. Some considerations are put forth for the future improvements of MIDD including refining regulatory considerations, improving the integrity of physiological data, applying the emerging technologies, and exploring the application of MIDD in new therapies like gene therapies for special populations.
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Affiliation(s)
- Yue-E Wu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yuan-Yuan Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiu-Yue Li
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jing Cao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hui-Xin Liu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA; Departments of Pediatrics, Pharmacology & Physiology, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA; Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland
| | - Yi Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.
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Jacobson MH, Yost E, Sylvester SV, Renz C, Wyszynski DF, Davis KJ. Understanding willingness and barriers to participate in clinical trials during pregnancy and lactation: findings from a US study. BMC Pregnancy Childbirth 2024; 24:504. [PMID: 39060985 PMCID: PMC11282851 DOI: 10.1186/s12884-024-06710-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 07/19/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Due to the exclusion of pregnant and lactating people from most clinical trials, there is an incomplete understanding of the risks and benefits of medication use in these populations and therapeutic decision-making is often conducted without adequate evidence. To change this paradigm, it is imperative to understand the perspectives of pregnant and lactating individuals concerning their participation in clinical trials. OBJECTIVES To describe attitudes, perceptions, barriers, and preferences of pregnant and postpartum people in the United States (US) regarding participation in clinical trials and to identify factors influencing participation. METHODS In November 2022, individuals aged ≥ 18 residing in the US who self-identified as pregnant or pregnant within the last 12 months were invited to complete an online survey about their perspectives regarding clinical trial participation. The survey included questions about demographic characteristics, health history, behaviors, and willingness to participate in clinical trials while pregnant and/or lactating. Multivariable logistic regression models were fit to identify predictors of clinical trial participation. RESULTS Among the 654 respondents, 34.8% and 40.9% reported being likely or extremely likely to participate in a clinical trial for a new medication while pregnant or lactating, respectively; and 24.5% and 41.7% for a new vaccine while pregnant or lactating, respectively. Higher educational attainment (≥ Bachelor's degree) was associated with greater likelihood of clinical trial participation in pregnancy (odds ratio (OR) = 1.50, 95% Confidence Interval (CI): 1.01, 2.25 for medications; OR = 2.00, 95% CI: 1.28, 3.12 for vaccines). Chronic medical conditions were associated with a greater likelihood of participation in clinical trials for vaccines during lactation (OR = 1.59, 95% CI: 1.07, 2.36). The most cited motivator for participation in a clinical trial while pregnant or lactating was anticipated personal medical benefit (85.8% and 75.6%, respectively), while the primary deterrent was possible risk to the fetus or baby (97.9% and 97.2%, respectively). CONCLUSIONS Willingness of a US sample to participate in clinical trials while pregnant or lactating varied by demographics and health status, with safety to the fetus being a nearly universal concern. These findings have implications for enhancing inclusion of pregnant and lactating people in clinical research and developing effective and equitable recruitment strategies.
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Affiliation(s)
- Melanie H Jacobson
- Global Epidemiology Organization, Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, US.
| | - Emily Yost
- Global Epidemiology Organization, Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, US
| | | | | | | | - Kourtney J Davis
- Global Epidemiology Organization, Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, US
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Van Neste M, Nauwelaerts N, Ceulemans M, Cuppers B, Annaert P, Smits A, Allegaert K. Very low monomethyl fumarate exposure via human milk: a case report-a contribution from the ConcePTION project. Front Public Health 2024; 12:1393752. [PMID: 39015385 PMCID: PMC11250615 DOI: 10.3389/fpubh.2024.1393752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/14/2024] [Indexed: 07/18/2024] Open
Abstract
Introduction While breastfeeding is recommended, knowledge regarding medicine transfer to human milk and its safety for nursing infants is limited. Only one paper has previously described dimethyl fumarate (DMF) transfer during breastfeeding in two patients at 5 and 6 months postpartum, respectively. The current case report describes maternal pharmacokinetic data of monomethyl fumarate (MMF), the active metabolite of DMF, and infant exposure estimations of MMF at 3 months postpartum. Methods A 32-year-old Caucasian woman started DMF therapy (120 mg, 2x/day) for multiple sclerosis at 3 months postpartum, after weaning her infant from breastfeeding. On day 99 after birth, the patient collected four milk samples over 24 h after 6 days of treatment at the initial dose. Additionally, a single maternal blood sample was collected to calculate the milk-to-plasma (M/P) ratio. The samples were analyzed using liquid chromatography coupled with the mass spectrometry method. Results A wide range of measured steady-state concentrations of MMF (5.5-83.5 ng/mL) was observed in human milk samples. Estimated daily infant dosage values for MMF, calculated with 150 and 200 mL/kg/day human milk intake, were 5.76 and 7.68 μg/kg/day, and the relative infant doses were 0.16 and 0.22%. The observed mean M/P ratio was 0.059, similar to the M/P ratio predicted using the empirical Koshimichi model (0.06). Discussion Combining this case report with the two previously described cases, the estimated infant exposure is low, albeit with relevant intra- and inter-patient variabilities. Research should further focus on infant exposure and safety.
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Affiliation(s)
- Martje Van Neste
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Child & Youth Institute, KU Leuven, Leuven, Belgium
| | - Nina Nauwelaerts
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Michael Ceulemans
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Child & Youth Institute, KU Leuven, Leuven, Belgium
- Teratology Information Service, Netherlands Pharmacovigilance Centre Lareb, ‘s-Hertogenbosch, Netherlands
| | - Benedikte Cuppers
- Teratology Information Service, Netherlands Pharmacovigilance Centre Lareb, ‘s-Hertogenbosch, Netherlands
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- BioNotus GCV, Niel, Belgium
| | - Anne Smits
- Child & Youth Institute, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Karel Allegaert
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Child & Youth Institute, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
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Ammerdorffer A, McDougall ARA, Tuttle A, Rushwan S, Chinery L, Vogel JP, Goldstein M, Gülmezoglu AM. The drug drought in maternal health: an ongoing predicament. Lancet Glob Health 2024; 12:e1174-e1183. [PMID: 38876763 PMCID: PMC11194164 DOI: 10.1016/s2214-109x(24)00144-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 02/28/2024] [Accepted: 03/26/2024] [Indexed: 06/16/2024]
Abstract
We developed a comprehensive database of medicines that are used or are being investigated for pre-eclampsia or eclampsia, preterm birth or labour, postpartum haemorrhage, intrauterine growth restriction, and fetal distress and that were in active development between 2000 and 2021. A total of 444 candidates were identified: approximately half of candidates were in active development, two-thirds had been repurposed after initially being used for another condition, and just under half were in preclinical studies. Only 64 candidates were in active late-stage (phase 3) development as of Oct 25, 2021, and given the slow pace of biomedical development, it could take years before any of these products eventually make it to market. A lack of innovation for maternal health medicines persists, and the market continues to fail pregnant individuals. There is a need for collective action from all relevant stakeholders to accelerate investment in the development of new or improved medicines for pregnancy-related conditions.
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Affiliation(s)
| | - Annie R A McDougall
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | | | | | | | - Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
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Koldeweij C, Kleuskens M, Litjens C, Franklin BD, Scheepers HCJ, de Wildt SN. Perceived barriers and facilitators for model-informed dosing in pregnancy: a qualitative study across healthcare practitioners and pregnant women. BMC Med 2024; 22:248. [PMID: 38886762 PMCID: PMC11184760 DOI: 10.1186/s12916-024-03450-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 05/28/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Most women use medication during pregnancy. Pregnancy-induced changes in physiology may require antenatal dose alterations. Yet, evidence-based doses in pregnancy are missing. Given historically limited data, pharmacokinetic models may inform pregnancy-adjusted doses. However, implementing model-informed doses in clinical practice requires support from relevant stakeholders. PURPOSE To explore the perceived barriers and facilitators for model-informed antenatal doses among healthcare practitioners (HCPs) and pregnant women. METHODS Online focus groups and interviews were held among healthcare practitioners (HCPs) and pregnant women from eight countries across Europe, Africa and Asia. Purposive sampling was used to identify pregnant women plus HCPs across various specialties prescribing or providing advice on medication to pregnant women. Perceived barriers and facilitators for implementing model-informed doses in pregnancy were identified and categorised using a hybrid thematic analysis. RESULTS Fifty HCPs and 11 pregnant women participated in 12 focus groups and 16 interviews between January 2022 and March 2023. HCPs worked in the Netherlands (n = 32), the UK (n = 7), South Africa (n = 5), Uganda (n = 4), Kenya, Cameroon, India and Vietnam (n = 1 each). All pregnant women resided in the Netherlands. Barriers and facilitators identified by HCPs spanned 14 categories across four domains whereas pregnant women described barriers and facilitators spanning nine categories within the same domains. Most participants found current antenatal dosing information inadequate and regarded model-informed doses in pregnancy as a valuable and for some, much-needed addition to antenatal care. Although willingness-to-follow model-informed antenatal doses was high across both groups, several barriers for implementation were identified. HCPs underlined the need for transparent model validation and endorsement of the methodology by recognised institutions. Foetal safety was deemed a critical knowledge gap by both groups. HCPs' information needs and preferred features for model-informed doses in pregnancy varied. Several pregnant women expressed a desire to access information and partake in decisions on antenatal dosing. CONCLUSIONS Given the perceived limitations of current pharmacotherapy for pregnant women and foetuses, model-informed dosing in pregnancy was seen as a promising means to enhance antenatal care by pregnant women and healthcare practitioners.
