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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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Li Y, Nelson R, Izem R, Broglio K, Mundayat R, Gamalo M, Wen Y, Pan H, Sun H, Ye J. Unlocking the Potential: A Systematic Review of Master Protocol in Pediatrics. Ther Innov Regul Sci 2024:10.1007/s43441-024-00656-z. [PMID: 38653950 DOI: 10.1007/s43441-024-00656-z] [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: 01/02/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
The use of master protocols allows for innovative approaches to clinical trial designs, potentially enabling new approaches to operations and analytics and creating value for patients and drug developers. Pediatric research has been conducted for many decades, but the use of novel designs such as master protocols in pediatric research is not well understood. This study aims to provide a systematic review on the utilization of master protocols in pediatric drug development. A search was performed in September 2022 using two data sources (PubMed and ClinicalTrials.gov) and included studies conducted in the past10 years. General study information was extracted such as study type, study status, therapeutic area, and clinical trial phase. Study characteristics that are specific to pediatric studies (such as age of the participants and pediatric drug dosing) and important study design elements (such as number of test drug arms and whether randomization and/or concurrent control was used) were also collected. Our results suggest that master protocol studies are being used in pediatrics, with platform and basket trials more common than umbrella trials. Most of this experience is in oncology and early phase studies. There is a rise in the use starting in 2020, largely in oncology and COVID-19 trials. However, adoption of master protocols in pediatric clinical research is still on a small scale and could be substantially expanded. Work is required to further understand the barriers in implementing pediatric master protocols, from setting up infrastructure to interpreting study findings.
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Affiliation(s)
- Yimei Li
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, 3501 Civic Center Blvd, Colket Translational Research Building Room 4032, 19034, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA.
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | | | - Rima Izem
- Statistical Methodology, Novartis Pharma AG, Basel, Switzerland
| | | | | | | | - Yansong Wen
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Haitao Pan
- Department of Biostatistics, St. Jude Children's Hospital, Memphis, TN, USA
| | - Hengrui Sun
- Food & Drug Administration, Silver Spring, MD, USA
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3
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Maas L, Joos A, Hiligsmann M. Pediatric Market Access: A Qualitative Study. Ther Innov Regul Sci 2024; 58:336-346. [PMID: 38172379 PMCID: PMC10850165 DOI: 10.1007/s43441-023-00601-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/14/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES This qualitative study aims to analyze current PM regulation and market access requirements and proposes potential solutions to mitigate current challenges. METHODS Twenty-two semi-structured interviews were conducted with experts from pharmaceutical industry, regulatory authorities, national health technology assessment (HTA) bodies, pediatricians, and academia from the Netherlands (NL), Germany (DE), the United Kingdom (UK), and France (FR) to get insight into the pediatric research, the regulatory and reimbursement processes, challenges, and solutions. Themes for further testing were developed on how to facilitate pediatric market access. Atlas.ti 9 was used to analyze the findings. RESULTS Heterogeneity in requirements for the European Medicines Agency (EMA) and HTA approvals are noted. By example, DE grants direct reimbursement after regulatory approval, the other countries require additional reimbursement which generate delays and challenges in patient access after marketing authorization. Key components in facilitating PM market access include multi-stakeholder collaboration, transparency, patient representatives, informed consent guidance, real-world evidence, and appropriate clinical trial designs. Pricing models based on the economic capabilities of individual countries could further reduce delays and challenges in market access. The additional specific pediatric incentives should be taken as best practice to encourage innovation in pediatric conditions. CONCLUSION This study highlights differences in requirements for regulatory and reimbursement approval, along with international differences in pricing and reimbursement procedures for pediatric market access.
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Affiliation(s)
- Lieke Maas
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Angelika Joos
- Global Regulatory Policy, Merck Research Laboratories, MSD (Europe) Inc., Brussels, Belgium
| | - Mickael Hiligsmann
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O Box 616, 6200 MD, Maastricht, The Netherlands
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Gamalo M, Kim Y, Zhang F, Lin J. Composite Likelihoods with Bounded Weights in Extrapolation of Data. J Biopharm Stat 2023; 33:708-725. [PMID: 36662162 DOI: 10.1080/10543406.2022.2152835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 11/23/2022] [Indexed: 01/21/2023]
Abstract
Among many efforts to facilitate timely access to safe and effective medicines to children, increased attention has been given to extrapolation. Loosely, it is the leveraging of conclusions or available data from adults or older age groups to draw conclusions for the target pediatric population when it can be assumed that the course of the disease and the expected response to a medicinal product would be sufficiently similar in the pediatric and the reference population. Extrapolation then can be characterized as a statistical mapping of information from the reference (adults or older age groups) to the target pediatric population. The translation, or loosely mapping of information, can be through a composite likelihood approach where the likelihood of the reference population is weighted by exponentiation and that this exponent is related to the value of the mapped information in the target population. The weight is bounded above and below recognizing the fact that similarity (of the disease and the expected response) is still valid despite variability of response between the cohorts. Maximum likelihood approaches are then used for estimation of parameters, and asymptotic theory is used to derive distributions of estimates for use in inference. Hence, the estimation of effects in the target population borrows information from the reference population. In addition, this manuscript also talks about how this method is related to the Bayesian statistical paradigm.
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Affiliation(s)
- Margaret Gamalo
- Global Biometrics & Data Management, Pfizer Inc Pennsylvania, Collegeville, Pennsylvania, USA
| | - Yoonji Kim
- Department of Statistics, Ohio State University, Columbus, Ohio, USA
| | - Fan Zhang
- Global Biometrics & Data Management, Pfizer Inc, Groton, Connecticut, USA
| | - Junjing Lin
- Statistical and Quantitative Sciences, Takeda Pharmaceuticals, Cambridge, MA, USA
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5
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Schanberg LE, Mulugeta LY, Akinlade B, Brunner HI, Chen J, Colbert RA, Delgaizo V, Gastonguay MR, Glaser R, Imundo L, Lovell DJ, Leu JH, Mostafa NM, Nelson RM, Nigrovic PA, Nikolov NP, Rider LG, Rothwell R, Sahajwalla C, Singh R, Sinha V, Yancey CL, Yao L. Therapeutic Development in Polyarticular Course Juvenile Idiopathic Arthritis: Extrapolation, Dose Selection, and Clinical Trial Design. Arthritis Rheumatol 2023; 75:1856-1866. [PMID: 37067688 DOI: 10.1002/art.42534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/15/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
OBJECTIVE Stakeholders met to address persistent challenges facing the development of therapeutics for polyarticular juvenile idiopathic arthritis (pJIA), which result in fewer approved therapies for children with pJIA than adults with rheumatoid arthritis (RA) and long lag times from adult RA approval to pediatric labeling. Ensuring that new medications are authorized in a timely manner to meet the needs of JIA patients worldwide is critically important to multiple stakeholders. METHODS The Food and Drug Administration in collaboration with the University of Maryland Center for Regulatory Science and Innovation held a public workshop entitled "Accelerating Drug Development for pJIA" on October 2, 2019, to address challenges surrounding access to new medications for children and adolescents with pJIA. Regulatory, academic, and industry stakeholders, as well as patient representatives, participated in the workshop, which consisted of 4 sessions, including panel discussions. RESULTS The workshop facilitated broad public discussion of challenges facing the development of pJIA therapeutics, highlighting areas of need and outlining opportunities to expedite development, while underscoring the necessity of close collaboration between all stakeholders, including patients and families. CONCLUSION This report summarizes key aspects of the workshop, including the appropriate application of innovative approaches to the development of pJIA therapeutics, including extrapolation, to address current challenges and provide timely access to newer safe and effective treatments. Long-term safety assessment is of pressing concern to stakeholders and cannot be fully extrapolated from adult studies but requires consistent postmarketing long-term follow-up.
