1
|
Cerreta F, Iskra EB, Cupelli A, Sepodes B, Rönnemaa E, Rosa MM, Mayrhofer S, Trauffler M, Torre C, Berntgen M, Vucic K, Bahri P, Koch A, Herdeiro MT, Mirošević Skvrce N, Pallos J, Laslop A. Medicines for an aging population: The EMA perspective and policies. J Am Geriatr Soc 2024. [PMID: 38757979 DOI: 10.1111/jgs.18953] [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: 01/04/2024] [Revised: 03/27/2024] [Accepted: 04/15/2024] [Indexed: 05/18/2024]
Abstract
The European Medicines Agency adopted their Geriatric Medicines Strategy more than a decade ago. The strategy aims at elucidating the evidence basis for marketing authorization of new medicines which will be used in the older population, and at ensuring the appropriate communication of findings to the patient and healthcare provider. During the past decade new tools and data sources have emerged to support the strategy goals, and their use should be considered. Possible concrete actions are presented to improve the design of clinical trials, the data collection both pre- and post-approval, the assessment of the findings, and the communication to assist informed prescription and safe medicine taking. Implementation and prioritization of these actions should be done from the perspective of addressing the needs of patients while maximizing efficient use of resources, with the aim of integrating geriatric aspects into routine medicines development and assessment.
Collapse
Affiliation(s)
| | - Ewa Balkowiec Iskra
- Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Mazowieckie, Poland
- Medical Devices and Biocidal Products, The Office for Registration of Medicinal Products, Warsaw, Poland
| | - Amelia Cupelli
- Italian Medicines Agency, Pharmacovigilance, Rome, Italy
| | - Bruno Sepodes
- Universidade de Lisboa Faculdade de Farmácia, Lisbon, Poland
| | | | - Mário Miguel Rosa
- Departamento de Neurociências/Laboratório de Farmacologia Clínica E Terapêutica, Universidade de Lisboa, Lisbon, Portugal
| | | | - Martine Trauffler
- Division of Pharmacy and Medicines, Directorate of Health, Ministry of Health, Luxembourg, Strassen, Luxembourg
| | - Carla Torre
- Universidade de Lisboa Faculdade de Farmácia, Lisbon, Poland
- Faculdade de Farmácia da Universidade de Lisboa, iMedULisboa, Lisbon, Portugal
| | - Michael Berntgen
- European Medicines Agency, Amsterdam, Noord-Holland, Netherlands
| | - Katarina Vucic
- European Medicines Agency, Amsterdam, Noord-Holland, Netherlands
| | - Priya Bahri
- European Medicines Agency, Amsterdam, Noord-Holland, Netherlands
| | - Armin Koch
- Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Maria Teresa Herdeiro
- Department of Medical Sciences, Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | | | - Julia Pallos
- National Institute of Pharmacy and Nutrition, Budapest, Hungary
| | - Andrea Laslop
- Austrian Agency for Health and Food Safety Division Medicines & Medical Devices, Scientific Office, Vienna, Austria
| |
Collapse
|
2
|
Schwartz JB. Current status of inclusion of older groups in evaluations of new medications: Gaps and implementation needs to fill them. J Am Geriatr Soc 2024. [PMID: 38600697 DOI: 10.1111/jgs.18912] [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: 03/05/2024] [Accepted: 03/16/2024] [Indexed: 04/12/2024]
Abstract
Under-representation of subgroups of the population in clinical trials has been and continues to be a problem despite goals of academia, industry, and government. Older adults are among the groups that are under-represented in trials of medications that they are likely to receive once marketing approval has been received. Recent legislation that mandates that clinical trial participants be representative of patient population has been passed and creates hope that greater numbers of older adults will be enrolled in clinical trials and that they will be representative of "typical" geriatric patients. However, there is the need for collection of current data on disease prevalences with granularity as to age, gender, and race as well as geriatric co-morbidities to assess the representativeness of clinical trial participants relative to patient populations. Consensus on definitions and collection of data relevant to geriatric patient populations are needed to evaluate effects of comorbidities, frailty, cognitive and physical function. There will also be a need for expansion of the geriatric research workforce, facilities for research both in academic centers but also in the community and long-term care facilities, and for engagement with and involvement of communities that have been traditionally under-represented to conduct clinical trials that enroll truly representative patient populations.
