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OMOZ-OARHE AE, HUGHES MD, BAO Y, SHORT WR, MNGQIBISA R, COHN SE, WEINBERG A, ROSA ALA, COLLIER A, SAMANEKA W, MORRONI C, LOCKMAN S. Incidence and Predictors of Pregnancy in Women Enrolled in Large Multinational HIV Treatment Trials of the AIDS Clinical Trials Group. J Acquir Immune Defic Syndr 2023; 94:461-467. [PMID: 37820116 PMCID: PMC10811622 DOI: 10.1097/qai.0000000000003299] [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: 11/22/2022] [Accepted: 08/21/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVES Women are under-represented in clinical trials and must often commit to using contraception to enroll. We sought to determine the incidence and predictors of pregnancy in women participating in HIV treatment trials. DESIGN Individual participant data meta-analysis. METHODS We included data from multicountry HIV treatment trials conducted during the period 2005-2019 by the AIDS Clinical Trials Group that included females with HIV who were of reproductive potential, did not intend to become pregnant, and agreed to use effective contraception during study treatment. We extracted data from all female participants of age 18-55 years, including occurrence and dates of pregnancy on-study; however, only a few incident pregnancy predictor variables were available for analysis. RESULTS One thousand six hundred twenty-six women from 4 trials were included. Over a median of 28 months (6461 person-years) of follow-up, 143 (9%) women became pregnant, for an overall incidence of 2.2 pregnancies/100 person-years (range 0.5-3/100 person-years, by study). In multivariable analysis including baseline age, type of regimen, and country as predictor variables, younger age remained the strongest predictor of incident pregnancy ( P < 0.0001 adjusted for country and antiretroviral treatment regimen). CD4 and HIV-1 RNA were not associated with pregnancy incidence. CONCLUSIONS Pregnancy incidence was 2.2/100 person-years in female participants of HIV treatment trials. Rather than leading to exclusion of young women from trials, this finding should prompt appropriate adaptations in study design and analysis for earlier generation of pregnancy safety information for drugs.
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Affiliation(s)
| | - Michael D. HUGHES
- Statistical and Data Analysis Center, Harvard University T H Chan School of Public Health, Boston, USA
| | - Yajing BAO
- Statistical and Data Analysis Center, Harvard University T H Chan School of Public Health, Boston, USA
| | - William R. SHORT
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, USA
| | - Rosie MNGQIBISA
- Durban International CRS, Enhancing Care Foundation, Durban, South Africa
| | - Susan E. COHN
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Adriana WEINBERG
- Molecular and Virology Clinical Laboratories, University of Colorado Denver, Colorado, USA
| | | | | | - Wadzanai SAMANEKA
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | - Shahin LOCKMAN
- Brigham and Women’s Hospital, Harvard T. H. Chan School of Public Health, Boston, USA
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2
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Slutsker L, Leke RGF. First-trimester use of ACTs for malaria treatment in pregnancy. Lancet 2023; 401:81-83. [PMID: 36442486 DOI: 10.1016/s0140-6736(22)02166-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/24/2022] [Indexed: 11/27/2022]
Affiliation(s)
| | - Rose Gana Fomban Leke
- Biotechnology Center, University of Yaounde, Yaounde, Cameroon; National Medical Research Institute, Yaounde, Cameroon
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3
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Xiao H, Vaidya R, Liu F, Chang X, Xia X, Unger JM. Sex, Racial, and Ethnic Representation in COVID-19 Clinical Trials: A Systematic Review and Meta-analysis. JAMA Intern Med 2023; 183:50-60. [PMID: 36469312 PMCID: PMC9857303 DOI: 10.1001/jamainternmed.2022.5600] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Since the onset of the COVID-19 pandemic, there have been calls for COVID-19 clinical trials to be fully representative of all demographic groups. However, limited evidence is available about the sex, racial, and ethnic representation among COVID-19 prevention and treatment trials. Objective To investigate whether female participants and racial and ethnic minority individuals are adequately represented in COVID-19 prevention and treatment trials in the US. Data Sources Identified studies were registered on ClinicalTrials.gov or published in the PubMed database from October 2019 to February 2022. Study Selection Included studies must have provided the number of enrolled participants by sex, race, or ethnicity. Only interventional studies conducted in the US for the primary purpose of the diagnosis, prevention, or treatment of (or supportive care for) COVID-19 conditions were included. Data Extraction and Synthesis Data on counts of enrollments by demographic variables (sex, race, and ethnicity) and location (country and state) were abstracted. Studies were broadly categorized by primary purpose as prevention (including vaccine and diagnosis studies) vs treatment (including supportive care studies). A random effects model for single proportions was used. Trial estimates were compared with corresponding estimates of representation in the US population with COVID-19. Main Outcomes and Measures Sex, racial, and ethnic representation in COVID-19 clinical trials compared with their representation in the US population with COVID-19. Results Overall, 122 US-based COVID-19 clinical trials comprising 176 654 participants were analyzed. Studies were predominantly randomized trials (n = 95) for treatment of COVID-19 (n = 103). Sex, race, and ethnicity were reported in 109 (89.3%), 95 (77.9%), and 87 (71.3%) trials, respectively. Estimated representation in prevention and treatment trials vs the US population with COVID-19 was 48.9% and 44.6% vs 52.4% for female participants; 23.0% and 36.6% vs 17.7% for Hispanic or Latino participants; 7.2% and 16.5% vs 14.1% for Black participants; 3.8% and 4.6% vs 3.7% for Asian participants; 0.2% and 0.9% vs 0.2% for Native Hawaiian or Other Pacific Islander participants; and 1.3% and 1.4% vs 1.1% for American Indian or Alaska Native participants. Compared with expected rates in the COVID-19 reference population, female participants were underrepresented in treatment trials (85.1% of expected; P < .001), Black participants (53.7% of expected; P = .003) and Asian participants (64.4% of expected; P = .003) were underrepresented in prevention trials, and Hispanic or Latino participants were overrepresented in treatment trials (206.8% of expected; P < .001). Conclusions and Relevance In this systematic review and meta-analysis, aggregate differences in representation for several demographic groups in COVID-19 prevention and treatment trials in the US were found. Strategies to better ensure diverse representation in COVID-19 studies are needed, especially for prevention trials.
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Affiliation(s)
- Hong Xiao
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Riha Vaidya
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Fang Liu
- Public Health Emergency Center, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Ximing Chang
- School of Public Health, Imperial College London, London, England, United Kingdom
| | - Xiaoqian Xia
- School of Nursing, Peking University Health Science Center, Beijing, China
- School of Public Health, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Joseph M Unger
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
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4
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Green O, Young EM, Oberman J, Stewart J, King Y, O'Donoghue K, Walker KF, Thornton JG. Recruitment of Pregnant Women to Randomised Trials of COVID 19 Treatments, and Pharmaceutical Treatments Received Outside such Trials: A Research Article. Eur J Obstet Gynecol Reprod Biol 2022. [PMCID: PMC9461280 DOI: 10.1016/j.ejogrb.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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5
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Green O, Young EM, Oberman J, Stewart J, King Y, O'Donoghue K, Walker KF, Thornton JG. Recruitment of pregnant women to randomised trials of COVID 19 treatments, and pharmaceutical treatments received outside such trials: A research article. Eur J Obstet Gynecol Reprod Biol 2022; 275:12-16. [PMID: 35696831 PMCID: PMC9106591 DOI: 10.1016/j.ejogrb.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/05/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To document how many pregnant women with COVID-19 reported in the literature had participated in randomised trials, what treatments they received outside such trials and compare the latter with evidence-based treatment recommendations. STUDY DESIGN A systematic review of observational studies. METHODS Two clinical trial registries were searched to identify COVID-19 trials open to pregnant women. Studies were then extracted from a regularly updated list of scientific case reports and case series of confirmed or suspected maternal COVID-19 in pregnancy to identify the number of women enrolled into a trial and the pharmaceutical treatments they received outside such trials. RESULTS 156 studies (case reports, case series and registries) reporting 43,185 pregnant women with COVID-19, after de-duplication. Of these 2,671 (6.2%) were potentially eligible for a randomised trial but only seven women (0.26%) were reported to have enrolled. For 2,839 women the papers included information on treatment received, 1515/2829 (54%) women had received ≥ 1 treatment and in total a COVID-19 pharmaceutical treatment was administered 1,296 times outside of a trial. In 566 (44%) cases the treatments administered to the pregnant women were not recommended by the National Institutes of Health (NIH) at the time of administration. Of 179 case reports of women with COVID 19 in pregnancy, 109/179 women received ≥ 1 COVID-19 pharmaceutical treatment and in total COVID-19 experimental pharmaceutical treatments were administered 274 times. CONCLUSION During the early phase of the COVID-19 pandemic, pregnant women excluded from randomised trials did not avoid unproven or ineffective treatments.