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Affiliation(s)
- Laura E Schanberg
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Lily Yeruk Mulugeta
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Jianmeng Chen
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Robert A Colbert
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Rachel Glaser
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Lisa Imundo
- Columbia University Irving Medical Center, New York, New York
| | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jocelyn H Leu
- Janssen Research and Development, Spring House, Pennsylvania
| | | | | | - Peter A Nigrovic
- Division of Immunology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Nikolay P Nikolov
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Lisa G Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, NIH, Bethesda, Maryland
| | - Rebecca Rothwell
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Chandrahas Sahajwalla
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Renu Singh
- Gilead Sciences, Foster City, California
| | - Vikram Sinha
- Novartis Pharmaceutical Corporation, One Health Plaza, East Hanover NJ, 07936, USA
| | - Carolyn L Yancey
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Lynne Yao
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
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6
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Savino R, Medoro A, Ali S, Scapagnini G, Maes M, Davinelli S. The Emerging Role of Flavonoids in Autism Spectrum Disorder: A Systematic Review. J Clin Med 2023; 12:jcm12103520. [PMID: 37240625 DOI: 10.3390/jcm12103520] [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: 03/09/2023] [Revised: 04/29/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
Although autism spectrum disorder (ASD) is a multifaceted neurodevelopmental syndrome, accumulating evidence indicates that oxidative stress and inflammation are common features of ASD. Flavonoids, one of the largest and best-investigated classes of plant-derived compounds, are known to exert antioxidant, anti-inflammatory, and neuroprotective effects. This review used a systematic search process to assess the available evidence on the effect of flavonoids on ASD. A comprehensive literature search was carried out in PubMed, Scopus, and Web of Science databases following the PRISMA guidelines. A total of 17 preclinical studies and 4 clinical investigations met our inclusion criteria and were included in the final review. Most findings from animal studies suggest that treatment with flavonoids improves oxidative stress parameters, reduces inflammatory mediators, and promotes pro-neurogenic effects. These studies also showed that flavonoids ameliorate the core symptoms of ASD, such as social deficits, repetitive behavior, learning and memory impairments, and motor coordination. However, there are no randomized placebo-controlled trials that support the clinical efficacy of flavonoids in ASD. We only found open-label studies and case reports/series, using only two flavonoids such as luteolin and quercetin. These preliminary clinical studies indicate that flavonoid administration may improve specific behavioral symptoms of ASD. Overall, this review is the first one to systematically report evidence for the putative beneficial effects of flavonoids on features of ASD. These promising preliminary results may provide the rationale for future randomized controlled trials aimed at confirming these outcomes.
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Affiliation(s)
- Rosa Savino
- Department of Woman and Child, Neuropsychiatry for Child and Adolescent Unit, General Hospital "Riuniti" of Foggia, 71122 Foggia, Italy
| | - Alessandro Medoro
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, 86100 Campobasso, Italy
| | - Sawan Ali
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, 86100 Campobasso, Italy
| | - Giovanni Scapagnini
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, 86100 Campobasso, Italy
| | - Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Sergio Davinelli
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, 86100 Campobasso, Italy
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Zeng L, Wang YL, Shen XT, Zhang ZC, Huang GX, Alshorman J, Serebour TB, Tator CH, Sun TS, Zhang YZ, Guo XD. Guidelines for management of pediatric acute hyperextension spinal cord injury. Chin J Traumatol 2023; 26:2-7. [PMID: 36137934 PMCID: PMC9912180 DOI: 10.1016/j.cjtee.2022.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/21/2022] [Accepted: 06/11/2022] [Indexed: 02/04/2023] Open
Abstract
Pediatric acute hyperextension spinal cord injury (SCI) named as PAHSCI by us, is a special type of thoracolumbar SCI without radiographic abnormality and highly related to back-bend in dance training, which has been increasingly reported. At present, it has become the leading cause of SCI in children, and brings a heavy social and economic burden. Both domestic and foreign academic institutions and dance education organizations lack a correct understanding of PAHSCI and relevant standards, specifications or guidelines. In order to provide standardized guidance, the expert team formulated this guideline based on the principles of science and practicability, starting from the diagnosis, differential diagnosis, etiology, admission evaluation, treatment, complications and prevention. This guideline puts forward 23 recommendations for 14 related issues.
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Affiliation(s)
- Lian Zeng
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yu-Long Wang
- Department of Orthopedics, Wuhan No. 1 Hospital, Wuhan Integrated TCM & Western Medicine Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xian-Tao Shen
- Department of Pediatric Orthopaedic Surgery, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430016, China
| | - Zhi-Cheng Zhang
- Department of Orthopedics, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China
| | - Gui-Xiong Huang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jamal Alshorman
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Tracy Boakye Serebour
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Charles H. Tator
- Toronto Western Research Institute, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Tian-Sheng Sun
- Department of Orthopedics, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China,Corresponding author. suntiansheng-@163.cm
| | - Ying-Ze Zhang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, China.
| | - Xiao-Dong Guo
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Kwolek EM. Does the light at the end of the tunnel shine for everyone? The need for early paediatric participation in vaccine trials during infectious pandemics. CLINICAL ETHICS 2022; 17:346-351. [PMID: 36471720 PMCID: PMC9659690 DOI: 10.1177/14777509211036661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
While most of the mortality associated with severe acute respiratory syndrome coronavirus 2 has been in elderly populations and adults with significant medical comorbidities, there has been death and morbidity in paediatric populations. As vaccine trial data is released to the public, many people look to the future with hope ; with good vaccine uptake there is the opportunity to reduce the spread of infectious pandemics. Initial vaccine trials were completed with adults and were expanded to include paediatric populations delaying paediatric COVID-19 vaccine initiatives. The exclusion of children from initial vaccine trials during a pandemic is not morally justifiable and fosters distrust with the pharmaceutical and medical industries and inevitably postpones vaccinating children when there is a surplus of available vaccines. The delayed vaccination of children under twelve may have significant public health and economic consequences as there may be ongoing viral transmission in the context of reopening strategies. The safety and efficacy of these candidate vaccines in children should be assessed expeditiously so that distribution to vulnerable paediatric populations is not impacted. Vaccine uptake compliance in the general population is important in establishing herd immunity and ensuring that there is thorough scientific evidence to support vaccination for children is important in establishing community trust.
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Affiliation(s)
- Erin M Kwolek
- Alberta Children’s Hospital, Canada
- Cumming School of Medicine, University
of Calgary, Canada
- Columbia University in the City of New
York, USA
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9
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The Role of Master Protocols in Pediatric Drug Development. Ther Innov Regul Sci 2022; 56:895-902. [PMID: 36045315 PMCID: PMC9433127 DOI: 10.1007/s43441-022-00448-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 08/09/2022] [Indexed: 12/27/2022]
Abstract
Master protocols are innovative clinical trial designs that enable new approaches to analytics and operations, creating value for patients and drug developers. To date, the use of master protocols in pediatric drug development has been limited, focused primarily on pediatric oncology with limited experience in rare and ultra-rare pediatric diseases. This article explores the application of master protocols to pediatric programs required by FDA and EMA based on adult developmental programs. These required programs involve multiple assets developed in limited pediatric populations for registrational purposes. However, these required programs include the possibility for extrapolation of efficacy and safety from the adult population. The use of master protocols is a potential solution to the challenge of conducting clinical trials in small pediatric populations provided that such use would improve enrollment or reduce the required sample size. Toward that end, Janssen and Lilly have been working on a collaborative cross-company pediatric platform trial in pediatric Crohn's disease using an innovative Bayesian analysis. We describe how two competing companies can work together to design and execute the proposed platform, focusing on selected aspects-the usefulness of a single infrastructure, the regulatory submission process, the choice of control group, and the use of pediatric extrapolation. Master protocols offer the potential for great benefit in pediatrics by streamlining clinical development, with the goal of reducing the delay in pediatric marketing approvals when compared to adults so that children have timelier access to safe and effective medications.
