1
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Erceg D, Jakirović M, Prgomet L, Madunić M, Turkalj M. Conducting Drug Treatment Trials in Children: Opportunities and Challenges. Pharmaceut Med 2024; 38:179-204. [PMID: 38730200 DOI: 10.1007/s40290-024-00523-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 05/12/2024]
Abstract
Children were often referred to as "therapeutic orphans" in the past due to different reasons such as ethical, regulatory, economic, scientific, etc., ones. They were exposed to avoidable risks while missing out on therapeutic advances. Pediatric patients have suffered from a lack of scientific and regulatory standards (e.g., proper drug testing, authorization of medicines for their use, etc.), although the pharmaceutical legislative framework, which ensures the high standards of safety, quality, and efficacy of medicinal products for use in adults, was developed primarily in response to past "drug disasters," mainly involving children. The adoption of pediatric regulatory initiatives first in the USA and then in Europe and other countries and regions has significantly changed the worldwide frameworks and permanently changed pediatric drug research and development. This article tries to give various perspectives with historical context, a review of the different challenges and opportunities as well as important stakeholders in pediatric drug development. The pediatric trial networks are probably the most important stakeholder that enables efficient patient recruitment, access to better resource utilization, and global collaboration of different stakeholders necessary for performing quality and well-designed clinical trials.
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Affiliation(s)
- Damir Erceg
- "Srebrnjak" Children's Hospital, Clinical Trials Unit, 10000, Zagreb, Croatia.
- School of Medicine, Catholic University of Croatia, 10000, Zagreb, Croatia.
- Faculty of Dental Medicine and Health, University of Osijek, "Josip Juraj Strossmayer", 31000, Osijek, Croatia.
- Medical School, University of Osijek "Josip Juraj Strossmayer", 31000, Osijek, Croatia.
| | - Marina Jakirović
- "Srebrnjak" Children's Hospital, Clinical Trials Unit, 10000, Zagreb, Croatia
| | - Luka Prgomet
- Institute of Emergency Medicine of Zagreb County, 10410, Velika Gorica, Croatia
| | - Marina Madunić
- Emergency Department, General Hospital Zabok, 49210, Zabok, Croatia
| | - Mirjana Turkalj
- "Srebrnjak" Children's Hospital, Clinical Trials Unit, 10000, Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, 10000, Zagreb, Croatia
- Medical School, University of Osijek "Josip Juraj Strossmayer", 31000, Osijek, Croatia
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2
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Kaguelidou F, Ouèdraogo M, Treluyer JM, Le Jeunne C, Annereau M, Blanc P, Bureau S, Ducassou S, Fiquet B, Flamein F, Gaillard S, Hankard R, Laugel V, Laurent C, Levy C, Marquet T, Polak M, Portefaix A, Vassal G. Paediatric drug development and evaluation: Existing challenges and recommendations. Therapie 2023; 78:105-114. [PMID: 36528416 DOI: 10.1016/j.therap.2022.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/07/2022] [Indexed: 12/11/2022]
Abstract
Despite various international regulatory initiatives over the last 20 years, many challenges remain in the field of paediatric drug development and evaluation. Indeed, drug research and development is still focused essentially on adult indications, thereby excluding many paediatric patients, limiting the feasibility of trials and favouring competing developments. Off-label prescribing persists and the development of age-appropriate dosage forms for children remains limited. Against this background, the members of this panel (TR) recommend the launch of multi-partner exchange forums on specific topics in order to focus new drug research and development on the real, unmet medical needs of children and adolescents, and in keeping with the underlying mechanisms of action. Scientific information sharing and cooperation between stakeholders are also essential for defining reference evaluation methods in each medical field. These forums can be organised through existing paediatric facilities and research networks at the French and European level. The latter are specifically dedicated to paediatric research and can facilitate clinical trial implementation and patient enrolment. Moreover, specific grants and public/private partnerships are still needed to support studies on the repositioning of drugs in paediatric indications, and pharmacokinetic studies aimed at defining appropriate dosages. The development of new pharmaceutical forms, better suited for paediatric use, and the promotion of resulting innovations will stimulate future investments. Initiatives to gather observational safety and efficacy data following off-label and/or derogatory early access should also be encouraged to compensate for the lack of information available in these situations. Finally, the creation of Ethics Committees (EC) with a specific "mother-child" advisory expertise should be promoted to ensure that the current regulation (Jardé law in France) is implemented whilst also taking into account the paediatric specificities in medical trials.