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Affiliation(s)
- Oleia Green
- University of Nottingham University of Nottingham Medical School, Nottingham NG7 2UH, England
| | - Eloise M Young
- Consultant Obstetrician and Gynaecologist Department of Obstetrics and Gynaecology, University College Cork College Road, University College, Cork, Ireland
| | - Jemma Oberman
- University of Nottingham University of Nottingham Medical School, Nottingham NG7 2UH, England
| | - Joel Stewart
- University of Nottingham University of Nottingham Medical School, Nottingham NG7 2UH, England
| | - Yasmin King
- University of Nottingham University of Nottingham Medical School, Nottingham NG7 2UH, England
| | - Keelin O'Donoghue
- University of Nottingham University of Nottingham Medical School, Nottingham NG7 2UH, England
| | - Kate F Walker
- University of Nottingham University of Nottingham Medical School, Nottingham NG7 2UH, England
| | - Jim G Thornton
- University of Nottingham University of Nottingham Medical School, Nottingham NG7 2UH, England.
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Valverde Mordt O, Tarral A, Strub-Wourgaft N. Development and Introduction of Fexinidazole into the Global Human African Trypanosomiasis Program. Am J Trop Med Hyg 2022; 106:61-66. [PMID: 35292581 PMCID: PMC9154641 DOI: 10.4269/ajtmh.21-1176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/18/2021] [Indexed: 12/27/2022] Open
Abstract
In this article, the authors show the strategy used to streamline the introduction of fexinidazole, the first all oral treatment of human African trypanosomiasis (HAT) caused by Trypanosoma brucei gambiense. The dose range was determined in phase 1 studies and a significant food effect was observed, which was tested with field-adapted meals. The pharmacokinetic profile required definition of a higher loading dosage for the first 4 days and administration of the daily dose together with a typical local meal to optimize product absorption and rapidly achieve drug steady state. This allowed for a combined phase II/III pivotal study directly after phase I trials. Partnerships with highly engaged actors from endemic country control programs and international research institutions started early through the HAT platform, building on an agreed target product profile (TPP), establishing a regulatory plan early and transparently including endemic countries in the research and data flow. A key element that enabled a quick start to access activities was preparing for World Health Organization guidelines early and starting the process prior to registration. Distribution plans were identified and supply was established from the start, by taking advantage of the existing supply agreement between the producers of all HAT drugs (Sanofi and Bayer) and the WHO. Pharmacovigilance and phase 4 studies were nested into wider implementation activities. Targeted sequential introduction into national programs was prioritized, based on medical need and epidemiologically updated information.
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Affiliation(s)
| | - Antoine Tarral
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
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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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Nooney J, Thor S, de Vries C, Clements J, Sahin L, Hua W, Everett D, Zaccaria C, Ball R, Saint‐Raymond A, Yao L, Raine J, Kweder S. Assuring Access to Safe Medicines in Pregnancy and Breastfeeding. Clin Pharmacol Ther 2021; 110:941-945. [PMID: 33615448 PMCID: PMC8518426 DOI: 10.1002/cpt.2212] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/29/2021] [Indexed: 11/07/2022]
Abstract
Scientists and regulators in Europe and the United States continue to seek methods and strategies to improve knowledge on rational use of medicines for pregnant and breastfeeding populations, an important subset of women's health. Regulatory agencies have made strides toward improvement, but much more is needed. Recognizing the importance of international collaboration, we have begun to consider how to address these important public health issues more globally. The health of the child begins with the health of the mother.