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10
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Mørk ML, Andersen JT, Lausten-Thomsen U, Gade C. The Blind Spot of Pharmacology: A Scoping Review of Drug Metabolism in Prematurely Born Children. Front Pharmacol 2022; 13:828010. [PMID: 35242037 PMCID: PMC8886150 DOI: 10.3389/fphar.2022.828010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/25/2022] [Indexed: 12/30/2022] Open
Abstract
The limit for possible survival after extremely preterm birth has steadily improved and consequently, more premature neonates with increasingly lower gestational age at birth now require care. This specialized care often include intensive pharmacological treatment, yet there is currently insufficient knowledge of gestational age dependent differences in drug metabolism. This potentially puts the preterm neonates at risk of receiving sub-optimal drug doses with a subsequent increased risk of adverse or insufficient drug effects, and often pediatricians are forced to prescribe medication as off-label or even off-science. In this review, we present some of the particularities of drug disposition and metabolism in preterm neonates. We highlight the challenges in pharmacometrics studies on hepatic drug metabolism in preterm and particularly extremely (less than 28 weeks of gestation) preterm neonates by conducting a scoping review of published literature. We find that >40% of included studies failed to report a clear distinction between term and preterm children in the presentation of results making direct interpretation for preterm neonates difficult. We present summarized findings of pharmacokinetic studies done on the major CYP sub-systems, but formal meta analyses were not possible due the overall heterogeneous approaches to measuring the phase I and II pathways metabolism in preterm neonates, often with use of opportunistic sampling. We find this to be a testament to the practical and ethical challenges in measuring pharmacokinetic activity in preterm neonates. The future calls for optimized designs in pharmacometrics studies, including PK/PD modeling-methods and other sample reducing techniques. Future studies should also preferably be a collaboration between neonatologists and clinical pharmacologists.
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Affiliation(s)
- Mette Louise Mørk
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Jón Trærup Andersen
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Ulrik Lausten-Thomsen
- Department of Neonatology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christina Gade
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
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11
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Extrapolation as a Default Strategy in Pediatric Drug Development. Ther Innov Regul Sci 2022; 56:883-894. [PMID: 35006587 DOI: 10.1007/s43441-021-00367-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 12/20/2021] [Indexed: 02/06/2023]
Abstract
Pediatric drug development lags adult development by about 8 years (Mulugeta et al. in Pediatr Clin 64(6):1185-1196, 2017). In such context, many incentives, regulations, and innovative techniques have been proposed to address the disparity for pediatric patients. One such strategy is extrapolation of efficacy from a reference population. Extrapolation is currently justified by providing evidence in support of the effective use of drugs in children when the course of the disease and the expected treatment response would be sufficiently similar in the pediatric and reference population. This paper's position is that, despite uncertainties, pediatric drug development programs should initially assume some degree of extrapolation. The degree to which extrapolation can be used lies along a continuum representing the uncertainties to be addressed through generation of new pediatric evidence. In addressing these uncertainties, the extrapolation strategy should reflect the level of tolerable uncertainty concerning the decision to expose a child to the risks of a new drug. This judgment about the level of tolerable uncertainty should vary with the context (e.g., disease severity, existing therapeutic options) and can be embedded into pediatric drug development archetypes to ascertain the extent of studies needed and whether simultaneous development for adults and adolescents be considered.
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12
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Leroy R, Bourgeois J, Verleye L, Carvalho JC, Eloot A, Cauwels R, Declerck D. Are systemic antibiotics indicated in children presenting with an odontogenic abscess in the primary dentition? A systematic review of the literature. Clin Oral Investig 2021; 25:2537-2544. [PMID: 33791867 DOI: 10.1007/s00784-021-03862-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/24/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This systematic review aimed to assess (1) whether systemic antibiotics are beneficial or harmful in healthy children who present with an odontogenic abscess in the primary dentition with or without systemic involvement and (2) if antibiotics are beneficial, which type, dosage and duration are the most effective. MATERIALS AND METHODS Electronic databases (Medline, Embase, and the Cochrane Library) were screened from 1948 up to August 2020. No filters with respect to study design were applied. Outcomes of interest included pain, swelling, pain relief, adverse effects, signs of infection, quality-of-life measurements and medication required for pain relief. RESULTS Altogether, 352 titles and abstracts were screened for eligibility; of these, 19 were selected for full text assessment. All were excluded because none of them fulfilled the inclusion criteria and addressed the (adjunctive) use of antibiotics in children who present with an odontogenic abscess in the primary dentition. CONCLUSIONS At present, there is no single randomised or non-randomised clinical study evaluating the effectiveness and harms of systemic antibiotics administered in children who present with an odontogenic abscess in the primary dentition. CLINICAL RELEVANCE There is no clinical evidence to support nor to refute the use of antibiotics in children who present with an odontogenic abscess in the primary dentition without signs of local spread or systemic involvement. Given this lack of scientific evidence, the use of antibiotics cannot be recommended in these children. Well-designed clinical trials are indicated to fully understand the impact and necessity of antibiotics in these situations.
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Affiliation(s)
- Roos Leroy
- Belgian Health Care Knowledge Centre (KCE), Kruidtuinlaan 55, B-1000, Brussels, Belgium.
| | - Jolyce Bourgeois
- Belgian Health Care Knowledge Centre (KCE), Kruidtuinlaan 55, B-1000, Brussels, Belgium
| | - Leen Verleye
- Belgian Health Care Knowledge Centre (KCE), Kruidtuinlaan 55, B-1000, Brussels, Belgium
| | - Joana C Carvalho
- Faculty of Medicine and Dentistry, UCLouvain, Av. Hippocrate 10, B-1200, Brussels, Belgium
| | - Anouk Eloot
- Private Dental Practice, Emiel Verhaerenlaan 37, B-9050, Gentbrugge, Belgium
| | - Rita Cauwels
- Department of Oral Health Sciences, UGent, C. Heymanslaan 10, B-9000, Ghent, Belgium
| | - Dominique Declerck
- Department of Oral Health Sciences, Population Studies in Oral Health, KU Leuven, Kapucijnenvoer 7/a-box 7001, B-3000, Leuven, Belgium
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13
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Basu C, Ma X, Mo M, Xia HA, Brundage R, Al-Kofahi M, Carlin BP. Pharmacokinetic/pharmacodynamic data extrapolation models for improved pediatric efficacy and toxicity estimation, with application to secondary hyperparathyroidism. Pharm Stat 2020; 19:882-896. [PMID: 32648333 DOI: 10.1002/pst.2043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 03/21/2020] [Accepted: 05/23/2020] [Indexed: 11/05/2022]
Abstract
In most drug development settings, the regulatory approval process is accompanied by extensive studies performed to understand the drug's pharmacokinetic (PK) and pharmacodynamic (PD) properties. In this article, we attempt to utilize the rich PK/PD data to inform the borrowing of information from adults during pediatric drug development. In pediatric settings, it is especially crucial that we are parsimonious with the patients recruited for experimentation. We illustrate our approaches in the context of clinical trials of cinacalcet for treating secondary hyperparathyroidism in pediatric and adult patients with chronic kidney disease, where we model both parathyroid hormone (efficacy endpoint) and corrected calcium levels (safety endpoint). We use population PK/PD modeling of the cinacalcet data to quantitatively assess the similarity between adults and children, and use this information in various hierarchical Bayesian adult borrowing rules whose statistical properties can then be evaluated. In particular, we simulate the bias and mean square error performance of our approaches in settings where borrowing is and is not warranted to inform guidelines for the future use of our methods.