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Affiliation(s)
- Charlotte Koldeweij
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Mirèse Kleuskens
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carlijn Litjens
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, The Netherlands
| | - Bryony Dean Franklin
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
- Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Grow, School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Saskia N de Wildt
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pediatric and Neonatal Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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8
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Deepak V, El-Balawi L, Harris LK. Placental Drug Delivery to Treat Pre-Eclampsia and Fetal Growth Restriction. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2024:e2311165. [PMID: 38745536 DOI: 10.1002/smll.202311165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 04/23/2024] [Indexed: 05/16/2024]
Abstract
Pre-eclampsia and fetal growth restriction (FGR) continue to cause unacceptably high levels of morbidity and mortality, despite significant pharmaceutical and technological advances in other disease areas. The recent pandemic has also impacted obstetric care, as COVID-19 infection increases the risk of poor pregnancy outcomes. This review explores the reasons why it lacks effective drug treatments for the placental dysfunction that underlies many common obstetric conditions and describes how nanomedicines and targeted drug delivery approaches may provide the solution to the current drug drought. The ever-increasing range of biocompatible nanoparticle formulations available is now making it possible to selectively deliver drugs to uterine and placental tissues and dramatically limit fetal drug transfer. Formulations that are refractory to placental uptake offer the possibility of retaining drugs within the maternal circulation, allowing pregnant individuals to take medicines previously considered too harmful to the developing baby. Liposomes, ionizable lipid nanoparticles, polymeric nanoparticles, and adenoviral vectors have all been used to create efficacious drug delivery systems for use in pregnancy, although each approach offers distinct advantages and limitations. It is imperative that recent advances continue to be built upon and that there is an overdue investment of intellectual and financial capital in this field.
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Affiliation(s)
- Venkataraman Deepak
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, M13 9WL, UK
- St Mary's Hospital, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK
| | - Lujain El-Balawi
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, M13 9PL, UK
| | - Lynda K Harris
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, M13 9WL, UK
- St Mary's Hospital, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, M13 9PL, UK
- Olson Center for Women's Health, Department of Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha, NE, 68198, USA
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Shankar M, Hazfiarini A, Zahroh RI, Vogel JP, McDougall ARA, Condron P, Goudar SS, Pujar YV, Somannavar MS, Charantimath U, Ammerdorffer A, Rushwan S, Gülmezoglu AM, Bohren MA. Factors influencing the participation of pregnant and lactating women in clinical trials: A mixed-methods systematic review. PLoS Med 2024; 21:e1004405. [PMID: 38814991 PMCID: PMC11139290 DOI: 10.1371/journal.pmed.1004405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/19/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Poor representation of pregnant and lactating women and people in clinical trials has marginalised their health concerns and denied the maternal-fetal/infant dyad benefits of innovation in therapeutic research and development. This mixed-methods systematic review synthesised factors affecting the participation of pregnant and lactating women in clinical trials, across all levels of the research ecosystem. METHODS AND FINDINGS We searched 8 databases from inception to 14 February 2024 to identify qualitative, quantitative, and mixed-methods studies that described factors affecting participation of pregnant and lactating women in vaccine and therapeutic clinical trials in any setting. We used thematic synthesis to analyse the qualitative literature and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. We compared quantitative data against the thematic synthesis findings to assess areas of convergence or divergence. We mapped review findings to the Theoretical Domains Framework (TDF) and Capability, Opportunity, and Motivation Model of Behaviour (COM-B) to inform future development of behaviour change strategies. We included 60 papers from 27 countries. We grouped 24 review findings under 5 overarching themes: (a) interplay between perceived risks and benefits of participation in women's decision-making; (b) engagement between women and the medical and research ecosystems; (c) gender norms and decision-making autonomy; (d) factors affecting clinical trial recruitment; and (e) upstream factors in the research ecosystem. Women's willingness to participate in trials was affected by: perceived risk of the health condition weighed against an intervention's risks and benefits, therapeutic optimism, intervention acceptability, expectations of receiving higher quality care in a trial, altruistic motivations, intimate relationship dynamics, and power and trust in medicine and research. Health workers supported women's participation in trials when they perceived clinical equipoise, had hope for novel therapeutic applications, and were convinced an intervention was safe. For research staff, developing reciprocal relationships with health workers, having access to resources for trial implementation, ensuring the trial was visible to potential participants and health workers, implementing a woman-centred approach when communicating with potential participants, and emotional orientations towards the trial were factors perceived to affect recruitment. For study investigators and ethics committees, the complexities and subjectivities in risk assessments and trial design, and limited funding of such trials contributed to their reluctance in leading and approving such trials. All included studies focused on factors affecting participation of cisgender pregnant women in clinical trials; future research should consider other pregnancy-capable populations, including transgender and nonbinary people. CONCLUSIONS This systematic review highlights diverse factors across multiple levels and stakeholders affecting the participation of pregnant and lactating women in clinical trials. By linking identified factors to frameworks of behaviour change, we have developed theoretically informed strategies that can help optimise pregnant and lactating women's engagement, participation, and trust in such trials.
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Affiliation(s)
- Mridula Shankar
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Alya Hazfiarini
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Rana Islamiah Zahroh
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Joshua P. Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Annie R. A. McDougall
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Patrick Condron
- University Library, University of Melbourne, Carlton, Victoria, Australia
| | - Shivaprasad S. Goudar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Yeshita V. Pujar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Manjunath S. Somannavar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Umesh Charantimath
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | | | - Sara Rushwan
- Concept Foundation, Geneva, Switzerland/Bangkok, Thailand
| | | | - Meghan A. Bohren
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
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10
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Yan Y, Wang Q, Wu W, Yi H, Xie F. Evaluation of Various Approaches to Estimate Transplacental Clearance of Vancomycin for Predicting Fetal Concentrations using a Maternal-Fetal Physiologically Based Pharmacokinetic Model. Pharm Res 2024; 41:899-910. [PMID: 38684563 DOI: 10.1007/s11095-024-03705-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Evaluating drug transplacental clearance is vital for forecasting fetal drug exposure. Ex vivo human placenta perfusion experiments are the most suitable approach for this assessment. Various in silico methods are also proposed. This study aims to compare these prediction methods for drug transplacental clearance, focusing on the large molecular weight drug vancomycin (1449.3 g/mol), using maternal-fetal physiologically based pharmacokinetic (m-f PBPK) modeling. METHODS Ex vivo human placenta perfusion experiments, in silico approaches using intestinal permeability as a substitute (quantitative structure property relationship (QSPR) model and Caco-2 permeability in vitro-in vivo correlation model) and midazolam calibration model with Caco-2 scaling were assessed for determining the transplacental clearance (CLPD) of vancomycin. The m-f PBPK model was developed stepwise using Simcyp, incorporating the determined CLPD values as a crucial input parameter for transplacental kinetics. RESULTS The developed PBPK model of vancomycin for non-pregnant adults demonstrated excellent predictive performance. By incorporating the CLPD parameterization derived from ex vivo human placenta perfusion experiments, the extrapolated m-f PBPK model consistently predicted maternal and fetal concentrations of vancomycin across diverse doses and distinct gestational ages. However, when the CLPD parameter was derived from alternative prediction methods, none of the extrapolated maternal-fetal PBPK models produced fetal predictions in line with the observed data. CONCLUSION Our study showcased that combination of ex vivo human placenta perfusion experiments and m-f PBPK model has the capability to predict fetal exposure for the large molecular weight drug vancomycin, whereas other in silico approaches failed to achieve the same level of accuracy.
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Affiliation(s)
- Yunan Yan
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Tongzipo Road 172, Changsha, 410013, China
| | - Qiushi Wang
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Tongzipo Road 172, Changsha, 410013, China
| | - Wei Wu
- The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, Changsha, China
- Department of Pharmacy, The First Hospital of Changsha, Changsha, China
| | - Hanxi Yi
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, China
| | - Feifan Xie
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Tongzipo Road 172, Changsha, 410013, China.
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11
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Caritis SN, Dodeja P, Sharma S, Zhao W, Venkataramanan R. The dosing regimen for 17-hydroxyprogesterone caproate was suboptimal: lessons for future pharmacotherapy for pregnant women. Am J Obstet Gynecol 2024:S0002-9378(24)00526-X. [PMID: 38670444 DOI: 10.1016/j.ajog.2024.04.020] [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: 07/15/2023] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Makena (17-hydroxyprogesterone caproate) was approved by the United States Food and Drug Administration for the prevention of recurrent spontaneous preterm birth in 2011 under the accelerated approval pathway, but fundamental pharmacokinetic or pharmacodynamic (Phase 1 and Phase 2) studies were not performed. At the time, there were no dose-response or concentration-response data. The therapeutic concentration was not known. The lack of such data brings into question the dosing regimen for 17-hydroxyprogesterone caproate and if it was optimized. OBJECTIVE The purpose of this study was to evaluate the dosing regimen for 17-hydroxyprogesterone by analyzing 3 data sets in which the 17-hydroxyprogesterone caproate pharmacology was evaluated, namely the Maternal-Fetal Medicine Omega 3 study, the Obstetric-Fetal Pharmacology Research Units study, and the Obstetrical-Fetal Pharmacology Research Centers study. If an inappropriate dosing regimen could be identified, such information could inform future studies of pharmacotherapy in pregnancy. STUDY DESIGN Data from the Omega 3 study were used to determine if plasma concentration was related to spontaneous preterm birth risk and if a threshold concentration could be identified. Data from the Obstetric-Fetal Pharmacology Research Units study were used to determine the half-life of 17-hydroxyprogesterone caproate and to develop a model to simulate drug concentrations with various dosing regimens. Data from the Obstetrical-Fetal Pharmacology Research Centers study were used to determine the relationship between dose and safety outcomes. RESULTS Analysis of the Omega 3 data set indicated that the risk for spontaneous preterm birth decreased as the log concentration of 17-hydroxyprogesterone caproate increased (odds ratio, 0.04; 95% confidence interval, 0.00-0.90). A steady state concentration of >9 ng/mL (equivalent to >8 ng/mL at 25-28 weeks) was associated with the lowest risk for spontaneous preterm birth (hazard ratio, 0.52; 95% confidence interval, 0.27-0.98; P=.04); this concentration was not achieved in 25% of subjects who received the 250 mg weekly dose. In the Obstetrical-Fetal Pharmacology Research Units study, the adjusted half-life (median and interquartile range) of 17-hydroxyprogesterone caproate was 14.0 (11.5-17.2) days. Simulations indicated that with the 250 mg weekly dose, >5 weekly injections were required to reach the 9 ng/mL target; however, those with the shortest half-life (corresponding to higher clearance), never reached the targeted 9 ng/mL concentration. In 75% of subjects, a loading dose of 500 mg weekly for 2 weeks followed by 250 mg weekly achieved and maintained the 9 ng/mL concentration within 2 weeks but in those 25% with the shortest half-life, concentrations exceeded the 9 ng/mL target for only 3 weeks. In the Obstetrical-Fetal Pharmacology Research Centers study, all 65 subjects who received a weekly dose of 500 mg exceeded the 9 ng/mL steady state. CONCLUSION The dosing regimen for 17-hydroxyprogesterone caproate was inadequate. There is a significant inverse relationship between drug concentration and spontaneous preterm birth. The risk was lowest when the concentration exceeded 9 ng/mL, but 25% of women who received the 250 mg weekly dose never reached or maintained this concentration. The drug's long half-life necessitates a loading dose to achieve therapeutic concentrations rapidly. The omission of basic pharmacologic studies to determine the proper dosing may have compromised the effectiveness of 17-hydroxyprogesterone caproate. Future pharmacotherapy trials in pregnancy must first complete fundamental pharmacology studies.