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Affiliation(s)
- Janet Nooney
- Medicines and Healthcare products Regulatory AgencyLondonUK
| | - Shannon Thor
- US Food and Drug AdministrationSilver SpringMarylandUSA
| | | | - John Clements
- Medicines and Healthcare products Regulatory AgencyLondonUK
| | - Leyla Sahin
- US Food and Drug AdministrationSilver SpringMarylandUSA
| | - Wei Hua
- US Food and Drug AdministrationSilver SpringMarylandUSA
| | | | | | - Robert Ball
- US Food and Drug AdministrationSilver SpringMarylandUSA
| | | | - Lynne Yao
- US Food and Drug AdministrationSilver SpringMarylandUSA
| | - June Raine
- Medicines and Healthcare products Regulatory AgencyLondonUK
| | - Sandra Kweder
- US Food and Drug AdministrationSilver SpringMarylandUSA
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9
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Visceral Leishmaniasis in pregnancy and vertical transmission: A systematic literature review on the therapeutic orphans. PLoS Negl Trop Dis 2021; 15:e0009650. [PMID: 34375339 PMCID: PMC8425569 DOI: 10.1371/journal.pntd.0009650] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 09/08/2021] [Accepted: 07/13/2021] [Indexed: 12/29/2022] Open
Abstract
Background Reports on the occurrence and outcome of Visceral Leishmaniasis (VL) in pregnant women is rare in published literature. The occurrence of VL in pregnancy is not systematically captured and cases are rarely followed-up to detect consequences of infection and treatment on the pregnant women and foetus. Methods A review of all published literature was undertaken to identify cases of VL infections among pregnant women by searching the following database: Ovid MEDLINE; Ovid Embase; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials; World Health Organization Global Index Medicus: LILACS (Americas); IMSEAR (South-East Asia); IMEMR (Eastern Mediterranean); WPRIM (Western Pacific); ClinicalTrials.gov; and the WHO International Clinical Trials Registry Platform. Selection criteria included any clinical reports describing the disease in pregnancy or vertical transmission of the disease in humans. Articles meeting pre-specified inclusion criteria and non-primary research articles such as textbook, chapters, letters, retrospective case description, or reports of accidental inclusion in trials were also considered. Results The systematic literature search identified 272 unique articles of which 54 records were included in this review; a further 18 records were identified from additional search of the references of the included studies or from personal communication leading to a total of 72 records (71 case reports/case series; 1 retrospective cohort study; 1926–2020) describing 451 cases of VL in pregnant women. The disease was detected during pregnancy in 398 (88.2%), retrospectively confirmed after giving birth in 52 (11.5%), and the time of identification was not clear in 1 (0.2%). Of the 398 pregnant women whose infection was identified during pregnancy, 346 (86.9%) received a treatment, 3 (0.8%) were untreated, and the treatment status was not clear in the remaining 49 (12.3%). Of 346 pregnant women, Liposomal amphotericin B (L-AmB) was administered in 202 (58.4%) and pentavalent antimony (PA) in 93 (26.9%). Outcomes were reported in 176 pregnant women treated with L-AmB with 4 (2.3%) reports of maternal deaths, 5 (2.8%) miscarriages, and 2 (1.1%) foetal death/stillbirth. For PA, outcomes were reported in 88 of whom 4 (4.5%) died, 24 (27.3%) had spontaneous abortion, 2 (2.3%) had miscarriages. A total of 26 cases of confirmed, probable or suspected cases of vertical transmission were identified with a median detection time of 6 months (range: 0–18 months). Conclusions Outcomes of VL treatment during pregnancy is rarely reported and under-researched. The reported articles were mainly case reports and case series and the reported information was often incomplete. From the studies identified, it is difficult to derive a generalisable information on outcomes for pregnant women and babies, although reported data favours the usage of liposomal amphotericin B for the treatment of VL in pregnant women. Visceral Leishmaniasis (VL) is a neglected tropical disease with an estimated incidence of 50,000 to 90,000 cases in 2019. Women who are susceptible to becoming pregnant or those who are pregnant and lactating are regularly excluded from clinical studies of VL. A specific concern of public health relevance is the little knowledge of the consequences of VL and its treatment on the mother and the foetus. We did a systematic review of all published literature with an overarching aim of identifying cases of VL in pregnancy and assessing the risk-benefit balance of antileishmanial treatment to the pregnant women and the child. We identified a total of 72 records (1926–2020) describing 451 VL cases in pregnant women. In 398, infection was identified during pregnancy of whom 202 received Liposomal Amphotericin B (L-AmB) and 93 received pentavalent antimony (PA). In studies that reported maternal outcomes, reports of maternal death abortion/spontaneous abortion, and miscarriages were proportionally lower among those who received L-AmB compared to PA (no formal test of significance carried out). A total of 26 cases of confirmed, probable or suspected cases of vertical transmission were identified and the median time to detection was 6 months (range: 0–18 months). Our review brings together scattered observations of VL in pregnant women in the clinical literature and clearly highlights that the disease in pregnancy is under-reported and under-studied. The collated evidence derived mainly from case reports and case series indicate that L-AmB has a favourable safety profile than the antimony regimen and should be the preferred treatment for VL during pregnancy.