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Affiliation(s)
| | - Xiaoye Ma
- Genentech Inc., San Francisco, California, USA
| | - May Mo
- Amgen Inc., Thousand Oaks, California, USA
| | | | - Richard Brundage
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahmoud Al-Kofahi
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
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14
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Nelson RM. The Use of Pediatric Extrapolation to Avoid Unnecessary Pediatric Clinical Trials. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:114-116. [PMID: 32208075 DOI: 10.1080/15265161.2020.1730489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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15
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Abstract
Pediatric brain tumors are the leading cause of cancer-related death in children. Recent advances in sequencing techniques, and collaborative efforts to encode the mutational landscape of various tumor subtypes, have resulted in the identification of recurrent mutations that may present as actionable targets in these tumors. A number of molecularly targeted agents are approved or in development for the treatment of various tumor types in adult patients. Similarly, these agents are increasingly being incorporated into pediatric clinical trials, allowing for a targeted approach to treatment. However, due to the genetic heterogeneity of these tumors, focused clinical trials in pediatric patients are challenging and regulatory hurdles may delay access to therapeutic compounds that are in regular use in adult patients. The tumor site-agnostic clinical development of TRK inhibitors for pediatric solid tumors is a current example of how the combination of genetic testing and innovative clinical trial design can accelerate the clinical development of targeted agents for pediatric patients.
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Affiliation(s)
- Miriam Bornhorst
- Department of Pediatric Hematology-Oncology, Center for Cancer and Immunology Research and Neuroscience Research, Children's National Medical Center, 111 Michigan Ave, NW, Washington, DC, 20010, USA.,Center for Cancer and Immunology Research and Neuroscience Research, The Brain Tumor Institute, Children's National Medical Center, Washington, DC, USA.,Center for Cancer and Immunology Research and Neuroscience Research, Gilbert Family Neurofibromatosis Institute, Children's National Medical Center, Washington, DC, USA
| | - Eugene I Hwang
- Department of Pediatric Hematology-Oncology, Center for Cancer and Immunology Research and Neuroscience Research, Children's National Medical Center, 111 Michigan Ave, NW, Washington, DC, 20010, USA. .,Center for Cancer and Immunology Research and Neuroscience Research, The Brain Tumor Institute, Children's National Medical Center, Washington, DC, USA.
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16
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Gamalo-Siebers M, Hampson L, Kordy K, Weber S, Nelson RM, Portman R. Incorporating Innovative Techniques Toward Extrapolation and Efficient Pediatric Drug Development. Ther Innov Regul Sci 2019; 53:567-578. [DOI: 10.1177/2168479019842541] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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17
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Cooner F, Gamalo-Siebers M, Xia A, Gao A, Ruan S, Jiang T, Thompson L. Use of Alternative Designs and Data Sources for Pediatric Trials. Stat Biopharm Res 2019. [DOI: 10.1080/19466315.2019.1671217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | | | - Amy Xia
- Amgen Inc., Thousand Oaks, CA
| | | | | | | | - Laura Thompson
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD
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18
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Lopes BC, Borges PSGN, Gallindo RM, Tenório TBS, Machado LB, Orange FA. Ethanol Lock Therapy for the Prevention of Nontunneled Catheter‐Related Bloodstream Infection in Pediatric Patients. JPEN J Parenter Enteral Nutr 2019; 43:1044-1052. [DOI: 10.1002/jpen.1508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/13/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Bellisa Caldas Lopes
- Division of Pediatric SurgeryInstituto de Medicina Integral Prof. Fernando Figueira (IMIP) Recife Pernambuco Brazil
| | | | - Rodrigo Melo Gallindo
- Division of Pediatric SurgeryInstituto de Medicina Integral Prof. Fernando Figueira (IMIP) Recife Pernambuco Brazil
| | | | - Lara Barreto Machado
- Division of Pediatric SurgeryInstituto de Medicina Integral Prof. Fernando Figueira (IMIP) Recife Pernambuco Brazil
| | - Flávia Augusta Orange
- Division of Anesthesiology and Postgraduate Program in Palliative CareIMIP Recife Pernambuco Brazil
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19
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Van Hoof W, Meesters K, Dossche L, Christiaens D, De Bruyne P, Vande Walle J. Ethical considerations of researchers conducting pediatric clinical drug trials: a qualitative survey in two Belgian university children's hospitals. Eur J Pediatr 2018; 177:1003-1008. [PMID: 29679141 DOI: 10.1007/s00431-018-3151-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 02/15/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
UNLABELLED There is a general consensus about the underlying theoretical ethical principles that ground the practice of pediatric clinical trials: scientific necessity, good risk/benefit ratio, minimized burden, and parental consent/child assent. However, these principles are so broadly construed that it is not always clear how they should be applied in clinical practice. We conducted a qualitative study at Ghent University Hospital and the hospital of the Dutch-speaking university of Brussels on how researchers weigh ethical principles, assess the risk/benefit balance, estimate patient experience, and experience informed consent procedures in pediatric drug studies. Based on our assessment of the burden and risk versus benefit ratio in 62 pediatric drug research protocols, we selected 21 studies for further study to maximize diversity. Twenty-seven researchers (17 physicians, 10 study nurses) completed a qualitative survey about their study. We compared their responses to our assessments. The risk benefit assessment of our participants about their own research projects resembled our assessment almost perfectly. Assessing burden appeared to be more subjective. The researchers were confident in their ability to obtain valid consent. However, we question whether this confidence is warranted. CONCLUSION We argue for constant ethical reflexivity in pediatric clinical trials, because broad ethical principles are not always easy to apply to specific situations. What is Known: • Several international guidelines and a large body of scientific literature indicate a broad consensus about the basic ethical framework for pediatric clinical trials, based on risk benefit assessment and respect for autonomy. • Little is known about how researchers implement these broad principles in practice. What is New: • Researchers' risk/benefit assessments about their own studies resembled the assessment of neutral peers, assessing burden was more subjective. • Researchers were very confident in their ability to obtain valid informed consent.
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Affiliation(s)
| | - Kevin Meesters
- Department of Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
- Department of Pediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Lien Dossche
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Daphné Christiaens
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Pauline De Bruyne
- Department of Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent University, Ghent, Belgium
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20
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Barker CIS, Standing JF, Kelly LE, Hanly Faught L, Needham AC, Rieder MJ, de Wildt SN, Offringa M. Pharmacokinetic studies in children: recommendations for practice and research. Arch Dis Child 2018; 103:695-702. [PMID: 29674514 PMCID: PMC6047150 DOI: 10.1136/archdischild-2017-314506] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/08/2018] [Accepted: 03/14/2018] [Indexed: 12/11/2022]
Abstract
Optimising the dosing of medicines for neonates and children remains a challenge. The importance of pharmacokinetic (PK) and pharmacodynamic (PD) research is recognised both in medicines regulation and paediatric clinical pharmacology, yet there remain barriers to undertaking high-quality PK and PD studies. While these studies are essential in understanding the dose-concentration-effect relationship and should underpin dosing recommendations, this review examines how challenges affecting the design and conduct of paediatric pharmacological studies can be overcome using targeted pharmacometric strategies. Model-based approaches confer benefits at all stages of the drug life-cycle, from identifying the first dose to be used in children, to clinical trial design, and optimising the dosing regimens of older, off-patent medications. To benefit patients, strategies to ensure that new PK, PD and trial data are incorporated into evidence-based dosing recommendations are needed. This review summarises practical strategies to address current challenges, particularly the use of model-based (pharmacometric) approaches in study design and analysis. Recommendations for practice and directions for future paediatric pharmacological research are given, based on current literature and our joint international experience. Success of PK research in children requires a robust infrastructure, with sustainable funding mechanisms at its core, supported by political and regulatory initiatives, and international collaborations. There is a unique opportunity to advance paediatric medicines research at an unprecedented pace, bringing the age of evidence-based paediatric pharmacotherapy into sight.
