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Bajcetic M, de Wildt SN, Dalinghaus M, Breitkreutz J, Klingmann I, Lagler FB, Keatley-Clarke A, Breur JM, Male C, Jovanovic I, Szatmári A, Ablonczy L, Burckhardt BB, Cawello W, Kleine K, Obarcanin E, Spatenkova L, Swoboda V, van der Meulen M, Wagner P, Walsh J, Läer S. Orodispersible minitablets of enalapril for use in children with heart failure (LENA): Rationale and protocol for a multicentre pharmacokinetic bridging study and follow-up safety study. Contemp Clin Trials Commun 2019; 15:100393. [PMID: 31249901 PMCID: PMC6586986 DOI: 10.1016/j.conctc.2019.100393] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/23/2019] [Accepted: 06/04/2019] [Indexed: 12/17/2022] Open
Abstract
Introduction Treatment of paediatric heart failure is based on paradigms extensively tested in the adult population assuming similar underlying pathophysiological mechanisms. Angiotensin converting enzyme inhibitors (ACEI) like enalapril are one of the cornerstones of treatment and commonly used off-label in children. Dose recommendations have been extrapolated from adult experience, but the relationship between dose and pharmacokinetics (PK) in (young) children is insufficiently studied. Furthermore, appropriate paediatric formulations are lacking. Within the European collaborative project LENA, a novel formulation of enalapril orodispersible minitablets (ODMT), suitable for paediatric administration, will be tested in (young) children with heart failure due to either dilated cardiomyopathy or congenital heart disease in two pharmacokinetic bridging studies. Paediatric PK data of enalapril and its active metabolite enalaprilat will be obtained. In a follow-up study, the safety of enalapril ODMTs will be demonstrated in patients on long-term treatment of up to 10 months. Furthermore, additional information about pharmacodynamics (PD) and ODMT acceptability will be collected in all three studies. Methods and Analysis Phase II/III, open-label, multicentre study. Children with dilated cardiomyopathy (DCM) (n = 25; 1 month to less than 12 years) or congenital heart disease (CHD) (n = 60; 0 to less than 6 years) requiring or already on ACEI will be included. Exclusion criteria include severe heart failure precluding ACEI use, hypotension, renal impairment, hypersensitivity to ACEI. For those naïve to ACEI up-titration to an optimal dose will be performed, those already on ACEI will be switched to an expected equivalent dose of enalapril ODMT and optimised. In the first 8 weeks of treatment, a PK profile will be obtained at the first dose (ACEI naïve patients) or when an optimal dose is reached. Furthermore, population PK will be done with concentrations detected over the whole treatment period. PD and safety data will be obtained at least at 2-weeks intervals. Subsequently, an intended number of 85 patients will be followed-up up to 10 months to demonstrate long-term safety, based on the occurrence of (severe) adverse events and monitoring of vital signs and renal function. Ethics and dissemination Clinical Trial Authorisation and a favourable ethics committee opinion were obtained in all five participating countries. Results of the studies will be submitted for publication in a peer-reviewed journal. Trial registration numbers EudraCT 2015-002335-17, EudraCT 2015-002396-18, EudraCT 2015-002397-21.
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Affiliation(s)
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michiel Dalinghaus
- Division of Pediatric Cardiology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | | | | | | | | | - Johannes Mpj Breur
- University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Christoph Male
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ida Jovanovic
- Univerzitetska Dečja Klinika (UDK), Belgrade, Serbia
| | - Andras Szatmári
- Göttsegen György Hungarian Institute of Cardiology (HPHC), Budapest, Hungary
| | - László Ablonczy
- Göttsegen György Hungarian Institute of Cardiology (HPHC), Budapest, Hungary
| | - Bjoern B Burckhardt
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Willi Cawello
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Emina Obarcanin
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Vanessa Swoboda
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Marijke van der Meulen
- Division of Pediatric Cardiology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Peter Wagner
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Stephanie Läer
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
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Kechagia IA, Kalantzi L, Dokoumetzidis A. Extrapolation of enalapril efficacy from adults to children using pharmacokinetic/pharmacodynamic modelling. ACTA ACUST UNITED AC 2015; 67:1537-45. [PMID: 26256099 DOI: 10.1111/jphp.12471] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 07/06/2015] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To extrapolate enalapril efficacy to children 0-6 years old, a pharmacokinetic/pharmacodynamic (PKPD) model was built using literature data, with blood pressure as the PD endpoint. METHODS A PK model of enalapril was developed from literature paediatric data up to 16 years old. A PD model of enalapril was fitted to adult literature response vs time data with various doses. The final PKPD model was validated with literature paediatric efficacy observations (diastolic blood pressure (DBP) drop after 2 weeks of treatment) in children of age 6 years and higher. The model was used to predict enalapril efficacy for ages 0-6 years. KEY FINDINGS A two-compartment PK model was chosen with weight, reflecting indirectly age as a covariate on clearance and central volume. An indirect link PD model was chosen to describe drug effect. External validation of the model's capability to predict efficacy in children was successful. Enalapril efficacy was extrapolated to ages 1-11 months and 1-6 years finding the mean DBP drop 11.2 and 11.79 mmHg, respectively. CONCLUSIONS Mathematical modelling was used to extrapolate enalapril efficacy to young children to support a paediatric investigation plan targeting a paediatric-use marketing authorization application.
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Affiliation(s)
| | - Lida Kalantzi
- Pharmaceutical Research Operations, Pharmathen SA, Athens, Greece
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