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Affiliation(s)
- Florentia Kaguelidou
- Center of Clinical Investigations and Pediatric Pharmacology, Inserm CIC1426, Robert-Debré hospital, AP-HP.Nord, 75000 Paris, France; Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France.
| | - Maria Ouèdraogo
- Lead « partenaires parcours de soins référents médicaux », laboratoire Roche, 92100 Boulogne, France
| | - Jean-Marc Treluyer
- Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France; Département de pharmacologie, CRPV, hôpital Cochin, AP-HP.Centre, 75014 Paris, France
| | - Claire Le Jeunne
- Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France; Service de médecine interne, hôpital Cochin, AP-HP Centre, 75014 Paris, France
| | - Maxime Annereau
- Département de pharmacie clinique, Gustave Roussy Cancer Campus, 94800 Villejuif, France
| | - Patricia Blanc
- Association de patients («) Imagine for Margo - Enfants sans Cancer », 78100 Saint-Germain-en-Laye, France
| | - Serge Bureau
- Direction de la recherche clinique, de l'innovation, des relations avec les universités et organismes de recherche (DRCI), Assistance publique-Hôpitaux de Paris, 75000 Paris, France
| | - Stéphane Ducassou
- Unité hématologie oncologie pédiatrique, CHU Bordeaux, 33000 Bordeaux, France
| | - Béatrice Fiquet
- Département médical, Amgen, 92100 Boulogne-Billancourt, France
| | - Florence Flamein
- University Lille, Inserm, CHU Lille, CIC-1403 Inserm-CHU, 59000 Lille, France; French Clinical Research Infrastructure Network (F-CRIN) - PEDSTART, 94000 Créteil, France
| | - Ségolène Gaillard
- Hospices civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, CHU-Lyon, 69677 Bron, France; Université Lyon 1, CNRS UMR 5558, laboratoire de biométrie et biologie évolutive, 69622 Villeurbanne, France
| | | | - Vincent Laugel
- Pôle médico-chirurgical de pédiatrie, centre d'investigation clinique, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France
| | | | - Corinne Levy
- Clinical Research Center (CRC), centre hospitalier intercommunal de Créteil, 94000 Créteil, France
| | - Thierry Marquet
- Accès des patients à l'innovation, Takeda, 75116 Paris, France
| | - Michel Polak
- Unité d'endocrinologie, gynécologie, diabétologie pédiatriques, Inserm U1016, Institut Imagine, centre de référence des maladies endocriniennes rares de la croissance et du développement, hôpital universitaire Necker-Enfants-Malades, AP-HP Centre, université Paris-Descartes, 75743 Paris, France
| | - Aurélie Portefaix
- Hospices civils de Lyon, Pediatric Clinic Investigation Center, Inserm P-1407, 69500 Bron, France
| | - Gilles Vassal
- Département de cancérologie de l'enfant et de l'adolescent, Gustave Roussy Comprehensive Cancer Center et université Paris-Saclay, 94805 Villejuif, France
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3
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Kaguelidou F, Ouèdraogo M, Treluyer JM, Le Jeunne C, Annereau M, Blanc P, Bureau S, Ducassou S, Fiquet B, Flamein F, Gaillard S, Hankard R, Laugel V, Laurent C, Levy C, Marquet T, Polak M, Portefaix A, Vassal G. Développement des médicaments en pédiatrie : défis existants et recommandations. Therapie 2023; 78:95-104. [PMID: 36543724 DOI: 10.1016/j.therap.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Florentia Kaguelidou
- Center of Clinical Investigations and Pediatric Pharmacology, Inserm CIC1426, Robert-Debré Hospital, AP-HP Nord, 75000 Paris, France; Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France.