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Affiliation(s)
- Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA.
| | - Prerna Dodeja
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Shringi Sharma
- Department of Clinical Pharmacology, AstraZeneca, South San Francisco, CA
| | - Wenchen Zhao
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Raman Venkataramanan
- Departments of Pharmaceutical Sciences and Pathology, University of Pittsburgh School of Pharmacy, Pittsburgh, PA; Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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12
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Van Neste M, Nauwelaerts N, Ceulemans M, Van Calsteren K, Eerdekens A, Annaert P, Allegaert K, Smits A. Determining the exposure of maternal medicines through breastfeeding: the UmbrelLACT study protocol-a contribution from the ConcePTION project. BMJ Paediatr Open 2024; 8:e002385. [PMID: 38599799 PMCID: PMC11015172 DOI: 10.1136/bmjpo-2023-002385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/20/2024] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION Breastfeeding is beneficial for the health of the mother and child. However, at least 50% of postpartum women need pharmacotherapy, and this number is rising due to the increasing prevalence of chronic diseases and pregnancies at a later age. Making informed decisions on medicine use while breastfeeding is often challenging, considering the extensive information gap on medicine exposure and safety during lactation. This can result in the unnecessary cessation of breastfeeding, the avoidance of pharmacotherapy or the off-label use of medicines. The UmbrelLACT study aims to collect data on human milk transfer of maternal medicines, child exposure and general health outcomes. Additionally, the predictive performance of lactation and paediatric physiologically based pharmacokinetic (PBPK) models, a promising tool to predict medicine exposure in special populations, will be evaluated. METHODS AND ANALYSIS Each year, we expect to recruit 5-15 breastfeeding mothers using pharmacotherapy via the University Hospitals Leuven, the BELpREG project (pregnancy registry in Belgium) or external health facilities. Each request and compound will be evaluated on relevance (ie, added value to available scientific evidence) and feasibility (including access to analytical assays). Participants will be requested to complete at least one questionnaire on maternal and child's general health and collect human milk samples over 24 hours. Optionally, two maternal and one child's blood samples can be collected. The maternal medicine concentration in human milk will be determined along with the estimation of the medicine intake (eg, daily infant dose and relative infant dose) and systemic exposure of the breastfed child. The predictive performance of PBPK models will be assessed by comparing the observed concentrations in human milk and plasma to the PBPK predictions. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee Research UZ/KU Leuven (internal study number S67204). Results will be published in peer-reviewed journals and presented at (inter)national scientific meetings. TRIAL REGISTRATION NUMBER NCT06042803.
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Affiliation(s)
- Martje Van Neste
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- L-C&Y, KU Leuven Child & Youth Institute, Leuven, Belgium
| | - Nina Nauwelaerts
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Michael Ceulemans
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- L-C&Y, KU Leuven Child & Youth Institute, Leuven, Belgium
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kristel Van Calsteren
- Gynaecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - An Eerdekens
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- BioNotus GCV, Niel, Belgium
| | - Karel Allegaert
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- L-C&Y, KU Leuven Child & Youth Institute, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Anne Smits
- L-C&Y, KU Leuven Child & Youth Institute, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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13
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Metcalfe A, Stephenson N, Cairncross ZF, Scime NV, Fidler‐Benaoudia M. Exclusion of pregnant and lactating persons from breast cancer clinical trials: a review of active trials registered on ClinicalTrials.gov. Acta Obstet Gynecol Scand 2024; 103:707-715. [PMID: 37377224 PMCID: PMC10993330 DOI: 10.1111/aogs.14599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/24/2023] [Accepted: 05/04/2023] [Indexed: 06/29/2023]
Abstract
INTRODUCTION Treatment of pregnancy-associated breast cancer is complex, as providers try to balance risks to the pregnant person and the developing fetus. Given increased case fatality and increasing incidence, there is a pressing need understand the efficacy and safety of different treatment regimens in this population; however, pregnant and lactating people have traditionally been excluded from participating in randomized controlled trials (RCTs). Given recent efforts to expand the inclusion criteria for oncology RCTs, this study aimed to review the inclusion/exclusion criteria of current breast cancer RCTs to assess what proportion of trials permitted enrollment of pregnant and lactating persons. MATERIAL AND METHODS We conducted a comprehensive search of ClinicalTrials.gov in January 2022 to identify interventional studies of breast cancer in adults that were actively recruiting. The primary outcomes were the exclusion of pregnant and lactating people. RESULTS The search identified 1706 studies, of which 1451 met eligibility criteria. Overall, 69.4% and 54.8% of studies excluded pregnant and lactating people, respectively. The exclusion of pregnant and lactating persons differed by study characteristics but extended across all trial designs, locations, phases and interventions. Exclusion of pregnant and lactating persons was most common in trials where the intervention was biological (86.3%), drug (83.5%) or radiation (81.5%). CONCLUSIONS The exclusion of pregnant and lactating people from clinical trials contributes to evidence gaps in how to treat this population. A paradigm shift is needed that focuses on how research can be used to protect pregnant people from future harms, instead of protecting pregnant people from research-related risks.
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Affiliation(s)
- Amy Metcalfe
- Department of Obstetrics and GynaecologyUniversity of CalgaryCalgaryAlbertaCanada
- Department of Community Health SciencesUniversity of CalgaryCalgaryAlbertaCanada
- Department of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Nikki Stephenson
- Department of Obstetrics and GynaecologyUniversity of CalgaryCalgaryAlbertaCanada
| | - Zoe F. Cairncross
- Department of Obstetrics and GynaecologyUniversity of CalgaryCalgaryAlbertaCanada
| | - Natalie V. Scime
- Department of Health & SocietyUniversity of Toronto ScarboroughTorontoOntarioCanada
| | - Miranda Fidler‐Benaoudia
- Department of Community Health SciencesUniversity of CalgaryCalgaryAlbertaCanada
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health ServicesCalgaryAlbertaCanada
- Department of OncologyUniversity of CalgaryCalgaryAlbertaCanada
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14
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Thornton HF, LaHue SC, Bove R, Waters J, O'Neal MA, Bui E. Emerging Subspecialties in Neurology: Women's Neurology. Neurology 2024; 102:e208009. [PMID: 38165380 PMCID: PMC10834140 DOI: 10.1212/wnl.0000000000208009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 09/27/2023] [Indexed: 01/03/2024] Open
Abstract
The influence of sex and gender on neurologic disease has become increasingly recognized in science and medicine. This is evident across a woman's lifespan especially during periods of hormonal transitions. Leaders in neurology have advocated for the importance of sex and gender-enriched clinical care, education, and research. The scope of women's neurology spans across a woman's life including puberty, adolescence, peripartum care, menopause, and aging. Women's neurology is a new subspecialty that aligns with a specific patient population and intersects with established neurology subspecialties and other specialties such as obstetrics, maternal fetal medicine, endocrinology, and psychiatry. Its establishment and collaboration with existing and emerging fields enables a more comprehensive approach to neurologic illness through the lens of sex and gender. Women's neurology is rapidly evolving through increased focus at academic centers, including expanded women's neurology curricula, dedicated women's neurology fellowship programs, improved understanding of sex and gender issues in neurosciences, and expansion of therapeutic options. Herein, we describe the history of the women's neurology field, emerging need for women's neurology specialists, information about training and career opportunities, and future directions.
