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Yeung CHT, Verstegen RHJ, Greenberg R, Lewis TR. Pharmacokinetic and pharmacodynamic principles: unique considerations for optimal design of neonatal clinical trials. Front Pediatr 2024; 11:1345969. [PMID: 38283405 PMCID: PMC10811156 DOI: 10.3389/fped.2023.1345969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Core clinical pharmacology principles must be considered when designing and executing neonatal clinical trials. In this review, the authors discuss important aspects of drug dose selection, pharmacokinetics, pharmacogenetics and pharmacodynamics that stakeholders may consider when undertaking a neonatal or infant clinical trial.
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Affiliation(s)
- Cindy Hoi Ting Yeung
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ruud H. J. Verstegen
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Rachel Greenberg
- Duke Clinical Research Institute, Durham, NC, United States
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Tamorah Rae Lewis
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Cardoso E, Guidi M, Nauwelaerts N, Nordeng H, Teil M, Allegaert K, Smits A, Gandia P, Edginton A, Ito S, Annaert P, Panchaud A. Safety of medicines during breastfeeding - from case report to modeling : A contribution from the ConcePTION project. Expert Opin Drug Metab Toxicol 2023. [PMID: 37269321 DOI: 10.1080/17425255.2023.2221847] [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: 12/06/2022] [Accepted: 06/01/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Despite many research efforts, current data on the safety of medicines during breastfeeding are either fragmented or lacking, resulting in restrictive labeling of most medicines. In the absence of pharmacoepidemiologic safety studies, risk estimation for breastfed infants is mainly derived from pharmacokinetic (PK) information on the medicine. This manuscript provides a description and a comparison of the different methodological approaches that can yield reliable information on medicine transfer into human milk and the resulting infant exposure. AREA COVERED Currently, most information on medicine transfer in human milk relies on case reports or traditional PK studies, which generate data that can hardly be generalized to the population. Some methodological approaches, such as population PK (popPK) and physiologically-based PK (PBPK) modeling, can be used to provide a more complete characterization of infant medicine exposure through human milk and simulate the most extreme situations, while decreasing the burden of sampling in breastfeeding women. EXPERT OPINION PBPK and popPK modeling are promising approaches to fill the gap of knowledge in medicine safety in breastfeeding, as illustrated with our escitalopram example.
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Affiliation(s)
- Evelina Cardoso
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monia Guidi
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nina Nauwelaerts
- Drug Delivery and Disposition Lab, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Strategic Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Karel Allegaert
- Child and Youth Institute, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy,erasmus MC, Rotterdam, GA, The Netherlands
| | - Anne Smits
- Child and Youth Institute, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Peggy Gandia
- Laboratory of Pharmacokinetics and Toxicology, Purpan Hospital, University Hospital of Toulouse
| | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, ON, Canada
| | - Pieter Annaert
- Drug Delivery and Disposition Lab, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
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Pan A, Scodellaro S, Khan T, Ushcatz I, Wu W, Curtis M, Cohen E, Cohn RD, Hayeems RZ, Meyn MS, Orkin J, Otal J, Reuter MS, Walker S, Scherer SW, Marshall CR, Cohn I, Costain G. Pharmacogenetic profiling via genome sequencing in children with medical complexity. Pediatr Res 2023; 93:905-910. [PMID: 36167815 PMCID: PMC10033400 DOI: 10.1038/s41390-022-02313-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 07/25/2022] [Accepted: 09/03/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Children with medical complexity (CMC) are a priority pediatric population, with high resource use and associated costs. Genome-wide sequencing is increasingly organized for CMC early in life as a diagnostic test. Polypharmacy becomes common as CMC age. Clinically relevant pharmacogenetic (PGx) information can be extracted from existing genome sequencing (GS) data via GS-PGx profiling. The role of GS-PGx profiling in the CMC population is unclear. METHODS Prescribed medications were extracted from care plans of 802 eligible CMC enrolled in a structured Complex Care Program over a 10-year period. Drug-gene associations were annotated using curated Clinical Pharmacogenetics Implementation Consortium data. GS-PGx profiling was then performed for a subset of 50 CMC. RESULTS Overall, 546 CMC (68%) were prescribed at least one medication with an established PGx association. In the GS-PGx subgroup, 24 (48%) carried variants in pharmacogenes with drug-gene guidelines for one or more of their current medications. All had findings of potential relevance to some medications, including 32 (64%) with variants in CYP2C19 that could affect their metabolism of proton-pump inhibitors. CONCLUSION GS-PGx profiling at the time of diagnostics-focused genetic testing could be an efficient way to incorporate precision prescribing practices into the lifelong care of CMC. IMPACT Polypharmacy and genetic test utilization are both common in children with medical complexity. The role of repurposing genome sequencing data for pharmacogenetic profiling in children with medical complexity was previously unclear. We identified a high rate of medication use with clinically relevant drug-gene associations in this priority pediatric population and demonstrated that relevant pharmacogenetic information can be extracted from their existing genome sequencing data. Pharmacogenetic profiling at the time of diagnostics-focused genetic testing could be an efficient way to incorporate precision prescribing practices into the lifelong care of children with medical complexity.
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Affiliation(s)
- Amy Pan
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sierra Scodellaro
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Tayyaba Khan
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Inna Ushcatz
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Wendy Wu
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Meredith Curtis
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Eyal Cohen
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, ON, Canada
| | - Ronald D Cohn
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Robin Z Hayeems
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Stephen Meyn
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
- Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Center for Human Genomics and Precision Medicine, University of Wisconsin, Madison, WI, USA
| | - Julia Orkin
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jaskiran Otal
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Miriam S Reuter
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Susan Walker
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephen W Scherer
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
- Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Christian R Marshall
- Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, ON, Canada
- Genome Diagnostics, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Iris Cohn
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Gregory Costain
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
- Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada.
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