| | - Maria Ouèdraogo
- Lead « partenaires parcours de soins référents médicaux », laboratoire Roche, 92100 Boulogne, France
| | - Jean-Marc Treluyer
- Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France; Département de pharmacologie, CRPV, hôpital Cochin, AP-HP Centre, 75014 Paris, France
| | - Claire Le Jeunne
- Paris Cité University, EA7323 « Therapeutic assessment, and perinatal and pediatric pharmacology », 75000 Paris, France; Service de médecine interne, hôpital Cochin, AP-HP Centre, 75014 Paris, France
| | - Maxime Annereau
- Département de pharmacie clinique, Gustave-Roussy Cancer Campus, 94800 Villejuif, France
| | - Patricia Blanc
- Association de patients « Imagine for Margo - Enfants sans Cancer », 78100 Saint-Germain-en-Laye, France
| | - Serge Bureau
- Direction de la recherche clinique, de l'innovation, des relations avec les universités et organismes de recherche (DRCI), Assistance publique-Hôpitaux de Paris, 75000 Paris, France
| | - Stéphane Ducassou
- Unité hématologie oncologie pédiatrique, CHU Bordeaux, 33000 Bordeaux, France
| | - Béatrice Fiquet
- Département médical, Amgen, 92100 Boulogne-Billancourt, France
| | - Florence Flamein
- Université Lille, Inserm, CHU Lille, CIC-1403 Inserm-CHU, 59000 Lille, France; French Clinical Research Infrastructure Network (F-CRIN) - PEDSTART, 94000 Créteil, France
| | - Ségolène Gaillard
- Hospices civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, CHU-Lyon, 69677 Bron, France; Université Lyon 1, CNRS UMR 5558, laboratoire de biométrie et biologie évolutive, 69622 Villeurbanne, France
| | | | - Vincent Laugel
- Pôle médicochirurgical de pédiatrie, centre d'investigation clinique, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France
| | | | - Corinne Levy
- Clinical Research Center (CRC), centre hospitalier intercommunal de Créteil, 94000 Créteil, France
| | - Thierry Marquet
- Directeur de l'accès des patients à l'innovation, Takeda, 75116 Paris, France
| | - Michel Polak
- Unité d'endocrinologie, gynécologie, diabétologie pédiatriques, Inserm U1016, Institut Imagine, centre de référence des maladies endocriniennes rares de la croissance et du développement, hôpital universitaire Necker-Enfants-Malades, AP-HP Centre, université Paris Descartes, 75743 Paris, France
| | - Aurélie Portefaix
- Hospices civils de Lyon, Pediatric Clinic Investigation Center, Inserm P-1407, 69500 Bron, France
| | - Gilles Vassal
- Département de cancérologie de l'enfant et de l'adolescent, Gustave-Roussy Comprehensive Cancer Center, université Paris-Saclay, 94805 Villejuif, France
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4
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Moore-Hepburn C, Rieder M. Paediatric pharmacotherapy and drug regulation: Moving past the therapeutic orphan. Br J Clin Pharmacol 2021; 88:4250-4257. [PMID: 33576523 DOI: 10.1111/bcp.14769] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 12/29/2022] Open
Abstract
The development of specific drug therapy for children was a paradigm-changing event that transformed paediatric medical practice. However, a series of tragedies involving drug treatment for children resulted in a gap developing between drug regulation and practice, with the majority of drugs used in child healthcare being used off-label, rendering children therapeutic orphans. Over the past two decades changes in drug regulation led by the US Food and Drug Administration and followed by the European Union's European Medicines Agency have led to substantial changes in how new drugs with potential use in children are studied and labelled. While these changes have substantially improved labelling for new drugs, there has been much less progress with older drugs. Although the unique challenges of conducting clinical research in children have been addressed by novel clinical trial designs, many of these innovations have not been translated into approaches accepted for the drug approval process. The regulations applying to the need for paediatric studies currently are only applicable in the United States and the European Union, and there is less impetus for paediatric labelling in other jurisdictions. This impacts on a number of issues beyond labelling, including the availability of child-friendly formulations. Finally, the impact of Brexit on paediatric drug studies in the UK remains unclear and is subject to ongoing negotiations between the UK government and the European Union.