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Affiliation(s)
- Hayley F Thornton
- From the Department of Clinical Neurosciences (H.F.T.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (S.C.L., R.B.), and UCSF Weill Institute for Neurosciences (S.C.L., R.B.), Department of Neurology, University of California, San Francisco; Buck Institute for Research on Aging (S.C.L.), Novato, CA; Department of Neurology (J.W.), University of Pittsburgh Medical Center, PA; Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA; Division of Neurology (E.B.), Department of Medicine, University of Toronto; and Krembil Brain Institute (E.B.), University Health Network, Toronto, Ontario, Canada
| | - Sara C LaHue
- From the Department of Clinical Neurosciences (H.F.T.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (S.C.L., R.B.), and UCSF Weill Institute for Neurosciences (S.C.L., R.B.), Department of Neurology, University of California, San Francisco; Buck Institute for Research on Aging (S.C.L.), Novato, CA; Department of Neurology (J.W.), University of Pittsburgh Medical Center, PA; Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA; Division of Neurology (E.B.), Department of Medicine, University of Toronto; and Krembil Brain Institute (E.B.), University Health Network, Toronto, Ontario, Canada
| | - Riley Bove
- From the Department of Clinical Neurosciences (H.F.T.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (S.C.L., R.B.), and UCSF Weill Institute for Neurosciences (S.C.L., R.B.), Department of Neurology, University of California, San Francisco; Buck Institute for Research on Aging (S.C.L.), Novato, CA; Department of Neurology (J.W.), University of Pittsburgh Medical Center, PA; Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA; Division of Neurology (E.B.), Department of Medicine, University of Toronto; and Krembil Brain Institute (E.B.), University Health Network, Toronto, Ontario, Canada
| | - Janet Waters
- From the Department of Clinical Neurosciences (H.F.T.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (S.C.L., R.B.), and UCSF Weill Institute for Neurosciences (S.C.L., R.B.), Department of Neurology, University of California, San Francisco; Buck Institute for Research on Aging (S.C.L.), Novato, CA; Department of Neurology (J.W.), University of Pittsburgh Medical Center, PA; Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA; Division of Neurology (E.B.), Department of Medicine, University of Toronto; and Krembil Brain Institute (E.B.), University Health Network, Toronto, Ontario, Canada
| | - Mary A O'Neal
- From the Department of Clinical Neurosciences (H.F.T.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (S.C.L., R.B.), and UCSF Weill Institute for Neurosciences (S.C.L., R.B.), Department of Neurology, University of California, San Francisco; Buck Institute for Research on Aging (S.C.L.), Novato, CA; Department of Neurology (J.W.), University of Pittsburgh Medical Center, PA; Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA; Division of Neurology (E.B.), Department of Medicine, University of Toronto; and Krembil Brain Institute (E.B.), University Health Network, Toronto, Ontario, Canada
| | - Esther Bui
- From the Department of Clinical Neurosciences (H.F.T.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Neurology (S.C.L., R.B.), and UCSF Weill Institute for Neurosciences (S.C.L., R.B.), Department of Neurology, University of California, San Francisco; Buck Institute for Research on Aging (S.C.L.), Novato, CA; Department of Neurology (J.W.), University of Pittsburgh Medical Center, PA; Department of Neurology (M.A.O.N.), Brigham and Women's Hospital, Boston, MA; Division of Neurology (E.B.), Department of Medicine, University of Toronto; and Krembil Brain Institute (E.B.), University Health Network, Toronto, Ontario, Canada
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15
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Davis K, Yost E, Brauneis J, Krumme A, Geldhof A, Tuck A, Sylvester S, Ephross S. Landscape review of global real-world data sources for studying medication use in pregnancy and lactation that support regulatory decision making. Pharmacoepidemiol Drug Saf 2024; 33:e5711. [PMID: 37850542 DOI: 10.1002/pds.5711] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 09/11/2023] [Accepted: 09/26/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE Most pregnant people take at least one medication during gestation or while breastfeeding, however data are lacking on the safety of medication use in these populations. We conducted a landscape review of real-world data sources specific to medication use in pregnancy and breastfeeding populations that have met, or have potential to meet, health authorities' requirements for post-authorization safety studies. METHODS A 2-phase approach identified data sources from literature, publicly available registers of non-interventional post-authorization studies of pregnant women, existing database inventories, and emerging data sources known to the authors. RESULTS Required key attributes were assessed according to current regulatory guidance, resulting in selection of 49 suitable data sources. All global regions were represented, with North America (37%) and Europe (33%) most common; 12% of the data sources included pregnancy information from low-to middle-income countries. Administrative healthcare claims (25%) and electronic healthcare records (21%) comprised the largest types of data sources. Across data sources, 53% were managed by national or regional governments, 27% by industry, and 20% by academic institutions. Maternal age, diagnoses, prenatal care, and reproductive history were available in most, whereas fewer included demographic data (e.g., race/ethnicity). Breastfeeding data were collected in 37% of the final data sources. CONCLUSION We conducted a systematic approach to data source evaluation of pregnancy and breastfeeding to be used as a resource for investigators to consider when designing pregnancy-related research studies to satisfy regulatory requirements.
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Affiliation(s)
- Kourtney Davis
- Global Epidemiology, Janssen Research and Development, LLC, Titusville, New Jersey, USA
| | - Emily Yost
- Global Epidemiology, Janssen Research and Development, LLC, Titusville, New Jersey, USA
| | | | - Alexis Krumme
- Global Epidemiology, Janssen Research and Development, LLC, Titusville, New Jersey, USA
| | - Anja Geldhof
- Medical Affairs, Janssen Biologics B.V, Leiden, The Netherlands
| | - Astrud Tuck
- Data Sciences, Janssen Research and Development, LLC, New Brunswick, New Jersey, USA
| | | | - Sara Ephross
- Real World & Late Phase, Syneos Health, Morrisville, North Carolina, USA
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16
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Crescioli G, Lombardi N, Vannacci A. Editorial: Safety of drugs and CAM products in pregnancy and breastfeeding: evidence from clinical toxicology. Front Pharmacol 2023; 14:1340283. [PMID: 38125890 PMCID: PMC10731452 DOI: 10.3389/fphar.2023.1340283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023] Open
Affiliation(s)
- Giada Crescioli
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
- Tuscan Regional Centre of Pharmacovigilance, Florence, Italy
| | - Niccolò Lombardi
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
- Tuscan Regional Centre of Pharmacovigilance, Florence, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
- Tuscan Regional Centre of Pharmacovigilance, Florence, Italy
- Joint Laboratory of Technological Solutions for Clinical Pharmacology, Pharmacovigilance and Bioinformatics, University of Florence, Florence, Italy
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17
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Baxter C, Crary I, Coler B, Marcell L, Huebner EM, Rutz S, Adams Waldorf KM. Addressing a broken drug pipeline for preterm birth: why early preterm birth is an orphan disease. Am J Obstet Gynecol 2023; 229:647-655. [PMID: 37516401 PMCID: PMC10818026 DOI: 10.1016/j.ajog.2023.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/19/2023] [Accepted: 07/23/2023] [Indexed: 07/31/2023]
Abstract
Preterm birth remains one of the most urgent unresolved medical problems in obstetrics, yet only 2 therapeutics for preventing preterm birth have ever been approved by the United States Food and Drug Administration, and neither remains on the market. The recent withdrawal of 17-hydroxyprogesterone caproate (17-OHPC, Makena) marks a new but familiar era for obstetrics with no Food and Drug Administration-approved pharmaceuticals to address preterm birth. The lack of pharmaceuticals reflects a broad and ineffective pipeline hindered by extensive regulatory hurdles, soaring costs of performing drug research, and concerns regarding adverse effects among a particularly vulnerable population. The pharmaceutical industry has historically limited investments in research for diseases with similarly small markets, such as cystic fibrosis, given their rarity and diminished projected financial return. The Orphan Drug Act, however, incentivizes drug development for "orphan diseases", defined as affecting <200,000 people in the United States annually. Although the total number of preterm births in the United States exceeds this threshold annually, the early subset of preterm birth (<34 weeks' gestation) would qualify, which is predominantly caused by inflammation and infection. The scientific rationale for classifying preterm birth into early and late subsets is strong given that their etiologies differ, and therapeutics that may be efficacious for one subset may not work for the other. For example, antiinflammatory therapeutics would be expected to be highly effective for early but not late preterm birth. A robust therapeutic pipeline of antiinflammatory drugs already exists, which could be used to target spontaneous early preterm birth, in combination with antibiotics shown to sterilize the amniotic cavity. New applications for therapeutics targeting spontaneous early preterm birth could categorize as orphan disease drugs, which could revitalize the preterm birth therapeutic pipeline. Herein, we describe why drugs targeting early preterm birth should qualify for orphan status, which may increase pharmaceutical interest for this vitally important obstetrical condition.
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Affiliation(s)
- Carly Baxter
- School of Medicine, University of Washington, Seattle, WA
| | - Isabelle Crary
- School of Medicine, University of Washington, Seattle, WA
| | - Brahm Coler
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| | - Lauren Marcell
- School of Medicine, University of Washington, Seattle, WA
| | | | - Sara Rutz
- School of Medicine, University of Washington, Seattle, WA
| | - Kristina M Adams Waldorf
- Departments of Obstetrics and Gynecology and Global Health, University of Washington, Seattle, WA.