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10
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Weld ED, Bailey TC, Waitt C. Ethical issues in therapeutic use and research in pregnant and breastfeeding women. Br J Clin Pharmacol 2021; 88:7-21. [PMID: 33990968 DOI: 10.1111/bcp.14914] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/28/2021] [Accepted: 05/10/2021] [Indexed: 12/15/2022] Open
Abstract
Pregnant or potentially pregnant women have historically been excluded from clinical trials of new medications. However, it is increasingly recognised that it is imperative to generate evidence from the population in whom the drugs are likely to be used to inform safe, evidence-based shared clinical decision making. Reluctance by researchers and regulators to perform such studies often relates to concerns about risk, particularly to the foetus. However, this must be offset against the risk of untreated disease or using a drug in pregnancy where safety, efficacy and dosing information are not known. This review summarises the historical perspective, and the ethical and legal frameworks that inform the conduct of such research, then highlights examples of innovative practice that have enabled high quality, ethical research to proceed to inform the evidence-based use of medication in pregnancy.
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Affiliation(s)
- Ethel D Weld
- Divisions of Clinical Pharmacology & Infectious Diseases, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Theodore C Bailey
- Division of Infectious Diseases, Department of Medicine, Greater Baltimore Medical Center, Baltimore, MD, USA
| | - Catriona Waitt
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK.,Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
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11
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Abrams EJ, Mofenson LM, Pozniak A, Lockman S, Colbers A, Belew Y, Clayden P, Mirochnick M, Siberry GK, Ford N, Khoo S, Renaud F, Vitoria M, Venter WDF, Doherty M, Penazzato M. Enhanced and Timely Investigation of ARVs for Use in Pregnant Women. J Acquir Immune Defic Syndr 2021; 86:607-615. [PMID: 33298793 DOI: 10.1097/qai.0000000000002597] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/23/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Concerns have been voiced that the exclusion of pregnant women from clinical trials results in a lack of safety and pharmacokinetic data for antiretroviral drugs (ARVs) in pregnancy, creating clear risks to pregnant women living with HIV (PWLHIV), and their infants. SETTING The World Health Organization convened a Paediatric Antiretroviral Drug Optimization group meeting, December 10-12, 2018, in Geneva, Switzerland. METHODS The group, comprised of clinicians, scientists, HIV program managers, regulators, and community representatives, were tasked to consider how ARVs are studied in PWLHIV, define alternative approaches to studying ARVs in PWLHIV, identify ways to shorten the timeline to determine safe use of new agents during pregnancy, and define strategies to collaborate with regulators and industry to change longstanding practices. RESULTS Most new ARVs are not studied in pregnant populations until after drug licensure, primarily opportunistically among women who become pregnant while taking the ARV of interest. Acceleration of the timeline will require earlier completion of preclinical studies and a new paradigm, namely-under certain conditions-allow women who become pregnant while participating in phase III ARV studies the option of remaining on study and enroll pregnant women into phase III trials of new agents to obtain preliminary safety and dosing and efficacy data. CONCLUSION A revision of the current approach to the study of antiretrovirals in pregnant women is urgently needed to improve timely access and safe use of new agents during pregnancy.
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Affiliation(s)
- Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Lynne M Mofenson
- Research Program, Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC
| | - Anton Pozniak
- HIV and Sexual Health Clinic, Chelsea and Westminster Hospital NHS Foundation Trust and LSHTM London, London, United Kingdom
| | - Shahin Lockman
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Angela Colbers
- Radboud University Medical Center, and HIV Institute, Nijmegen, the Netherlands
| | - Yodit Belew
- Division of Antiviral Products, US Food and Drug Administration (FDA), Silver Spring, MD
| | | | - Mark Mirochnick
- Department of Pediatrics, Boston University School of Medicine, Boston, MA
| | - George K Siberry
- Division of Prevention Care and Treatment, Office of HIV/AIDS, United States Agency for International Development (USAID), Washington, DC
| | - Nathan Ford
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Saye Khoo
- Department of Pharmacy, Research Institute, University of Liverpool, United Kingdom; and
| | - Francoise Renaud
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Marco Vitoria
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Willem D F Venter
- Ezintsha, Wits Reproductive Health Sciences, University of Witwatersrand, South Africa
| | - Meg Doherty
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Martina Penazzato
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
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