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Affiliation(s)
| | - Michael Rieder
- Division of Paediatric Clinical Pharmacology, Department of Paediatrics, University of Western Ontario, Canada
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5
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Ndwandwe D, Dube K, Mathebula L, Wiysonge CS. Description of vaccine clinical trials in Africa: a narrative review. Hum Vaccin Immunother 2020; 16:972-980. [PMID: 31730397 PMCID: PMC7227700 DOI: 10.1080/21645515.2019.1693720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/26/2019] [Accepted: 10/12/2019] [Indexed: 01/10/2023] Open
Abstract
Clinical research is important in establishing the effects of health-care interventions. Vaccine clinical trials are to examine the effectiveness and safety of vaccines for the prevention of diseases. Africa has a high burden of infectious diseases such as malaria, tuberculosis, HIV/AIDS, and Ebola virus disease. Here we report a database surveillance study of vaccine-related clinical trials conducted in Africa. An objective is to address and profile vaccine clinical trials conducted in Africa. Data were extracted from the WHO International Clinical Trials Registry Platform on 22 July 2018 and updated on 05 September 2019. We found that 61% of the 377 clinical trials were registered prospectively and 35% registered retrospectively. About 72% of the trials were single-country studies and within the country, most trials (86%) were single-center studies. The proportion of trials involving multiple African countries was 11% and that of trials involving countries outside of Africa was 16%. The biggest funder of the vaccine trials (34%) was industry, followed by governments (25%) and universities (21%). The most studied diseases were malaria (20%), HIV/AIDS (15%), tuberculosis (7%), and Ebola virus disease (6%). Most of the vaccine trials were conducted in adults (42%). The trials ranged from phase I to phase IV, with most of the trials being in phase I (18%) and phase III (18%). The conduct of vaccine clinical trials in Africa seeks to address the disease epidemics faced by the continent. There is a need for more investments from governmental bodies toward vaccine research in Africa. Further, African country collaborations are needed in efforts to find African solutions to the current infectious disease threats faced by the continent.
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Affiliation(s)
- Duduzile Ndwandwe
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Kopano Dube
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Lindi Mathebula
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Charles S. Wiysonge
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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6
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Lu J, Li Q, Zhu L, Chen C, Li Z. Oral ibuprofen is superior to oral paracetamol for patent ductus arteriosus in very low and extremely low birth weight infants. Medicine (Baltimore) 2019; 98:e16689. [PMID: 31374055 PMCID: PMC6709086 DOI: 10.1097/md.0000000000016689] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Paracetamol (acetaminophen) has been proposed as an alternative medication for closing hemodynamically significant patent ductus arteriosus (PDA). However, the clinical outcomes remain inconclusive in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants.The aim of this study was to compare the efficacy and safety of oral paracetamol and ibuprofen for pharmacological closure of PDA in premature infants from a real-world study.This retrospective study enrolled 255 preterm infants with birthweights of ≤1.5 kg, and echocardiographically confirmed significant PDA. Subjects were classified into 3 groups: Group I (standard-dose ibuprofen group) received 10 mg/kg oral ibuprofen followed by 5 mg/kg/day for 2 days. Group II (high-dose ibuprofen group) received 10 mg/kg/day oral ibuprofen for 3 days. Group III (paracetamol group) received 15 mg/kg/6 h oral paracetamol for 3 days.On day 9 after medication start, PDA closure was achieved in 61 (71.7%) patients assigned to the high-dose ibuprofen group, (63.8%) in the standard-dose ibuprofen group, and 33 (37.9%) of those in the oral paracetamol group (P <.001). Oral standard-dose ibuprofen was more effective than oral paracetamol (P = .001). The ductus closed faster in the high-dose ibuprofen group than in the standard-dose group (median closure time 3.9 ± 1.0 versus 4.4 ± 1.0 days, P = .009). Total bilirubin significantly increased in the high-dose ibuprofen group (P = .02). No gastrointestinal, renal, or hematological adverse effects were reported. Subgroup analyses indicated paracetamol was minimally effective in ELBW infants (PDA closure 13%).This study demonstrated that paracetamol may be a poor medical alternative for PDA management in VLBW and ELBW infants. High dosage ibuprofen was associated with a faster clinical improvement and higher rate of PDA closure.