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18
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Subramanian A, Lee SI, Hemali Sudasinghe SPB, Wambua S, Phillips K, Singh M, Azcoaga-Lorenzo A, Cockburn N, Wang J, Fagbamigbe A, Usman M, Damase-Michel C, Yau C, Kent L, McCowan C, OReilly D, Santorelli G, Hope H, Kennedy J, Mhereeg M, Abel KM, Eastwood KA, Black M, Loane M, Moss N, Brophy S, Brocklehurst P, Dolk H, Nelson-Piercy C, Nirantharakumar K. Detection and evaluation of signals associated with exposure to individual and combination of medications in pregnancy: a signal detection study protocol. BMJ Open 2023; 13:e073162. [PMID: 37813531 PMCID: PMC10565241 DOI: 10.1136/bmjopen-2023-073162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/15/2023] [Indexed: 10/13/2023] Open
Abstract
INTRODUCTION Considering the high prevalence of polypharmacy in pregnant women and the knowledge gap in the risk-benefit safety profile of their often-complex treatment plan, more research is needed to optimise prescribing. In this study, we aim to detect adverse and protective effect signals of exposure to individual and pairwise combinations of medications during pregnancy. METHODS AND ANALYSIS Using a range of real-world data sources from the UK, we aim to conduct a pharmacovigilance study to assess the safety of medications prescribed during the preconception period (3 months prior to conception) and first trimester of pregnancy. Women aged between 15 and 49 years with a record of pregnancy within the Clinical Practice Research Datalink (CPRD) Pregnancy Register, the Welsh Secure Anonymised Information Linkage (SAIL), the Scottish Morbidity Record (SMR) data sets and the Northern Ireland Maternity System (NIMATS) will be included. A series of case control studies will be conducted to estimate measures of disproportionality, detecting signals of association between a range of pregnancy outcomes and exposure to individual and combinations of medications. A multidisciplinary expert team will be invited to a signal detection workshop. By employing a structured framework, signals will be transparently assessed by each member of the team using a questionnaire appraising the signals on aspects of temporality, selection, time and measurement-related biases and confounding by underlying disease or comedications. Through group discussion, the expert team will reach consensus on each of the medication exposure-outcome signal, thereby excluding spurious signals, leaving signals suggestive of causal associations for further evaluation. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Independent Scientific Advisory Committee, SAIL Information Governance Review Panel, University of St. Andrews Teaching and Research Ethics Committee and Office for Research Ethics Committees Northern Ireland (ORECNI) for access and use of CPRD, SAIL, SMR and NIMATS data, respectively.
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Affiliation(s)
| | - Siang Ing Lee
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Steven Wambua
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Katherine Phillips
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Megha Singh
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Amaya Azcoaga-Lorenzo
- Division of Population and Behavioural Sciences, University of Saint Andrews School of Medicine, St. Andrews, Fife, UK
- Hospital Rey Juan Carlos. Research Network on Chronicity, Primary Care and Health Promotion-RICAPPS (RICORS), Instituto de Investigación Sanitaria Fundación Jimenez Diaz, Madrid, Spain
| | - Neil Cockburn
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jingya Wang
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Adeniyi Fagbamigbe
- Division of Population and Behavioural Sciences, University of Saint Andrews School of Medicine, St. Andrews, Fife, UK
- Department of Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria
| | - Muhammad Usman
- Division of Population and Behavioural Sciences, University of Saint Andrews School of Medicine, St. Andrews, Fife, UK
| | - Christine Damase-Michel
- Medical and Clinical Pharmacology, School of Medicine, Université Toulouse III, Toulouse, France
- Center for Epidemiology and Research in Population Health (CERPOP), INSERM, Toulouse, France
| | - Christopher Yau
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Lisa Kent
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Colin McCowan
- Division of Population and Behavioural Sciences, University of Saint Andrews School of Medicine, St. Andrews, Fife, UK
| | - Dermot OReilly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | | | - Holly Hope
- Centre for Women's Mental Health, Faculty of Biology Medicine & Health, University of Manchester, Manchester, UK
| | | | | | - Kathryn Mary Abel
- Centre for Women's Mental Health, Faculty of Biology Medicine & Health, University of Manchester, Manchester, UK
- Manchester Mental Health & Social Care Trust, Manchester, UK
| | - Kelly-Ann Eastwood
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Mairead Black
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Science and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Maria Loane
- The Institute of Nursing and Health Research, University of Ulster, Belfast, UK
| | | | - Sinead Brophy
- Data Science, Medical School, Swansea University, Swansea, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Helen Dolk
- The Institute of Nursing and Health Research, University of Ulster, Belfast, UK
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19
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Li Y, Wu Y, Jiang T, Xing H, Xu J, Li C, Ni R, Zhang N, Xiang G, Li L, Li Z, Gan L, Liu Y. Opportunities and challenges of pharmacovigilance in special populations: a narrative review of the literature. Ther Adv Drug Saf 2023; 14:20420986231200746. [PMID: 37780667 PMCID: PMC10540608 DOI: 10.1177/20420986231200746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023] Open
Abstract
The relatively new discipline of pharmacovigilance (PV) aims to monitor the safety of drugs throughout their evolution and is essential to discovering new drug risks. Due to their specific and complex physiology, children, pregnant women, and elderly adults are more prone to adverse drug reactions (ADRs). Additionally, the lack of clinical trial data exacerbates the challenges faced with pharmacotherapy in these populations. Elderly patients tend to have multiple comorbidities often requiring more extensive medication, which adds additional challenges for healthcare professionals (HCPs) in delivering safe and effective pharmacotherapy. Clinical trials often have inherent limitations, including insufficient sample size and limited duration of research; as some ADRs are attributed to long-term use of a drug, these may go undetected during the course of the trial. Therefore, the implementation of PV is key to insuring the safe and effective use of drugs in special populations. We conducted a thorough review of the scientific literature on PV systems across the European Union, the United States, and China. Our review focused on basic physiological characteristics, drug use, and PV for specific populations (children, pregnant women, and the elderly). This article aims to provide a reference for the development of follow-up policies and improvement of existing policies as well as provide insight into drug safety with respect to patients of special populations.
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Affiliation(s)
- Yanping Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Yuanlin Wu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Tingting Jiang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Haiyan Xing
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Jing Xu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Chen Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Rui Ni
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Ni Zhang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Guiyuan Xiang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Li Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Ziwei Li
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Lanlan Gan
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Yao Liu
- Department of Pharmacy, Daping Hospital, Army Medical University, No. 10 Changjiang Branch Road, Yuzhong District, Chongqing 400042, China
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20
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Crooks CM, Chan C, Permar SR. Leveraging preclinical study designs to close gaps in vaccine development for perinatal pathogens. J Exp Med 2023; 220:e20230184. [PMID: 37289272 PMCID: PMC10250551 DOI: 10.1084/jem.20230184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
Vaccines to perinatal pathogens are critical for both reducing the burden of endemic pathogens and preparing for the next pandemic. Although they are often at greater risk of severe disease from infection, pregnant people and children are routinely marginalized in the vaccine development process. We highlight several challenges in the vaccine development process and how three tools-translational animal models, human cohort studies of natural infection, and innovative data-use strategies-can speed vaccine development and ensure equity for pregnant people and children in the next pandemic.
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Affiliation(s)
| | - Cliburn Chan
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Sallie R. Permar
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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21
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Shareef J, Sridhar SB, Bhupathyraaj M, Shariff A, Thomas S, Salim Karattuthodi M. Assessment of the scope, completeness, and consistency of various drug information resources related to COVID-19 medications in pregnancy and lactation. BMC Pregnancy Childbirth 2023; 23:296. [PMID: 37106456 PMCID: PMC10134615 DOI: 10.1186/s12884-023-05609-2] [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: 11/30/2022] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Drug use in pregnancy and lactation is challenging. It becomes more challenging in pregnant and lactating women with certain critical clinical conditions such as COVID-19, because of inconsistent drug safety data. Therefore, we aimed to evaluate the various drug information resources for the scope, completeness, and consistency of the information related to COVID-19 medications in pregnancy and lactation. METHODS Data related to COVID-19 medications from various drug information resources such as text references, subscription databases, and free online tools were used for the comparison. The congregated data were analyzed for scope, completeness, and consistency. RESULTS Scope scores were highest for Portable Electronic Physician Information Database (PEPID), Up-to-date, and drugs.com compared to other resources. The overall completeness scores were higher for Micromedex and drugs.com (p < 0.05 compared to all other resources). The inter-reliability analysis for overall components by Fleiss kappa among all the resources was found to be 'slight' (k < 0.20, p < 0.0001). The information related to the older drugs in most of the resources, provides in-depth details on various components such as pregnancy safety, clinical data related to lactation, the effect of the drug distribution into breast milk, reproductive potential/infertility risk and the pregnancy category/recommendations. However, the information related to these components for newer drugs was superficial and incomplete, with insufficient data and inconclusive evidence, which is a statistically significant observation. The strength of observer agreement for the various COVID-19 medications ranged from poor to fair and moderate for the various recommendation categories studied. CONCLUSION This study reports discrepancies in the information related to pregnancy, lactation, drug level, reproductive risk, and pregnancy recommendations among the resources directing to refer to more than one resource for information about the safe and quality use of medications in this special population.The present study also emphasizes the need for development of comprehensive, evidence-based, and precise information guide that can promote safe and effective drug use in this special population.
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Affiliation(s)
- Javedh Shareef
- Department of Clinical Pharmacy & Pharmacology, RAK College of Pharmacy, RAK Medical & Health Sciences University, Ras Al Khaimah, United Arab Emirates.
| | - Sathvik Belagodu Sridhar
- Department of Clinical Pharmacy & Pharmacology, RAK College of Pharmacy, RAK Medical & Health Sciences University, Ras Al Khaimah, United Arab Emirates
| | | | - Atiqulla Shariff
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Mysuru, Karnataka, India
| | - Sabin Thomas
- School of Pharmacy, College of Health Sciences, University of Nizwa, Nizwa, 616, Oman
| | - Mohammed Salim Karattuthodi
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
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22
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Thiele LR, Spong CY. Inclusion of Pregnant and Lactating People in Clinical Research: Lessons Learned and Opportunities. Obstet Gynecol Clin North Am 2023; 50:17-25. [PMID: 36822702 DOI: 10.1016/j.ogc.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Pregnant and lactating individuals historically have been excluded from research studies because of the ethical concerns surrounding potential harm to the fetus. Several National Institutes of Health and Food and Drug Administration initiatives have attempted to improve inclusion; however, clinical trials continue to exclude pregnant and lactating people. Drug labeling for safety and efficacy in pregnancy has thus been forced to rely on data from animal studies or limited case reports. Recent changes have sought to improve prescriber understanding of risks, benefits, and limitations of safety information on medications; however, confusion persists.