Collapse
Affiliation(s)
- Janice B Schwartz
- Department of Medicine, Divisions of Geriatrics and Clinical Pharmacology, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
3
|
Schwartz JB, Liu RY, Boscardin J, Liu Q, Lau SWJ, Khatri S, Tarn D. Attitudes on participation in clinical drug trials: A nationally representative survey of older adults with multimorbidity. J Am Geriatr Soc 2024. [PMID: 38485469 DOI: 10.1111/jgs.18857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Older adults with multimorbidity are under-represented in clinical drug trials. Their inclusion will not increase unless they are willing and able to participate. Data on motivators and barriers to participation in trials of new medications of older adults with multimorbidity are needed. METHODS Cross-sectional internet and telephone survey of a nationally representative sample of adults ≥65 years with ≥3 chronic conditions (NORC University of Chicago Amerispeak Panel) conducted from March-April, 2023 to determine motivators and barriers to drug trial participation, described graphically and using statistics. RESULTS Surveyed 1318 (1142 Internet, 176 phone) with mean age 72.3 ± 6.3 (SD), 52% women; race: 83% White, 10% Black or African American, 5% Hispanic or Latino, 1.1% Asian; 4.4 ± 1.9 chronic conditions (of 16 queried), taking 7.5 ± 3.3 medications. Barriers included fear of side effects (48%), taking too many medications (44%), placebo (44%), mobility (33%), bathroom needs (25%), hearing (19%), eyesight (15%), video visits (33%; higher in women, Black or African-American respondents, and those ≥80 years). Sixty-five percent would join all in-person trials, 49% would join all-video trials. Travel >1 h was difficult for 66%, most difficult for women. Trust was a concern in 25% of Black respondents. Caregiving responsibilities or lack of time were not obstacles. Participants were most likely to consider a drug trial for a problem they have (63%) versus prevention (44%) and if invited by a physician (80%) or University healthcare system (58%). Getting better care was ranked very important (79%) followed by helping others (57%). CONCLUSIONS Major concerns of older patients with multimorbidity about participation in drug trials are potential side effects, taking too many medicines, and video visits. Physicians have the greatest influence on decisions and in-person visits are preferred. Proposed changes in trial design to increase enrollment of under-represented older adults may not align with patient-reported preferences.
Collapse
Affiliation(s)
- Janice B Schwartz
- Department of Medicine, Division of Geriatrics and Division of Clinical Pharmacology, University of California, San Francisco, California, USA
| | - Ruey-Ying Liu
- Department of Sociology, National Chengchi University, Taipei, Taiwan
| | - John Boscardin
- Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Qi Liu
- Center for Drug Evaluation and Research, Office of Translational Sciences and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Springs, Maryland, USA
| | - S W Johnny Lau
- Center for Drug Evaluation and Research, Office of Translational Sciences and Office of Clinical Pharmacology, U.S. Food and Drug Administration, Silver Springs, Maryland, USA
| | - Sadhna Khatri
- Center for Biologics Evaluation and Research, Office of Compliance Biologics Quality, U.S. Food and Drug Administration, Silver Springs, Maryland, USA
| | - Derjung Tarn
- Department of Family Medicine, University of California, Los Angeles, California, USA
| |
Collapse
|
4
|
Schwartz JB. Representative enrolment of older adults in clinical trials: the time is now. THE LANCET. HEALTHY LONGEVITY 2023:S2666-7568(23)00088-0. [PMID: 37263282 DOI: 10.1016/s2666-7568(23)00088-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023] Open
Affiliation(s)
- Janice B Schwartz
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA 94143-1265, USA.