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Affiliation(s)
| | | | | | - Chao Chen
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
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7
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Hepburn CM, Gilpin A, Autmizguine J, Denburg A, Dupuis LL, Finkelstein Y, Gruenwoldt E, Ito S, Jong G, Lacaze-Masmonteil T, Levy D, Macleod S, Miller SP, Offringa M, Pinsk M, Power B, Rieder M, Litalien C. L’amélioration des médicaments à usage pédiatrique : une prescription pour les enfants et les adolescents canadiens. Paediatr Child Health 2019. [DOI: 10.1093/pch/pxz094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Andrea Gilpin
- Le Centre de formulations pédiatriques de la famille Rosalind et Morris Goodman du Centre hospitalier universitaire Sainte-Justine, Montréal (Québec)
| | - Julie Autmizguine
- Le Centre de formulations pédiatriques de la famille Rosalind et Morris Goodman du Centre hospitalier universitaire Sainte-Justine, Montréal (Québec)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Catherine Litalien
- Le Centre de formulations pédiatriques de la famille Rosalind et Morris Goodman du Centre hospitalier universitaire Sainte-Justine, Montréal (Québec)
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8
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Hepburn CM, Gilpin A, Autmizguine J, Denburg A, Dupuis LL, Finkelstein Y, Gruenwoldt E, Ito S, Jong G', Lacaze-Masmonteil T, Levy D, Macleod S, P Miller S, Offringa M, Pinsk M, Power B, Rieder M, Litalien C. Improving paediatric medications: A prescription for Canadian children and youth. Paediatr Child Health 2019; 24:333-339. [PMID: 31379437 DOI: 10.1093/pch/pxz079] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/18/2019] [Indexed: 12/24/2022] Open
Affiliation(s)
| | - Andrea Gilpin
- The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Julie Autmizguine
- The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Avram Denburg
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - L Lee Dupuis
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Yaron Finkelstein
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Emily Gruenwoldt
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Shinya Ito
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Geert 't Jong
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Thierry Lacaze-Masmonteil
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Deborah Levy
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Stuart Macleod
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Steven P Miller
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Martin Offringa
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Maury Pinsk
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Barry Power
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Michael Rieder
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Catherine Litalien
- The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
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9
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Abstract
Pediatric brain tumors are the primary cause of cancer-related death during childhood. Unfortunately, the number of primary and metastatic brain tumors is steadily increasing while the mortality rates for many central nervous system (CNS) lesions have remained stagnant. Molecularly defined tumor classes have been added to the most recent 2016 World Health Organization (WHO) Classification System of Central Nervous System Brain Tumors, driving potential new treatments and identifying targets to improve survival for these patients. Focusing on the genetic mutations most commonly seen in the pediatric CNS tumor population provides the ability to better define tumors based on shared molecular characteristics. Consequently, there is the potential for greater efficacy in targeted therapy to treat these identified genetic aberrations. Understanding the growing importance of molecular diagnosis in pediatric CNS tumors is vital to successfully using novel targeted therapies and improving patient outcomes.
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10
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Balevic SJ, Cohen-Wolkowiez M. Innovative Study Designs Optimizing Clinical Pharmacology Research in Infants and Children. J Clin Pharmacol 2018; 58 Suppl 10:S58-S72. [PMID: 30248192 PMCID: PMC6310922 DOI: 10.1002/jcph.1053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/07/2017] [Indexed: 12/16/2022]
Abstract
Almost half of recent pediatric trials failed to achieve labeling indications, in large part because of inadequate study design. Therefore, innovative study methods are crucial to optimizing trial design while also reducing the potential harms inherent with drug investigation. Several methods exist to optimize the amount of pharmacokinetic data collected from the smallest possible volume and with the fewest number of procedures, including the use of opportunistic and sparse sampling, alternative and noninvasive matrices, and microvolume assays. In addition, large research networks using master protocols promote collaboration, reduce regulatory burden, and increase trial efficiency for both early- and late-phase trials. Large pragmatic trials that leverage electronic health records can capitalize on central management strategies to reduce costs, enroll patients with rare diseases on a large scale, and augment study generalizability. Further, trial efficiency and safety can be optimized through Bayesian adaptive techniques that permit planned protocol changes based on analyses of prior and accumulated data. In addition to these trial design features, advances in modeling and simulation have paved the way for systems-based and physiologically based models that individualize pediatric dosing recommendations and support drug approval. Last, given the low prevalence of many pediatric diseases, collecting deidentified genetic and clinical data on a large scale is a potentially transformative way to augment clinical pharmacology research in children.