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Affiliation(s)
- Lisa R Thiele
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9032, USA
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9032, USA; Parkland Health, Dallas, TX 75390-9032, USA.
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23
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Prenatal Exposure to Parental Lifestyle Factors, Diseases, and Use of Medications and Male Pubertal Development: a Review of Epidemiological Studies Published 2017–2022. CURR EPIDEMIOL REP 2023. [DOI: 10.1007/s40471-023-00320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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24
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Van Norman GA. Off-Label Use vs Off-Label Marketing of Drugs: Part 1: Off-Label Use-Patient Harms and Prescriber Responsibilities. JACC Basic Transl Sci 2023; 8:224-233. [PMID: 36908673 PMCID: PMC9998554 DOI: 10.1016/j.jacbts.2022.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 03/02/2023]
Abstract
Once medical drugs and devices are approved for marketing by the FDA they can legally be used for purposes and in ways other than the ones for which they have been tested and approved. However, it is illegal for manufacturers to advertise or promote such unapproved uses of the drugs and devices. Part 1 of this review focuses on off-label use of FDA-approved therapies. Part 2 addresses illegal off-label marketing of drugs and devices. While off-label use can be beneficial to patients, unless carefully undertaken off label use may undermine the important safety mission of the FDA, can expose patients to elevated risks without proven benefits (or possibly no benefit), and can reduce motivation of companies to study the safety and risks of off-label use of therapies. These problems are further amplified when off-label use occurs among very vulnerable patient populations such as the elderly, patients with mental health disorders, pregnant women and pediatric patients. This review considers ethical issues in off-label use, as well as important steps for physicians considering an off-label prescription of a drug or device.
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Affiliation(s)
- Gail A Van Norman
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
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25
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Human Maternal-Fetal Interface Cellular Models to Assess Antiviral Drug Toxicity during Pregnancy. REPRODUCTIVE MEDICINE 2022. [DOI: 10.3390/reprodmed3040024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Pregnancy is a period of elevated risk for viral disease severity, resulting in serious health consequences for both the mother and the fetus; yet antiviral drugs lack comprehensive safety and efficacy data for use among pregnant women. In fact, pregnant women are systematically excluded from therapeutic clinical trials to prevent potential fetal harm. Current FDA-recommended reproductive toxicity assessments are studied using small animals which often do not accurately predict the human toxicological profiles of drug candidates. Here, we review the potential of human maternal-fetal interface cellular models in reproductive toxicity assessment of antiviral drugs. We specifically focus on the 2- and 3-dimensional maternal placental models of different gestational stages and those of fetal embryogenesis and organ development. Screening of drug candidates in physiologically relevant human maternal-fetal cellular models will be beneficial to prioritize selection of safe antiviral therapeutics for clinical trials in pregnant women.
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26
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Olagunju A, Mathad J, Eke A, Delaney-Moretlwe S, Lockman S. Considerations for the Use of Long-Acting and Extended-Release Agents During Pregnancy and Lactation. Clin Infect Dis 2022; 75:S571-S578. [PMID: 36410383 PMCID: PMC10200321 DOI: 10.1093/cid/ciac659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Long-acting agents hold significant promise for treating and preventing common illnesses, including infections. Pharmacokinetic and safety data during pregnancy and lactation are often unavailable for new drugs; these data are vital to facilitate optimal drug use by pregnant and lactating women and women who may conceive. In this commentary, we summarize the circumstances in which pregnant and lactating women are likely to use and benefit from long-acting agents. We focus on long-acting formulations of small molecules (rather than biologics such as monoclonal antibodies) and on several infections of global importance (human immunodeficiency virus, tuberculosis, malaria, and hepatitis C). We discuss pregnancy pharmacokinetic/pharmacodynamic and potential safety and efficacy considerations pertaining to the use of long-acting agents in pregnancy and lactation. Finally, we summarize existing preclinical and pregnancy pharmacokinetic data that are available (or expected in the near future) for several agents that are under development or approved, and how key research gaps may be addressed.
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Affiliation(s)
- Adeniyi Olagunju
- Centre of Excellence for Long-acting Therapeutics, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Jyoti Mathad
- Department of Medicine and Obstetrics and Gynecology, Center for Global Health, Weill Cornell Medicine, New York, New York, USA
| | - Ahizechukwu Eke
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sinead Delaney-Moretlwe
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Shahin Lockman
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
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27
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Hardy S, Choo YM, Hamann M, Cray J. Manzamine-A Alters In Vitro Calvarial Osteoblast Function. Mar Drugs 2022; 20:647. [PMID: 36286470 PMCID: PMC9604769 DOI: 10.3390/md20100647] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/07/2022] [Accepted: 10/14/2022] [Indexed: 11/17/2022] Open
Abstract
Manzamine-A is a marine-derived alkaloid which has anti-viral and anti-proliferative properties and is currently being investigated for its efficacy in the treatment of certain viruses (malaria, herpes, HIV-1) and cancers (breast, cervical, colorectal). Manzamine-A has been found to exert effects via modulation of SIX1 gene expression, a gene critical to craniofacial development via the WNT, NOTCH, and PI3K/AKT pathways. To date little work has focused on Manzamine-A and how its use may affect bone. We hypothesize that Manzamine-A, through SIX1, alters bone cell activity. Here, we assessed the effects of Manzamine-A on cells that are responsible for the generation of bone, pre-osteoblasts and osteoblasts. PCR, qrtPCR, MTS cell viability, Caspase 3/7, and functional assays were used to test the effects of Manzamine-A on these cells. Our data suggests Six1 is highly expressed in osteoblasts and their progenitors. Further, osteoblast progenitors and osteoblasts exhibit great sensitivity to Manzamine-A treatment exhibited by a significant decrease in cell viability, increase in cellular apoptosis, and decrease in alkaline phosphatase activity. In silico binding experiment showed that manzamine A potential as an inhibitor of cell proliferation and survival proteins, i.e., Iκb, JAK2, AKT, PKC, FAK, and Bcl-2. Overall, our data suggests Manzamine-A may have great effects on bone health overall and may disrupt skeletal development, homeostasis, and repair.
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Affiliation(s)
- Samantha Hardy
- Department of Biomedical Education and Anatomy, College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Yeun-Mun Choo
- Chemistry Department, Faculty of Science, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Mark Hamann
- Departments of Drug Discovery and Biomedical Sciences and Public Health, Colleges of Pharmacy and Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - James Cray
- Department of Biomedical Education and Anatomy, College of Medicine, The Ohio State University, Columbus, OH 43210, USA
- Division of Biosciences, The Ohio State College of Dentistry, Columbus, OH 43210, USA
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Timms K, Holder B, Day A, Mclaughlin J, Forbes KA, Westwood M. Watermelon-Derived Extracellular Vesicles Influence Human Ex Vivo Placental Cell Behavior by Altering Intestinal Secretions. Mol Nutr Food Res 2022; 66:e2200013. [PMID: 35938208 PMCID: PMC9787345 DOI: 10.1002/mnfr.202200013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 06/20/2022] [Indexed: 12/30/2022]
Abstract
SCOPE During pregnancy, mother-to-fetus transfer of nutrients is mediated by the placenta; sub-optimal placental development and/or function results in fetal growth restriction (FGR), and the attendant risk of stillbirth, neurodevelopmental delay, and non-communicable diseases in adulthood. A maternal diet high in fruit and vegetables lowers the risk of FGR but the association cannot be explained fully by known macro- and micronutrients. METHODS AND RESULTS This study investigates if dietary-derived extracellular vesicles (EVs) can regulate placental function. The study characterizes the microRNA and protein cargo of EVs isolated from watermelon, show they are actively internalized by human intestinal epithelial cells in vitro, use mass spectrometry to demonstrate that they alter the intestinal secretome and bioinformatic analyses to predict the likely affected pathways in cells/tissues distal to gut. Application of the watermelon EV-modified intestinal secretome to human placental trophoblast cells and ex vivo tissue explants affects the trophoblast proteome and key aspects of trophoblast behavior, including migration and syncytialization. CONCLUSION Dietary-derived plant EVs can modify intestinal communication with distal tissues, including the placenta. Harnessing the beneficial properties of dietary-derived plant EVs and/or exploiting their potential as natural delivery agents may provide new ways to improve placental function and reduce rates of FGR.