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Affiliation(s)
- Charlotte I S Barker
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, University College London, London, UK,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK,Paediatric Infectious Diseases Unit, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Infection, Inflammation and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, University College London, London, UK,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
| | - Lauren E Kelly
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada,Clinical Trials Platform, George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada
| | - Lauren Hanly Faught
- Departments of Paediatrics, Physiology and Pharmacology and Medicine, Western University, London, Ontario, Canada,Molecular Medicine Group, Robarts Research Institute, London, Ontario, Canada
| | - Allison C Needham
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael J Rieder
- Departments of Paediatrics, Physiology and Pharmacology and Medicine, Western University, London, Ontario, Canada,Molecular Medicine Group, Robarts Research Institute, London, Ontario, Canada
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University, Nijmegen, The Netherlands,Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia, Rotterdam, The Netherlands
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada,Division of Neonatology, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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21
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Hume M, Lewis LL, Nelson RM. Meeting the goal of concurrent adolescent and adult licensure of HIV prevention and treatment strategies. JOURNAL OF MEDICAL ETHICS 2017; 43:857-860. [PMID: 28507222 PMCID: PMC5685924 DOI: 10.1136/medethics-2016-103600] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 03/23/2017] [Accepted: 04/18/2017] [Indexed: 06/07/2023]
Abstract
The ability of adolescents to access safe and effective new products for HIV prevention and treatment is optimised by adolescent licensure at the same time these products are approved and marketed for adults. Many adolescent product development programmes for HIV prevention or treatment products may proceed simultaneously with adult phase III development programmes. Appropriately implemented, this strategy is not expected to delay licensure as information regarding product efficacy can often be extrapolated from adults to adolescents, and pharmacokinetic properties of drugs in adolescents are expected to be similar to those in adults. Finally, adolescents enrolled in therapeutic HIV prevention and treatment research can be considered adults, based on US Food and Drug Administration (FDA) regulations and the appropriate application of state law. The FDA permits local jurisdictions to apply state and local HIV/sexually transmitted infection minor treatment laws so that adolescents who are HIV-positive or at risk of contracting HIV may be enrolled in therapeutic or prevention trials without obtaining parental permission.
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Affiliation(s)
- Michelle Hume
- Department of Psychiatry, University of Wisconsin, Madison, Wisconsin, USA
| | - Linda L Lewis
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Robert M Nelson
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration, Silver Spring, Maryland, USA
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22
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Parents' perceived obstacles to pediatric clinical trial participation: Findings from the clinical trials transformation initiative. Contemp Clin Trials Commun 2017; 9:33-39. [PMID: 29696222 PMCID: PMC5898566 DOI: 10.1016/j.conctc.2017.11.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/08/2017] [Accepted: 11/22/2017] [Indexed: 11/23/2022] Open
Abstract
Enrollment of children into pediatric clinical trials remains challenging. More effective strategies to improve recruitment of children into trials are needed. This study used in-depth qualitative interviews with parents who were approached to enroll their children in a clinical trial in order to gain an understanding of the barriers to pediatric clinical trial participation. Twenty-four parents whose children had been offered the opportunity to participate in a clinical trial were interviewed: 19 whose children had participated in at least 1 clinical trial and 5 who had declined participation in any trial. Each study aspect, from the initial explanation of the study to the end of the study, can affect the willingness of parents to consent to the proposed study and future studies. Establishing trust, appropriate timing, a transparent discussion of risks and benefits oriented to the layperson, and providing motivation for children to participate were key factors that impacted parents' decisions. In order for clinical trial accrual to be successful, parents' priorities and considerations must be a central focus, beginning with initial trial design. The recommendations from the parents who participated in this study can be used to support budget allocations that ensure adequate training of study staff and improved staffing on nights and weekends. Studies of parent responses in outpatient settings and additional inpatient settings will provide valuable information on the consent process from the child's and parent's perspectives. Further studies are needed to explore whether implementation of such strategies will result in improved recruitment for pediatric clinical trials.
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23
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Gamalo-Siebers M, Savic J, Basu C, Zhao X, Gopalakrishnan M, Gao A, Song G, Baygani S, Thompson L, Xia HA, Price K, Tiwari R, Carlin BP. Statistical modeling for Bayesian extrapolation of adult clinical trial information in pediatric drug evaluation. Pharm Stat 2017; 16:232-249. [PMID: 28448684 DOI: 10.1002/pst.1807] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/19/2017] [Accepted: 03/03/2017] [Indexed: 11/06/2022]
Abstract
Children represent a large underserved population of "therapeutic orphans," as an estimated 80% of children are treated off-label. However, pediatric drug development often faces substantial challenges, including economic, logistical, technical, and ethical barriers, among others. Among many efforts trying to remove these barriers, increased recent attention has been paid to extrapolation; that is, the leveraging of available data from adults or older age groups to draw conclusions for the pediatric population. The Bayesian statistical paradigm is natural in this setting, as it permits the combining (or "borrowing") of information across disparate sources, such as the adult and pediatric data. In this paper, authored by the pediatric subteam of the Drug Information Association Bayesian Scientific Working Group and Adaptive Design Working Group, we develop, illustrate, and provide suggestions on Bayesian statistical methods that could be used to design improved pediatric development programs that use all available information in the most efficient manner. A variety of relevant Bayesian approaches are described, several of which are illustrated through 2 case studies: extrapolating adult efficacy data to expand the labeling for Remicade to include pediatric ulcerative colitis and extrapolating adult exposure-response information for antiepileptic drugs to pediatrics.
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Affiliation(s)
| | | | - Cynthia Basu
- Division of Biostatistics, University of Minnesota, Minneapolis, 55455, MN, USA
| | - Xin Zhao
- Biostatistics, Johnson & Johnson, South San Francisco, 94080, CA, USA
| | - Mathangi Gopalakrishnan
- Research Assistant Professor, Center for Translational Medicine, University of Maryland, Baltimore, 21201, MD, USA
| | - Aijun Gao
- Biostatistics, Chiltern International Ltd., King of Prussia, 19406, PA, USA
| | | | - Simin Baygani
- Global Statistical Science, Eli Lilly & Co, Lilly Corporate Center, Indianapolis, 46285, IN, USA
| | - Laura Thompson
- Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, 20993, MD, USA
| | - H Amy Xia
- Biostatistics, Amgen, Thousand Oaks, 91320, CA, USA
| | - Karen Price
- Advanced Analytics, Eli Lilly & Co, Lilly Corporate Center, Indianapolis, 46285, IN, USA
| | - Ram Tiwari
- Office of Biostatistics, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, 20993, MD, USA
| | - Bradley P Carlin
- Division of Biostatistics, University of Minnesota, Minneapolis, 55455, MN, USA
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24
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Finkel RS, Bishop KM, Nelson RM. Spinal Muscular Atrophy Type I: Is It Ethical to Standardize Supportive Care Intervention in Clinical Trials? J Child Neurol 2017; 32:155-160. [PMID: 27760875 PMCID: PMC5258738 DOI: 10.1177/0883073816671236] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The natural history of spinal muscular atrophy type I (SMA-I) has changed as improved medical support has become available. With investigational drugs for spinal muscular atrophy now in clinical trials, efficient trial design focuses on enrolling recently diagnosed infants, providing best available supportive care, and minimizing subject variation. The quandary has arisen whether it is ethically appropriate to specify a predefined level of nutritional and/or ventilation support for spinal muscular atrophy type I subjects while participating in these studies. We conducted a survey at 2 spinal muscular atrophy investigator meetings involving physician investigators, clinical evaluators, and study coordinators from North America, Europe, and Asia-Pacific. Each group endorsed the concept that having a predefined degree of nutritional and ventilation support was warranted in this context. We discuss how autonomy, beneficence/non-maleficence, noncoercion, social benefit, and equipoise can be maintained when a predefined level of supportive care is proposed, for participation in a clinical trial.