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Affiliation(s)
- Stephen J. Balevic
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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11
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Ryan J, Patel J, Lucas CJ, Martin JH. Optimal cancer drug dosing in adolescents: new issues and the old unaddressed ones. Intern Med J 2018; 48:1023-1027. [PMID: 30182398 DOI: 10.1111/imj.14020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Jessica Ryan
- Discipline of Clinical Pharmacology, School of Medicine and Public Health, University of Newcastle, Level 3 Hunter Medical Research Institute, and Hunter New England Local Health District, Kookaburra Circuit, Newcastle, New South Wales, Australia
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12
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Waligora M, Bala MM, Koperny M, Wasylewski MT, Strzebonska K, Jaeschke RR, Wozniak A, Piasecki J, Sliwka A, Mitus JW, Polak M, Nowis D, Fergusson D, Kimmelman J. Risk and surrogate benefit for pediatric Phase I trials in oncology: A systematic review with meta-analysis. PLoS Med 2018; 15:e1002505. [PMID: 29462168 PMCID: PMC5819765 DOI: 10.1371/journal.pmed.1002505] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 01/12/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Pediatric Phase I cancer trials are critical for establishing the safety and dosing of anti-cancer treatments in children. Their implementation, however, must contend with the rarity of many pediatric cancers and limits on allowable risk in minors. The aim of this study is to describe the risk and benefit for pediatric cancer Phase I trials. METHODS AND FINDINGS Our protocol was prospectively registered in PROSPERO (CRD42015015961). We systematically searched Embase and PubMed for solid and hematological malignancy Phase I pediatric trials published between 1 January 2004 and 1 March 2015. We included pediatric cancer Phase I studies, defined as "small sample size, non‑randomized, dose escalation studies that defined the recommended dose for subsequent study of a new drug in each schedule tested." We measured risk using grade 3, 4, and 5 (fatal) drug-related adverse events (AEs) and benefit using objective response rates. When possible, data were meta-analyzed. We identified 170 studies meeting our eligibility criteria, accounting for 4,604 patients. The pooled overall objective response rate was 10.29% (95% CI 8.33% to 12.25%), and was lower in solid tumors, 3.17% (95% CI 2.62% to 3.72%), compared with hematological malignancies, 27.90% (95% CI 20.53% to 35.27%); p < 0.001. The overall fatal (grade 5) AE rate was 2.09% (95% CI 1.45% to 2.72%). Across the 4,604 evaluated patients, there were 4,675 grade 3 and 4 drug-related AEs, with an average grade 3/4 AE rate per person equal to 1.32. Our study had the following limitations: trials included in our review were heterogeneous (to minimize heterogeneity, we separated types of therapy and cancer types), and we relied on published data only and encountered challenges with the quality of reporting. CONCLUSIONS Our meta-analysis suggests that, on the whole, AE and response rates in pediatric Phase I trials are similar to those in adult Phase I trials. Our findings provide an empirical basis for the refinement and review of pediatric Phase I trials, and for communication about their risk and benefit.