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Affiliation(s)
- Kate Timms
- Maternal and Fetal Health Research CentreSchool of Medical SciencesUniversity of ManchesterManchesterM13 9WLUK,Manchester University NHS Foundation TrustManchester Academic Health Sciences CentreManchesterM13 9WLUK
| | - Beth Holder
- Department of MetabolismDigestion and ReproductionInstitute of Reproductive and Developmental BiologyImperial College LondonLondonUK
| | - Anil Day
- Division of Molecular and Cellular FunctionSchool of Biological SciencesUniversity of ManchesterManchesterM13 9PTUK
| | - John Mclaughlin
- Division of DiabetesEndocrinology and GastroenterologyUniversity of ManchesterManchesterM13 9PTUK,Department of GastroenterologySalford Royal NHS Foundation TrustSalfordM6 8HDUK
| | - Karen A. Forbes
- Discovery and Translational Science DepartmentLeeds Institute of Cardiovascular and Metabolic MedicineFaculty of Medicine and HealthUniversity of LeedsLeedsLS2 9JTUK
| | - Melissa Westwood
- Maternal and Fetal Health Research CentreSchool of Medical SciencesUniversity of ManchesterManchesterM13 9WLUK,Manchester University NHS Foundation TrustManchester Academic Health Sciences CentreManchesterM13 9WLUK
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Burnham J, Darsey E. Maternal-Fetal Drug Development: An Industry Perspective. J Clin Pharmacol 2022; 62 Suppl 1:S18-S29. [PMID: 36106788 PMCID: PMC9541578 DOI: 10.1002/jcph.2124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/12/2022] [Indexed: 11/29/2022]
Abstract
Medicines and vaccines prescribed to pregnant women often have not had pregnant women or lactating women included in clinical trials and products are often not approved by regulatory agencies for use in pregnant women. As a result, practitioners may need to prescribe medicines and give vaccines to this special population with limited drug efficacy and safety information available. Multiple regulatory guidance documents regarding the development of medications for pregnant and lactating women have been developed to encourage drug development and the investigation of medicines and vaccines used in this population. However, clinical, regulatory, ethical, and drug development challenges are encountered when designing clinical trials that include pregnant women and their fetuses, in which innovative methods and trial designs are essential. This article provides an overview of an industry perspective on maternal-fetal drug development that includes a review of the regulatory landscape for developing medicines for pregnant women and their fetuses, trial designs that include pregnant women, identification of gaps and challenges, and strategies for potential maternal-fetal drug development considerations for the future development of medicines and vaccines for pregnant women. Early involvement and discussion of drug and vaccine products with multiple stakeholders, including therapeutic experts, patients, physicians, and regulators, is encouraged to optimize the development of safe and effective medicines and vaccines for pregnant women and their fetuses.
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Affiliation(s)
- Janelle Burnham
- Pfizer, Global Product DevelopmentPediatric Center of ExcellenceNew York CityNew YorkUSA
| | - Edress Darsey
- Pfizer, Global Product DevelopmentPediatric Center of ExcellenceNew York CityNew YorkUSA
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30
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Brummel SS, Stringer J, Mills E, Tierney C, Caniglia EC, Colbers A, Chi BH, Best BM, Gaaloul ME, Hillier S, Jourdain G, Khoo SH, Mofenson LM, Myer L, Nachman S, Stranix‐Chibanda L, Clayden P, Sachikonye M, Lockman S. Clinical and population-based study design considerations to accelerate the investigation of new antiretrovirals during pregnancy. J Int AIDS Soc 2022; 25 Suppl 2:e25917. [PMID: 35851758 PMCID: PMC9294861 DOI: 10.1002/jia2.25917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 04/28/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Pregnant women are routinely excluded from clinical trials, leading to the absence or delay in even the most basic pharmacokinetic (PK) information needed for dosing in pregnancy. When available, pregnancy PK studies use a small sample size, resulting in limited safety information. We discuss key study design elements that may enhance the timely availability of pregnancy data, including the role and timing of randomized controlled trials (RCTs) to evaluate pregnancy safety; efficacy and safety outcome measures; stand-alone protocols, platform trials, single arm studies, sample size and the effect that follow-up time during gestation has on analysis interpretations; and observational studies. DISCUSSION Pregnancy PK should be studied during drug development, after dosing in non-pregnant persons is established (unless non-clinical or other data raise pregnancy concerns). RCTs should evaluate the safety during pregnancy of priority new HIV agents that are likely to be used by large numbers of females of childbearing age. Key endpoints for pregnancy safety studies include birth outcomes (prematurity, small for gestational age and stillbirth) and neonatal death, with traditional adverse events and infant growth also measured (congenital anomalies are best studied through surveillance). We recommend that viral efficacy be studied as a secondary endpoint of pregnancy RCTs, once PK studies confirm adequate drug exposure in pregnancy. RCTs typically use a stand-alone protocol for new agents. In contrast, master protocols using a platform design can add agents over time, possibly speeding safety data ascertainment. To speed accrual, stand-alone pregnancy trial protocols can include pre-specified starting rules based upon adequate PK levels in pregnancy; and seamless master protocols or platform trials can include a pregnancy PK and safety component. When RCTs are unethical or cost-prohibitive, observational studies should be conducted, preferably using target trial emulation to avoid bias. CONCLUSIONS Pregnancy PK needs to be obtained earlier in drug evaluation. Timely RCTs are needed to understand safety in pregnancy for high-priority new HIV agents. RCTs that enrol pregnant women should focus on outcomes unique to pregnancy, and observational studies should focus on questions that RCTs are not equipped to answer.
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Affiliation(s)
- Sean S. Brummel
- Department of BiostatisticsCenter for Biostatistics in AIDS ResearchBostonMassachusettsUSA
- Harvard T.H. Chan School of Public HeathBostonMassachusettsUSA
| | - Jeff Stringer
- School of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Ed Mills
- MTEK SciencesVancouverBritish ColumbiaCanada
- MTEK SciencesKigaliRwanda
| | - Camlin Tierney
- Department of BiostatisticsCenter for Biostatistics in AIDS ResearchBostonMassachusettsUSA
- Harvard T.H. Chan School of Public HeathBostonMassachusettsUSA
| | - Ellen C. Caniglia
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Angela Colbers
- Department of PharmacyRadboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Benjamin H. Chi
- Department of Obstetrics and GynecologyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical SciencesSan DiegoCaliforniaUSA
- Pediatrics Department – Rady Children's Hospital San DiegoUniversity of California San DiegoLa JollaCaliforniaUSA
| | | | - Sharon Hillier
- Department of ObstetricsGynecology and Reproductive SciencesUniversity of Pittsburgh and the Magee‐Womens Research InstitutePittsburghPennsylvaniaUSA
| | | | - Saye H. Khoo
- Department of PharmacologyUniversity of LiverpoolLiverpoolUK
| | - Lynne M. Mofenson
- Research DepartmentElizabeth Glaser Pediatric AIDS FoundationWashingtonDCUSA
| | - Landon Myer
- Division of Epidemiology & BiostatisticsSchool of Public Health & Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Sharon Nachman
- Department of PediatricsThe State University of New York (SUNY)Stony BrookNew YorkUSA
| | - Lynda Stranix‐Chibanda
- Child and Adolescent Health UnitFaculty of Medicine and Health Sciences, University of ZimbabweHarareZimbabwe
| | | | | | - Shahin Lockman
- Harvard T.H. Chan School of Public HeathBostonMassachusettsUSA
- Brigham and Women's HospitalBostonMassachusettsUSA
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Sun ML, Bai WP, Song QK, Wang HY, Gao GL, Zheng L, Wang XH. Metformin With or Without Clomiphene Citrate Versus Laparoscopic Ovarian Drilling With or Without Clomiphene Citrate to Treat Patients With Clomiphene Citrate-Resistant Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis. Front Pharmacol 2022; 13:576458. [PMID: 35814214 PMCID: PMC9256960 DOI: 10.3389/fphar.2022.576458] [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: 09/04/2020] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Which is optimal to treat clomiphene citrate-resistant polycystic ovary syndrome (CCR-PCOS) with LOD or metformin remains a problem. There are three inconsistent or even contradictory views.Objectives: The present meta-analysis aimed to evaluate the effectiveness and safety of Metformin with or without CC and to compare them with LOD with or without CC (Met/Met-CC vs. LOD/LOD-CC) in women with CCR-PCOS who also have anovulation.Data source: The PubMed, Cochrane, and Embase databases were searched to identify relevant studies reported between 1 Jan 1966 and 31 Aug 2019; the search was updated on 17 May 2022.Study eligibility criteria: We included randomized controlled trials (RCTs) of CCR-PCOS that had considered Met/Met-CC and LOD/LOD-CC as the exposure variables and fertility as the main outcome variable.Study appraisal and synthesis methods: We assessed study quality using the Cochrane risk-of-bias tool. The primary effectiveness outcome was live birth/ongoing pregnancy rate and the primary safety outcome was miscarriage rate. A fixed-effect meta-analysis was performed. The robustness of the results was assessed using sensitivity analyses. Meta-regression and subgroup analysis were performed to examine the reasons for heterogeneity. Publication bias was examined using the funnel plot, Egger linear regression, and Begg rank correlation tests. The quality of this meta-analysis was estimated according to the GRADE approach. This meta-analysis has been registered in PROSPERO (CRD42021240156).Results: Among 71 potentially relevant studies, we included five RCTs in our meta-analysis. We found no difference in effectiveness between Met-CC and LOD in terms of live birth/ongoing pregnancy (RR = 1.02, 95% CI: 0.87–1.21, z = 0.28; p = 0.780), and miscarriage rates (RR = 0.79, 95% CI: 0.46–1.36, z = 0.86; p = 0.390). I2 tests results revealed moderate or no heterogeneity (I2 = 51.4%, p = 0.083; I2= 0.0%; p = 0.952). Sensitivity analysis confirmed the robustness of the results. Funnel plot, Egger linear regression, and Begg rank correlation tests implied no publication bias (p > 0.05). LOD was more expensive than Met (€1050 vs. €50.16). The evidence quality was moderate.Conclusion: There is no evidence on the difference in the outcomes between the two interventions regarding ovulation, pregnancy, and live birth. As LOD is an invasive procedure and carries inherent risks, the use of Met/Met-CC should be the second-line treatment for women with CCR-PCOS.Systematic Review Registration: identifier CRD42021240156.