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Affiliation(s)
- Richard S Finkel
- 1 Division of Neurology, Nemours Children's Hospital, Orlando, FL, USA
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25
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Fiorino S, Loggi E, Verucchi G, Comparcola D, Vukotic R, Pavoni M, Grandini E, Cursaro C, Maselli S, Bacchi Reggiani ML, Puggioli C, Badia L, Galli S, Viale P, Bernardi M, Andreone P. Vitamin E for the treatment of E-antigen-positive chronic hepatitis B in paediatric patients: results of a randomized phase 2 controlled study. Liver Int 2017; 37:54-61. [PMID: 27333382 DOI: 10.1111/liv.13192] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 06/18/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS The treatment of chronic hepatitis B infection (CHB) in children is still an area of great uncertainty. Vitamin E is an immunostimulating/antioxidant compound proven to be safe and effective for the treatment of adult CHB. The aim of this phase 2 controlled study was to evaluate the safety and efficacy of vitamin E for the treatment of paediatric HBeAg-positive CHB. METHODS Forty-six children were randomized in a 1:1 ratio to receive vitamin E at a dose of 15 mg/kg/day (in galenic preparation) or no treatment for 12 months and were monitored for the subsequent 12 months. Clinical, biochemical, haematological and serovirological evaluations were carried out every 3 months. RESULTS No significant side effects were associated with the vitamin E treatment. At the end of the study, anti-HBe seroconversion was obtained in 7 of 23 (30.4%) of vitamin E-treated versus 1 of 23 (4.3%) of the control patients (P = 0.05), while a virological response (≥2 log decrease in HBV-DNA from baseline) was observed in 9 of 23 (39.1%) vs. 2 of 23 (8.7%) respectively (P = 0.035). CONCLUSIONS Vitamin E administration for the treatment of paediatric CHB at the tested dosage has no significant side effects and may induce anti-HBe seroconversion. Vitamin E could represent a tool for the treatment of paediatric CHB.
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Affiliation(s)
- Sirio Fiorino
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy.,Unità Operativa di Medicina Interna, Ospedale Maggiore, AUSL Bologna, Bologna, Italy
| | - Elisabetta Loggi
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Gabriella Verucchi
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Donatella Comparcola
- Unità Operativa Malattie Epatometaboliche, Ospedale Pediatrico del Bambin Gesù, Rome, Italy
| | - Ranka Vukotic
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Michele Pavoni
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Elena Grandini
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Carmela Cursaro
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Silvia Maselli
- Unità Operativa di Farmacia Clinica, Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | | | - Cristina Puggioli
- Unità Operativa di Farmacia Clinica, Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | - Lorenzo Badia
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Silvia Galli
- Unità Operativa di Microbiologia e Virologia, Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | - Pierluigi Viale
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Mauro Bernardi
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Pietro Andreone
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
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26
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Bornhorst M, Hwang EI. Experimental Therapeutic Trial Design for Pediatric Brain Tumors. J Child Neurol 2016; 31:1421-32. [PMID: 26353880 DOI: 10.1177/0883073815604221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 08/11/2015] [Indexed: 11/17/2022]
Abstract
Pediatric brain tumors are the leading cause of cancer-related death during childhood. Since the first pediatric brain tumor clinical trials, the field has seen improved outcomes in some, but not all tumor types. In the past few decades, a number of promising new therapeutic agents have emerged, yet only a few of these agents have been incorporated into clinical trials for pediatric brain tumors. In this review, the authors discuss the process of and challenges in pediatric clinical trial design; this will allow for highly efficient and effective clinical trials with appropriate endpoints to ensure rapid and safe investigation of novel therapeutics for children with brain tumors.
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Affiliation(s)
- Miriam Bornhorst
- Department of Pediatric Hematology-Oncology, Children's National Medical Center, Washington, DC, USA Brain Tumor Institute, Washington, DC, USA
| | - Eugene I Hwang
- Department of Pediatric Hematology-Oncology, Children's National Medical Center, Washington, DC, USA Gilbert Family Neurofibromatosis Institute, Centers for Cancer and Immunology Research & Neuroscience Research, Children's National Medical Center, Washington, DC, USA
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27
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Del Ry S, Cabiati M, Bianchi V, Caponi L, Maltinti M, Caselli C, Kozakova M, Palombo C, Morizzo C, Marchetti S, Randazzo E, Clerico A, Federico G. C-type natriuretic peptide is closely associated to obesity in Caucasian adolescents. Clin Chim Acta 2016; 460:172-7. [PMID: 27376982 DOI: 10.1016/j.cca.2016.06.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 02/08/2023]
Abstract
CNP is a natural regulator of adipogenesis playing a role in the development of obesity in childhood. Aim of the study was to evaluate CNP plasma levels in normal-weight (N), overweight (OW) and obese adolescents (O). Eighty two subjects (age:12.8±2.4, years) without cardiac dysfunction were enrolled and CNP plasma levels were measured by RIA. NT-proBNP, MR-proANP, AGEs, reactive hyperemia index (RHI) and standard clinical chemistry parameters were also measured. O and OW adolescents had higher values of BMI and fat mass than N. CNP levels were significantly lower in OW:4.79[3.29-21.15] and O:3.81[1.55-13.4] than in N:13.21[7.6-37.8]; p<0.0001N vs O, p=0.0003N vs OW). LogCNP values correlated significantly and inversely with BMI z-score, FM%, TF% and circulating levels of CRP, insulin, total cholesterol, LDL, and triglycerides, in addition to an inverse relationship with skin AGEs and a direct correlation with RHI. LogCNP was also inversely associated with LogNT-proBNP and LogMR-proANP values. Using ROC analysis the risk of obesity resulted significantly (p≪0.0001) associated with CNP values (AUC=0.9724). These results suggest that CNP may play a more important role than BNP and ANP related peptides, as risk marker of obesity, in addition to its involvement in adipogenesis and endothelial dysfunction.
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Affiliation(s)
- Silvia Del Ry
- Laboratory of Biochemistry and Molecular Biology, Institute of Clinical Physiology, CNR, Pisa, Italy.