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Affiliation(s)
- Marcin Waligora
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Malgorzata M. Bala
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Kraków, Poland
- * E-mail: (MMB); (JK)
| | - Magdalena Koperny
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
- Department of Public Health and Health Promotion, Regional Sanitary-Epidemiological Station in Kraków, Poland
| | - Mateusz T. Wasylewski
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Karolina Strzebonska
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Rafał R. Jaeschke
- Section of Affective Disorders, Department of Psychiatry, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Wozniak
- Agency for Health Technology Assessment and Tariff System, Warsaw, Poland
| | - Jan Piasecki
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Sliwka
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
- Department of Rehabilitation in Internal Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Jerzy W. Mitus
- Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Maciej Polak
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
- Chair of Epidemiology and Population Studies, Jagiellonian University Medical College, Kraków, Poland
| | - Dominika Nowis
- Department of Immunology, Medical University of Warsaw, Warsaw, Poland
- Genomic Medicine, Medical University of Warsaw, Warsaw, Poland
- Laboratory of Experimental Medicine, Centre of New Technologies, University of Warsaw, Warsaw, Poland
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montreal, Canada
- * E-mail: (MMB); (JK)
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Carpenter D, Gonzalez D, Retsch-Bogart G, Sleath B, Wilfond B. Methodological and Ethical Issues in Pediatric Medication Safety Research. Pediatrics 2017; 140:e20170195. [PMID: 28778857 PMCID: PMC5574727 DOI: 10.1542/peds.2017-0195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 12/26/2022] Open
Abstract
In May 2016, the Eshelman School of Pharmacy at The University of North Carolina at Chapel Hill convened the PharmSci conference to address the topic of "methodological and ethical issues in pediatric medication safety research." A multidisciplinary group of experts representing a diverse array of perspectives, including those of the US Food and Drug Administration, children's hospitals, and academia, identified important considerations for pediatric medication safety research and opportunities to advance the field. This executive summary describes current challenges that clinicians and researchers encounter related to pediatric medication safety research and identifies innovative and ethically sound methodologies to address these challenges to improve children's health. This article addresses 5 areas: (1) pediatric drug development and drug trials; (2) conducting comparative effectiveness research in pediatric populations; (3) child and parent engagement on study teams; (4) improving communication with children and parents; and (5) assessing child-reported outcomes and adverse drug events.
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Affiliation(s)
| | | | - George Retsch-Bogart
- Department of Pediatrics, School of Medicine
- Clinical and Translational Research Center of the North Carolina Translational and Clinical Sciences Institute, and
- Cystic Fibrosis Therapeutics Development Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | | | - Benjamin Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, University of Washington, Seattle, Washington
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14
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Vermeulen E, van den Anker JN, Della Pasqua O, Hoppu K, van der Lee JH. How to optimise drug study design: pharmacokinetics and pharmacodynamics studies introduced to paediatricians. J Pharm Pharmacol 2017; 69:439-447. [PMID: 27671925 PMCID: PMC6084327 DOI: 10.1111/jphp.12637] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/10/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES In children, there is often lack of sufficient information concerning the pharmacokinetics (PK) and pharmacodynamics (PD) of a study drug to support dose selection and effective evaluation of efficacy in a randomised clinical trial (RCT). Therefore, one should consider the relevance of relatively small PKPD studies, which can provide the appropriate data to optimise the design of an RCT. METHODS Based on the experience of experts collaborating in the EU-funded Global Research in Paediatrics consortium, we aimed to inform clinician-scientists working with children on the design of investigator-initiated PKPD studies. KEY FINDINGS The importance of the identification of an optimal dose for the paediatric population is explained, followed by the differences and similarities of dose-ranging and efficacy studies. The input of clinical pharmacologists with modelling expertise is essential for an efficient dose-finding study. CONCLUSIONS The emergence of new laboratory techniques and statistical tools allows for the collection and analysis of sparse and unbalanced data, enabling the implementation of (observational) PKPD studies in the paediatric clinic. Understanding of the principles and methods discussed in this study is essential to improve the quality of paediatric PKPD investigations, and to prevent the conduct of paediatric RCTs that fail because of inadequate dosing.