| |
Collapse
|
5
|
Identification of a Link between Suspected Metabolic Syndrome and Cognitive Impairment within Pharmaceutical Care in Adults over 75 Years of Age. Healthcare (Basel) 2023; 11:healthcare11050718. [PMID: 36900723 PMCID: PMC10000537 DOI: 10.3390/healthcare11050718] [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: 01/27/2023] [Revised: 02/20/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023] Open
Abstract
The prevalence of metabolic syndrome (MetS) and cognitive impairment (CI) is increasing with age. MetS reduces overall cognition, and CI predicts an increased risk of drug-related problems. We investigated the impact of suspected MetS (sMetS) on cognition in an aging population receiving pharmaceutical care in a different state of old age (60-74 vs. 75+ years). Presence or absence of sMetS (sMetS+ or sMetS-) was assessed according to criteria modified for the European population. The Montreal Cognitive Assessment (MoCA) score, being ≤24 points, was used to identify CI. We found a lower MoCA score (18.4 ± 6.0) and a higher rate of CI (85%) in the 75+ group when compared to younger old subjects (23.6 ± 4.3; 51%; p < 0.001). In the age group of 75+, a higher occurrence, of MoCA ≤ 24 points, was in sMetS+ (97%) as compared to sMetS- (80% p < 0.05). In the age group of 60-74 years, a MoCA score of ≤24 points was identified in 63% of sMetS+ when compared to 49% of sMetS- (NS). Conclusively, we found a higher prevalence of sMetS, the number of sMetS components and lower cognitive performance in subjects aged 75+. This age, the occurrence of sMetS and lower education can predict CI.
Collapse
|
6
|
Liu Q, Schwartz JB, Slattum PW, Lau SWJ, Guinn D, Madabushi R, Burckart G, Califf R, Cerreta F, Cho C, Cook J, Gamerman J, Goldsmith P, van der Graaf PH, Gurwitz JH, Haertter S, Hilmer S, Huang SM, Inouye SK, Kanapuru B, Pirmohamed M, Posner P, Radziszewska B, Keipp Talbot H, Temple R. Roadmap to 2030 for Drug Evaluation in Older Adults. Clin Pharmacol Ther 2021; 112:210-223. [PMID: 34656074 DOI: 10.1002/cpt.2452] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 10/04/2021] [Indexed: 12/17/2022]
Abstract
Changes that accompany older age can alter the pharmacokinetics (PK), pharmacodynamics (PD), and likelihood of adverse effects (AEs) of a drug. However, older adults, especially the oldest or those with multiple chronic health conditions, polypharmacy, or frailty, are often under-represented in clinical trials of new drugs. Deficits in the current conduct of clinical evaluation of drugs for older adults and potential steps to fill those knowledge gaps are presented in this communication. The most important step is to increase clinical trial enrollment of older adults who are representative of the target treatment population. Unnecessary eligibility criteria should be eliminated. Physical and financial barriers to participation should be removed. Incentives could be created for inclusion of older adults. Enrollment goals should be established based on intended treatment indications, prevalence of the condition, and feasibility. Relevant clinical pharmacology data need to be obtained early enough to guide dosing and reduce risk for participation of older adults. Relevant PK and PD data as well as patient-centered outcomes should be measured during trials. Trial data should be analyzed for differences in PK, PD, effectiveness, and safety arising from differences in age or from the presence of conditions common in older adults. Postmarket evaluations with real-world evidence and drug labeling updates throughout the product lifecycle reflecting new knowledge are also needed. A comprehensive plan is needed to ensure adequate evaluation of the safety and effectiveness of drugs in older adults.