| | - Manuela Cabiati
- Laboratory of Biochemistry and Molecular Biology, Institute of Clinical Physiology, CNR, Pisa, Italy
| | - Vanessa Bianchi
- Unit of Pediatric Endocrinology and Diabetes, Dep. Clinical and Experimental Medicine, University of Pisa, Italy
| | - Laura Caponi
- Translational Research Department, University of Pisa, Italy
| | | | - Chiara Caselli
- Laboratory of Biochemistry and Molecular Biology, Institute of Clinical Physiology, CNR, Pisa, Italy
| | - Michaela Kozakova
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Carlo Palombo
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Italy
| | - Carmela Morizzo
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Italy
| | - Sara Marchetti
- Unit of Pediatric Endocrinology and Diabetes, Dep. Clinical and Experimental Medicine, University of Pisa, Italy
| | - Emioli Randazzo
- Unit of Pediatric Endocrinology and Diabetes, Dep. Clinical and Experimental Medicine, University of Pisa, Italy
| | | | - Giovanni Federico
- Unit of Pediatric Endocrinology and Diabetes, Dep. Clinical and Experimental Medicine, University of Pisa, Italy
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Caselli C, Cangemi G, Masotti S, Ragusa R, Gennai I, Del Ry S, Prontera C, Clerico A. Plasma cardiac troponin I concentrations in healthy neonates, children and adolescents measured with a high sensitive immunoassay method. Clin Chim Acta 2016; 458:68-71. [DOI: 10.1016/j.cca.2016.04.029] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 04/22/2016] [Indexed: 10/21/2022]
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Caselli C, Ragusa R, Prontera C, Cabiati M, Cantinotti M, Federico G, Del Ry S, Trivella MG, Clerico A. Distribution of circulating cardiac biomarkers in healthy children: from birth through adulthood. Biomark Med 2016; 10:357-65. [DOI: 10.2217/bmm-2015-0044] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Aim: While circulating biomarkers are critical tools for cardiovascular adult care, their relevance in childhood is unknown. Methods: We evaluated the behavior of plasma concentrations of clinically relevant cardiac biomarkers (NT-proBNP, hs-cTnI, sST2, Galectin-3) in 106 healthy children. Results: Subjects were divided into age subgroups: 24 newborns (0–30 days), 26 infants (1–12 months), 30 children (1–12 years) and 26 adolescents (13–18 years). Healthy adults were used as control. NT-proBNP (newborns: 504.3 [211.07–942.7] ng/L, median [25–75 percentiles]; infants: 200.64 [76.88–306.73]; children: 97.27 [49.24–271.80]; adolescents: 24.35 [13.14–58.83]; p < 0.001) and hs-cTnI (newborns: 9.3 [3.3–93.8] ng/L; infants: 13.8 [4.82–72.52]; children: 11.45 [4.0–48.10]; adolescents: 2.6[2.07–3.90]; p < 0.001) were highest in the first month of life, showing a decline in the next years. sST2 and Galectin-3 showed no differences. Conclusion: Changes in hs-cTnI and NT-proBNP suggest the design of age- and sex-based reference intervals that will have to be explored in a larger population.
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Affiliation(s)
| | | | | | | | | | - Giovanni Federico
- U.O. Pediatria Universitaria, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | | | - Aldo Clerico
- Fondazione Toscana G. Monasterio, Pisa and Massa, Italy
- U.O. Pediatria Universitaria, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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30
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Strategies to improve the understanding of long-term renal consequences after neonatal acute kidney injury. Pediatr Res 2016; 79:502-8. [PMID: 26595535 PMCID: PMC9677947 DOI: 10.1038/pr.2015.241] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 08/28/2015] [Indexed: 11/08/2022]
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31
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De Clercq E, Badarau DO, Ruhe KM, Wangmo T. Body matters: rethinking the ethical acceptability of non-beneficial clinical research with children. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2015; 18:421-431. [PMID: 25433817 DOI: 10.1007/s11019-014-9616-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The involvement of children in non-beneficial clinical research is extremely important for improving pediatric care, but its ethical acceptability is still disputed. Therefore, various pro-research justifications have been proposed throughout the years. The present essay aims at contributing to the on-going discussion surrounding children's participation in non-beneficial clinical research. Building on Wendler's 'contribution to a valuable project' justification, but going beyond a risk/benefit analysis, it articulates a pro-research argument which appeals to a phenomenological view on the body and vulnerability. It is claimed that children's bodies are not mere physical objects, but body-subjects due to which children, as persons, can contribute to research that may hold no direct clinical benefit to them even before they can give informed consent.
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Affiliation(s)
- Eva De Clercq
- Institute for Biomedical Ethics, University of Basel, Bernoullistr 28, 4056, Basel, Switzerland,
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32
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Ruemmele FM, Hyams JS, Otley A, Griffiths A, Kolho KL, Dias JA, Levine A, Escher JC, Taminiau J, Veres G, Colombel JF, Vermeire S, Wilson DC, Turner D. Outcome measures for clinical trials in paediatric IBD: an evidence-based, expert-driven practical statement paper of the paediatric ECCO committee. Gut 2015; 64:438-46. [PMID: 24821616 DOI: 10.1136/gutjnl-2014-307008] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Although paediatric-onset IBD is becoming more common, few medications have a registered paediatric indication. There are multiple hurdles to performing clinical trials in children, emphasising the importance of choosing an appropriate outcome measure, which can facilitate enrolment, and thereby also drug approval. The aim of this consensus statement is to highlight paediatric specific issues and key factors critical for the optimal conduct of paediatric IBD trials. DESIGN The Paediatric European Crohn's and Colitis Organisation (ECCO) committee has established an international expert panel to determine the best outcome measures in paediatric IBD, following a literature search and a modified Delphi process. All recommendations were endorsed by at least 80% agreement. RESULTS Recognising the importance of mucosal healing (MH), the panel defined steroid-free MH as primary outcome measure for all drugs of new category with one or two postintervention endoscopies per trial (at 8-12 weeks and/or 54 weeks). Since endoscopic evaluation is a barrier for recruitment in children, trials with medications already shown to induce MH in children or adults, could use paediatric-specific disease activity scores as primary outcome, including a modified Paediatric Crohn's Disease Activity Index in Crohn's disease and the Paediatric Ulcerative Colitis Activity Index in UC. Secondary outcomes should include safety issues, MR enterography-based damage and inflammatory scores (in Crohn's disease), faecal calprotectin, quality of life scales, and a patient-reported outcome. CONCLUSIONS It is crucial to perform paediatric trials early in the development of new drugs in order to reduce off-label use of IBD medication in children. The thoughtful choice of feasible and standardised outcome measures can help move us towards this goal.
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Affiliation(s)
- Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France INSERM U989, Institut IMAGINE, Paris, France APHP, Hôpital Necker Enfants Malades, Service de Gastroentérologie pédiatrique, Paris, France
| | - Jeffrey S Hyams
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Anthony Otley
- Division of Pediatric Gastroenterology, IWK Health Centre, Halifax, Canada
| | - Anne Griffiths
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Sackler School of Medicine, Tel Aviv University, Holon, Israel
| | - Johanna C Escher
- Pediatric Gastroenterology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jan Taminiau
- Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands
| | - Gabor Veres
- Ist Dept of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Jean-Frederic Colombel
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University Hospital Leuven, Leuven, Belgium
| | - David C Wilson
- Department of Child Life and Health, University of Edinburgh, Scotland, UK
| | - Dan Turner
- The Juliet Keidan Institute for Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
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Abstract
The assessment of safety and efficacy of therapeutics for children and adolescents requires the use of multi-centered designs. However, the need to obtain ethical approval from multiple independent research ethics boards (REBs) presents as a challenge to investigators and sponsors who must consider local requirements while ensuring that the protection of human subjects is consistent across sites. In pediatrics, this requirement is complicated by pediatric-specific ethical concerns such as the acquisition of assent and consent and the need for pediatric expertise to assess the scholarly merit of the proposed research. Efforts to tackle these challenges have focused on the process of ethics review, which will improve efficiency. In addition to improving process, we suggest further research to fill gaps in the evidence base for recommendations and decisions made by REBs, specifically their effectiveness to protect human subjects. Evidence gathered will contribute to the successful development, adoption and implementation of harmonized guidance to apply ethics principles in order to protect children through research rather than from research.