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Affiliation(s)
- Ming-Li Sun
- Phase I Clinical Trial Center, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Wen-Pei Bai
- Department of Gynecology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Qing-Kun Song
- Department of Science and Technology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Hui-Ying Wang
- Department of Gynecology, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Guo-Lan Gao
- Department of Gynecology, Shenzhen Hospital Affiliated to Savaid Medical School, University of Chinese Academy of Sciences, Shenzhen, China
- *Correspondence: Guo-Lan Gao, ; Liang Zheng, ; Xing-He Wang,
| | - Liang Zheng
- Research Center for Translational Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Guo-Lan Gao, ; Liang Zheng, ; Xing-He Wang,
| | - Xing-He Wang
- Phase I Clinical Trial Center, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing, China
- *Correspondence: Guo-Lan Gao, ; Liang Zheng, ; Xing-He Wang,
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Influence of Liposomes’ and Lipoplexes’ Physicochemical Characteristics on Their Uptake Rate and Mechanisms by the Placenta. Int J Mol Sci 2022; 23:ijms23116299. [PMID: 35682978 PMCID: PMC9181748 DOI: 10.3390/ijms23116299] [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: 05/12/2022] [Revised: 05/29/2022] [Accepted: 06/02/2022] [Indexed: 02/04/2023] Open
Abstract
Pregnant women are still considered as drug orphans. Developing new medications for pregnancy complications is an urgent need. Nanomedicines seem to be a promising approach to control the biodistribution of drugs to ensure both the mother’s and the fetus’ safety. Understanding the interaction between nanoparticles and the placental barrier is a key factor to the success of the development of nanomedicines for pregnant women. In this study, we evaluated the behavior of fluorescent PEGylated liposomes and lipoplexes in human placental tissue using in vitro and ex vivo models, BeWo cell culture and suspended villous placental explants, respectively. Fluorescent based analytical tools such as Fluorescence activated cells sorting (FACS), confocal microscopy and HPLC coupled to fluorescence detection were used to assess liposomes penetration and their endocytosis mechanisms in the placenta. First, no influence of the PEGylation density was observed on the cellular internalization of liposomal formulations using both models. The comparison between neutral and cationic liposomes exhibits a significant higher internalization of the cationic formulation compared to the neutral ones. In addition, the HPLC quantification of the fluorescent liposomes in human villous explants demonstrated an increase of cationic liposomes uptake with increasing incubation concentrations. Similar uptake of cationic liposomes and lipoplexes, containing the same cationic lipid, the DMAPAP but with an overall neutral surface charge, was observed and evidenced the higher effect of composition than charge surface on trophoblast penetration. Moreover, both cationic liposomes and lipoplexes exhibited an endocytosis mechanism of internalization via pathways implicating dynamin. These data highlight the key role of the liposome’s lipid composition and the possibility to modulate their internalization in the placenta by adjusting their design.
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Shawahna R, Zaid L. Concentrations of antiseizure medications in breast milk of lactating women with epilepsy: A systematic review with qualitative synthesis. Seizure 2022; 98:57-70. [PMID: 35427849 DOI: 10.1016/j.seizure.2022.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 03/20/2022] [Accepted: 03/25/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Recent position papers and guidelines encourage women with epilepsy (WWE) to exclusively breastfeed their infants because the benefits to their infants outweigh the potential adverse effects caused by exposure to antiseizure medications (ASMs). OBJECTIVE The objectives of this review were: to evaluate concentrations of ASMs in breastmilk of lactating WWE, qualitatively synthesize evidence that can be used to estimate theoretical doses as estimated daily intake (EDI) and relative infant dose (RID) of ASMs, and to evaluate potential risks to infants as a result of exposure to ASMs from breastmilk. METHODS This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) as CRD42020223645. The databases: MEDLINE/PubMed, EMBASE, CINAHL/EBSCO, COCHRANE, SpringerLink, ScienceDirect, Summon, WHO International Clinical Trials Registry Platform, and SCOPUS were systematically searched. A qualitative synthesis was adopted in this study. RESULTS A total of 15 records were included in this systematic review. The included studies reported levels of 8 ASMs in the breastmilk of WWE. The highest RIDs of carbamazepine, lamotrigine, primidone, phenobarbital, gabapentin, valproic acid, ethosuximide, levetiracetam, and topiramate were 3.70%, 36.33%, 4.96%, 3.15%, 4.37%, 1.90%, 31.49%, 12.50%, and 12.18%, respectively. Breastfeeding might be limited or even discontinued when signs of excessive sedation/drowsiness and/or poor weight gain are evident on infants exposed to primidone and phenobarbital, ethosuximide/primidone, or ethosuximide/phenobarbital. CONCLUSIONS Concentrations of ASMs can be detected in breastmilk of WWE and plasma/serum of infants exposed via breastmilk. Healthcare providers and WWE might use the findings of this study to make informed decisions on the safety of breastfeeding while taking ASMs.
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Riad A, Jouzová A, Üstün B, Lagová E, Hruban L, Janků P, Pokorná A, Klugarová J, Koščík M, Klugar M. COVID-19 Vaccine Acceptance of Pregnant and Lactating Women (PLW) in Czechia: An Analytical Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:13373. [PMID: 34948987 PMCID: PMC8708407 DOI: 10.3390/ijerph182413373] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/04/2021] [Accepted: 12/16/2021] [Indexed: 01/08/2023]
Abstract
Pregnant and lactating women (PLW) represent a particular population subset with increased susceptibility for COVID-19 morbidity and mortality, even though the evidence about the safety and efficacy of COVID-19 vaccines was delayed due to their initial exclusion from development trials. This unclear situation could have led to increased COVID-19 vaccine hesitancy levels among PLW; therefore, this study aimed to evaluate the attitudes of Czech PLW towards COVID-19 vaccines and the determinants of their attitudes. An analytical cross-sectional survey-based study was carried out in the University Hospital Brno (South Moravia, Czechia) between August and October 2021. The study utilised a self-administered questionnaire (SAQ) adapted from previous instruments used for the same purpose. The SAQ included closed-ended items covering demographic characteristics, clinical and obstetric characteristics, attitudes towards COVID-19 vaccination, and potential psychosocial predictors of vaccine acceptance. Out of the 362 included participants, 278 were pregnant (PW) and 84 were lactating women (LW). The overall COVID-19 vaccine acceptance (immediate and delayed) level was substantially high (70.2%), with a significant difference between PW (76.6%) and LW (48.8%). Out of the 70.2% who agreed to receive the vaccine, 3.6% indicated immediate acceptance, and 66.6% indicated delayed acceptance. Only 13.3% of the participants indicated their acceptance of their physician's vaccination recommendation during pregnancy or while lactating, and 62.2% were against it. Our results agreed with the recent studies that revealed that PW tended to have a high level of COVID-19 vaccine acceptance, and they were also inclined to resist professional recommendations because they predominantly preferred to delay their vaccination. The pregnancy trimester, education level, employment status, and previous live births were significant determinants for COVID-19 vaccine acceptance. The most commonly preferred vaccine type was mRNA-based vaccines, followed by viral vector-based and inactivated virus vaccines. The first top priority of PLW was vaccine safety for their children, followed by vaccine safety for the PLW and vaccine effectiveness. Regarding psychosocial predictors, media/social media, trust in the government, the pharmaceutical industry, and healthcare professionals, partners, and a positive risk-benefit ratio were significant promoters for COVID-19 vaccine acceptance. Findings from this study suggest that promotional interventions targeting PLW should use web platforms and focus on vaccine safety evidence, the expected benefits of vaccines and potential harms of the infection.
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Affiliation(s)
- Abanoub Riad
- Department of Public Health, Faculty of Medicine, Masaryk University, Kamenice 5, 62500 Brno, Czech Republic; (E.L.); (M.K.)
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Kamenice 5, 62500 Brno, Czech Republic; (A.P.); (J.K.)
| | - Anna Jouzová
- Department of Obstetrics and Gynecology, University Hospital Brno and Medical Faculty, Masaryk University, Obilní Trh 11, 60200 Brno, Czech Republic; (A.J.); (L.H.); (P.J.)
| | - Batuhan Üstün
- Department of Gynecology and Obstetrics, Faculty of Medicine, Namık Kemal University, Namık Kemal Kampüs Caddesi No. 1, Merkez, Tekirdağ 59030, Turkey;
| | - Eliška Lagová
- Department of Public Health, Faculty of Medicine, Masaryk University, Kamenice 5, 62500 Brno, Czech Republic; (E.L.); (M.K.)
| | - Lukáš Hruban
- Department of Obstetrics and Gynecology, University Hospital Brno and Medical Faculty, Masaryk University, Obilní Trh 11, 60200 Brno, Czech Republic; (A.J.); (L.H.); (P.J.)
| | - Petr Janků
- Department of Obstetrics and Gynecology, University Hospital Brno and Medical Faculty, Masaryk University, Obilní Trh 11, 60200 Brno, Czech Republic; (A.J.); (L.H.); (P.J.)
- Department of Health Sciences, Faculty of Medicine, Masaryk University, Kamenice 5, 62500 Brno, Czech Republic
| | - Andrea Pokorná
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Kamenice 5, 62500 Brno, Czech Republic; (A.P.); (J.K.)
- Department of Health Sciences, Faculty of Medicine, Masaryk University, Kamenice 5, 62500 Brno, Czech Republic
| | - Jitka Klugarová
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Kamenice 5, 62500 Brno, Czech Republic; (A.P.); (J.K.)
- Department of Health Sciences, Faculty of Medicine, Masaryk University, Kamenice 5, 62500 Brno, Czech Republic
| | - Michal Koščík
- Department of Public Health, Faculty of Medicine, Masaryk University, Kamenice 5, 62500 Brno, Czech Republic; (E.L.); (M.K.)
| | - Miloslav Klugar
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Kamenice 5, 62500 Brno, Czech Republic; (A.P.); (J.K.)
- Department of Health Sciences, Faculty of Medicine, Masaryk University, Kamenice 5, 62500 Brno, Czech Republic
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