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Affiliation(s)
- Eric Vermeulen
- Pediatric Clinical Research OfficeEmma Children's HospitalAcademic Medical CenterAmsterdamThe Netherlands
| | - John N. van den Anker
- Division of Pediatric Clinical PharmacologyChildren's National Health SystemWashingtonDCUSA
- Division of Paediatric Pharmacology and PharmacometricsUniversity of Basel Children's HospitalBaselSwitzerland
- Intensive Care and Department of Pediatric SurgeryErasmus Medical CenterSophia Children's HospitalRotterdamThe Netherlands
| | - Oscar Della Pasqua
- Clinical Pharmacology Modelling & SimulationGlaxoSmithKlineStockley ParkUK
- Clinical Pharmacology & TherapeuticsUniversity College LondonLondonUK
| | - Kalle Hoppu
- Poison Information CentreHelsinki University Central HospitalHelsinkiFinland
| | - Johanna H. van der Lee
- Pediatric Clinical Research OfficeEmma Children's HospitalAcademic Medical CenterAmsterdamThe Netherlands
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15
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Sohn JA, Kim HS, Oh J, Cho JY, Yu KS, Lee J, Shin SH, Lee JA, Choi CW, Kim EK, Kim BI, Park EA. Prediction of serum theophylline concentrations and cytochrome P450 1A2 activity by analyzing urinary metabolites in preterm infants. Br J Clin Pharmacol 2017; 83:1279-1286. [PMID: 27995649 DOI: 10.1111/bcp.13211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 11/08/2016] [Accepted: 12/12/2016] [Indexed: 01/17/2023] Open
Abstract
AIMS The purpose of this study was to explore clinical markers reflecting developmental changes in drug clearance by preterm infants. METHODS Preterm infants administered aminophylline or theophylline to treat apnoea of prematurity were enrolled in this study. Trough and one of 2 h, 4 h or 6 h post-dose blood samples and urine samples were collected during steady state, to determine the concentrations of theophylline and its targeted metabolites. CYP1A2*1C and CYP1A2*1F genotypes were analyzed. Total, renal and nonrenal clearances of theophylline were calculated, and cytochrome P450 1A2 (CYP1A2) activity was obtained from the ratio of 1-methyluric acid and 3-methylxanthine to theophylline in urine. Multiple linear regression analysis was performed to evaluate the relationships between theophylline clearance and the clinical characteristics of preterm infants. RESULTS A total of 152 samples from 104 preterm infants were analyzed. A strong association between the serum trough and urine theophylline concentrations was found (P < 0.001). Total, renal and nonrenal clearances of theophylline were 0.50 ± 0.29 ml kg-1 min-1 , 0.16 ± 0.06 ml kg-1 min-1 and 0.34 ± 0.28 ml kg-1 min-1 , respectively. CYP1A2 activity correlated positively with the postnatal age and postmenstrual age. However, CYP1A2 genotype was not associated with CYP1A2 activity, which was significantly associated with nonrenal clearance. CYP1A2 activity, postnatal age , weight and 24-h urine output were significantly associated with total theophylline clearance. CONCLUSIONS CYP1A2 activity can be monitored using noninvasive random urine samples, and it can be used to assess developmental changes in theophylline clearance by preterm infants.
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Affiliation(s)
- Jin A Sohn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Jaeseong Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Juyoung Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin A Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Beyong Il Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Eun Ae Park
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, South Korea
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16
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Rieder M, Hawcutt D. Design and conduct of early phase drug studies in children: challenges and opportunities. Br J Clin Pharmacol 2016; 82:1308-1314. [PMID: 27353241 PMCID: PMC5061783 DOI: 10.1111/bcp.13058] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/03/2016] [Accepted: 06/12/2016] [Indexed: 12/14/2022] Open
Abstract
It has historically been very difficult to conduct early phase drug studies in children for a number of reasons related to ethics, acceptability, rarity, standardization, end points, safety, dosing and feasibility. Over the past decade there have been a number of developments including novel clinical trial design, in silico pharmacology and microdosing that have significantly enhanced the ability of investigators to conduct early phase drug studies in children. While the evolution of drug therapy is creating a series of new challenges, there has never been a better time for conducting drug studies in children.
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Affiliation(s)
- Michael Rieder
- Department of Paediatrics, Robarts Research Institute, University of Western Ontario, Canada.
- Department of Paediatrics, Western University, London, Ontario, Canada.
| | - Daniel Hawcutt
- NIHR Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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