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Affiliation(s)
- Allison C Needham
- Child Health Evaluative Sciences CHES, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON, M5G 1X8, Canada,
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Wakefield CE, McLoone JK, Donovan LA, Cohn RJ. Thank you for your lovely card: ethical considerations in responding to bereaved parents invited in error to participate in childhood cancer survivorship research. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2015; 18:113-119. [PMID: 25070880 DOI: 10.1007/s11019-014-9587-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Research exploring the needs of families of childhood cancer survivors is critical to improving the experiences of future families faced by this disease. However, there are numerous challenges in conducting research with this unique population, including a relatively high mortality rate. In recognition that research with cancer survivors is a relational activity, this article presents a series of cases of parents bereaved by childhood cancer who unintentionally received invitations to participate in survivorship research. We explore six ethical considerations, and compare our experiences with that described previously. Our considerations include the sharing of confidential information with external parties to confirm past patients' vital status and appropriate researcher responses to bereaved parents. The management of researchers' emotional safety when working with illness populations and the fact that study invitations can elicit grief responses in non-bereaved families are discussed. To conclude, we argue for the benefits of inviting bereaved parents whose children died after treatment completion in survivorship research. Such parents' early survivorship experiences will otherwise be systemically neglected. We argue that discussing complex cases can assist researchers to protect participants' and researchers' emotional well-being. We hope to contribute to the dearth of discussion about research operating procedures to address these issues.
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Affiliation(s)
- Claire E Wakefield
- Kids Cancer Centre, Sydney Children's Hospital, High St, Randwick, NSW, 2031, Australia,
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A mechanistic approach to understanding oral drug absorption in pediatrics: an overview of fundamentals. Drug Discov Today 2014; 19:1322-36. [DOI: 10.1016/j.drudis.2014.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 02/18/2014] [Accepted: 03/14/2014] [Indexed: 01/04/2023]
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36
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Constand M, Tanel N, Ryan SE. PAeDS-MoRe: A framework for the development and review of research assent protocols involving children and adolescents. RESEARCH ETHICS REVIEW 2014. [DOI: 10.1177/1747016114523772] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We systematically reviewed contemporary literature to create an evidence-informed framework for research studies involving children and adolescents who can assent to participate. We searched seven citation indices to locate peer-reviewed research published in English language journals between 2000 and 2012. After screening 1,231 titles and abstracts for relevance, we assessed levels of evidence, extracted information, and analysed content from 87 articles. Most articles narrowly focused on paediatric assent barriers and facilitators for decision-making about research participation. No articles provided a single, comprehensive ethical framework to guide the development and review of research assent protocols. We developed a 6-step framework that provides guidance to: prepare the child for the assent process; assess the child’s readiness to engage in decision making; discuss the elements of informed consent to the greatest extent possible; seek an initial assent decision; monitor and affirm assent; and respect the child’s role as a research participant. The PAeDS-MoRe framework also supports the creation of process models that address the unique, developmental needs of paediatric sub-groups, and guides the operationalization of jurisdictional requirements for ethical research involving children who are unable to provide free, informed and ongoing consent.
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Affiliation(s)
| | - Nadia Tanel
- Holland Bloorview Kids Rehabilitation Hospital, Canada
| | - Stephen E Ryan
- Holland Bloorview Kids Rehabilitation Hospital and Department of Occupational Science and Occupational Therapy, University of Toronto, Canada
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37
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Abstract
Pediatricians play a key role in advancing child health research to best attain and improve the physical, mental, and social health and well-being of all infants, children, adolescents, and young adults. Child health presents unique issues that require investigators who specialize in pediatric research. In addition, the scope of the pediatric research enterprise is transdisciplinary and includes the full spectrum of basic science, translational, community-based, health services, and child health policy research. Although most pediatricians do not directly engage in research, knowledge of research methodologies and approaches promotes critical evaluation of scientific literature, the practice of evidence-based medicine, and advocacy for evidence-based child health policy. This statement includes specific recommendations to promote further research education and support at all levels of pediatric training, from premedical to continuing medical education, as well as recommendations to increase support and mentorship for research activities. Pediatric research is crucial to the American Academy of Pediatrics' goal of improving the health of all children. The American Academy of Pediatrics continues to promote and encourage efforts to facilitate the creation of new knowledge and ways to reduce barriers experienced by trainees, practitioners, and academic faculty pursuing research.
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Weimer K, Gulewitsch MD, Schlarb AA, Schwille-Kiuntke J, Klosterhalfen S, Enck P. Placebo effects in children: a review. Pediatr Res 2013; 74:96-102. [PMID: 23598811 DOI: 10.1038/pr.2013.66] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 12/23/2012] [Indexed: 12/19/2022]
Abstract
Of more than 155,000 PubMed citations found with the search term "placebo," only ~9,000 (5.8%) included the terms "children" or "adolescents." When all these papers were screened, only ~2,000 of them investigated the placebo effect per se, and of those, only ~50 (2.5%) discussed the placebo effect in children and adolescents. In this narrative review, we explore four aspects of the placebo response in children and adolescents: (i) the legal and ethical limitations and restrictions for the inclusion of children in clinical trials as well as in experimental (placebo) research that may explain the poor knowledge base; (ii) the question of whether or not the placebo effect is larger in children and adolescents as compared with adults; (iii) whether the mechanisms underlying the placebo effect are similar between children and adults; and (iv) whether mediators and moderators of the placebo effect are comparable between children and adults. We finally discuss some of the consequences from the current placebo research in adults that may affect both experimental and clinical research in children and adolescents.
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Affiliation(s)
- Katja Weimer
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.
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Abstract
Children have been identified as uniquely vulnerable clinical research subjects since the early 1970s. This article reviews the historical underpinnings of this designation, the current regulatory framework for pediatric and neonatal research, and common problems in pediatric research oversight. It also presents 3 areas of pediatric and neonatal research (genomic screening, healthy children donating stem cells, and therapeutic hypothermia for neonates with hypoxic-ischemic encephalopathy) that highlight contemporary challenges in pediatric research ethics, including balancing risk and benefit, informed consent and assent, and clinical equipoise.
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Affiliation(s)
- Naomi Laventhal
- Department of Pediatrics and Communicable Diseases, Division of Neonatal-Perinatal Medicine, University of Michigan School of Medicine, 8-621 C&W Mott Hospital, 1540 E. Hospital Drive, SPC 4254, Ann Arbor, MI 48109-4254, Phone: 734-763-4109, Fax: 734-763-7728,
| | - Beth Tarini
- Department of Pediatrics and Communicable Diseases, Child Health Evaluation and Research Unit, University of Michigan School of Medicine, 300 North Ingalls 6C11, Ann Arbor, Michigan 48109-5456, Phone: 734-615-8153, Fax: 734-264-2599,
| | - John Lantos
- Children’s Mercy Bioethics Center, Children’s Mercy Hospital, 2401 Gilham Rd., Kansas, City, MO 64108, Phone: 816-701-5283, Fax: 816-701-5286,
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Purohit VS. Biopharmaceutic planning in pediatric drug development. AAPS JOURNAL 2012; 14:519-22. [PMID: 22562590 DOI: 10.1208/s12248-012-9364-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 04/16/2012] [Indexed: 11/30/2022]
Abstract
Pediatric drug development is a required consideration for all drug development programs. Age-appropriate formulations such as suspensions, chewable tablets, oral disintegrating tablets, etc., are typically developed and used in the pediatric clinical studies. However, it is not uncommon to use enabling formulations in the pivotal pediatric clinical study followed by bridging bioavailability and/or bioequivalence studies. Development of age-appropriate formulations is an essential part of pediatric drug development and adds additional biopharmaceutical considerations to an already complex problem. Careful planning of biopharmaceutic data collection during the adult and pediatric development program can contribute significantly to the biopharmaceutic risk assessment and planning of appropriate clinical studies leading to successful development of pediatric formulations.
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Affiliation(s)
- Vivek S Purohit
- Department of Clinical Pharmacology, Pfizer, Inc., Groton, Connecticut 06340, USA.
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