Collapse
Affiliation(s)
- Qi Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Janice B Schwartz
- Departments of Medicine, Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Patricia W Slattum
- Department of Pharmacotherapy and Outcomes Science and Virginia Center on Aging, Virginia Commonwealth University, Richmond, Virginia, USA
| | - S W Johnny Lau
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Daphne Guinn
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rajanikanth Madabushi
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gilbert Burckart
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Robert Califf
- Verily and Google Health (Alphabet), South San Francisco, California, USA
| | - Francesca Cerreta
- Portfolio office, European Medicines Agency (EMA), Amsterdam, The Netherlands
| | - Carolyn Cho
- Oncology Early Development and Translational Research, Merck & Co., Kenilworth, New Jersey, USA
| | - Jack Cook
- Department of Clinical Pharmacology, Pfizer Global Research and Development, Groton, Connecticut, USA
| | - Jamie Gamerman
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Paul Goldsmith
- Lilly Exploratory Medicine and Pharmacology, Bracknell, UK
| | | | - Jerry H Gurwitz
- Meyers Health Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA
| | - Sebastian Haertter
- Boehringer Ingelheim Pharma, Translational Medicine & Clinical Pharmacology, Ingelheim, Germany
| | - Sarah Hilmer
- Kolling Institute, University of Sydney and Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Shiew-Mei Huang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sharon K Inouye
- Marcus Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School, Boston. Massachusetts, USA
| | - Bindu Kanapuru
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK
| | - Phil Posner
- Patient-Centered Outcomes Research Institute Ambassador, Gainesville, Florida, USA
| | - Barbara Radziszewska
- National Institute of Aging, National Institute of Health, Bethesda, Maryland, USA
| | - H Keipp Talbot
- Departments of Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert Temple
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| |
Collapse
|
7
|
Wahlich J, Orlu M, Mair A, Stegemann S, van Riet-Nales D. Age-Related Medicine. Pharmaceutics 2019; 11:E172. [PMID: 30970554 PMCID: PMC6523864 DOI: 10.3390/pharmaceutics11040172] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 04/02/2019] [Indexed: 12/12/2022] Open
Abstract
A meeting organised by the Academy of Pharmaceutical Sciences focussed on the challenges of developing medicines for older adults. International experts discussed the complexity introduced by polypharmacy and multiple morbidities and how the risk⁻benefit ratio of a medicine changes as an individual ages. The way in which regulatory authorities are encouraging the development of age-appropriate medicines was highlighted. Examples were provided of the difficulties faced by the older population with some medicinal products and suggestions given as to how the pharmaceutical scientist can build the requirements of the older population into their development of new medicines, as well as improvements to existing ones.
Collapse
Affiliation(s)
- John Wahlich
- Academy of Pharmaceutical Sciences, 4 Heydon Road, Great Chishill, Royston, Herts SG8 8SR, UK.
| | - Mine Orlu
- Department of Pharmaceutics, School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK.
| | - Alpana Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh EH6 5NL, Scotland, UK.
| | - Sven Stegemann
- Institute of Process and Particle Engineering, Graz University of Technology, Inffeldgasse 13, 8010 Graz, Austria.
| | - Diana van Riet-Nales
- Medicines Evaluation Board in the Netherlands, Quality Department, Chemical Pharmaceutical Assessments, P.O. Box 8275, 3503 RG Utrecht, The Netherlands.
| |
Collapse
|
8
|
De Spiegeleer B, Wynendaele E, Bracke N, Veryser L, Taevernier L, Degroote A, Stalmans S. Regulatory development of geriatric medicines: To GIP or not to GIP? Ageing Res Rev 2016; 27:23-36. [PMID: 26899877 DOI: 10.1016/j.arr.2016.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 02/12/2016] [Accepted: 02/12/2016] [Indexed: 12/13/2022]
Abstract
Geriatric patients represent the main users of medicines, but are historically often minimally included in clinical trials, resulting in a gap in the knowledge of the benefit/risk balance of medicines in this heterogeneous population. As the worldwide population is aging, the need for safe and effective medicines for older patients is proportionally increasing. The aim of this review is to provide an overview of the current regulatory status of the development of geriatric medicines, the encountered challenges and the view of the involved stakeholders, coming to the conclusion whether it is necessary or not to implement a Geriatric Investigation Plan (GIP), by analogy with pediatrics.
Collapse
Affiliation(s)
- Bart De Spiegeleer
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Postal address: Ottergemsesteenweg 460 (second floor), B-9000 Ghent, Belgium.
| | - Evelien Wynendaele
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Postal address: Ottergemsesteenweg 460 (second floor), B-9000 Ghent, Belgium.
| | - Nathalie Bracke
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Postal address: Ottergemsesteenweg 460 (second floor), B-9000 Ghent, Belgium.
| | - Lieselotte Veryser
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Postal address: Ottergemsesteenweg 460 (second floor), B-9000 Ghent, Belgium.
| | - Lien Taevernier
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Postal address: Ottergemsesteenweg 460 (second floor), B-9000 Ghent, Belgium.
| | - Agnes Degroote
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Postal address: Ottergemsesteenweg 460 (second floor), B-9000 Ghent, Belgium.
| | - Sofie Stalmans
- Drug Quality and Registration (DruQuaR) group, Faculty of Pharmaceutical Sciences, Ghent University, Postal address: Ottergemsesteenweg 460 (second floor), B-9000 Ghent, Belgium.
| |
Collapse
|