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Mathevula H, Schellack N, Orubu S, Godman B, Matlala M. Off-Label and Unlicenced Medicine Use among Hospitalised Children in South Africa: Practice and Policy Implications. PHARMACY 2023; 11:174. [PMID: 37987384 PMCID: PMC10661306 DOI: 10.3390/pharmacy11060174] [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: 09/14/2023] [Revised: 10/25/2023] [Accepted: 11/05/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Information regarding off-label and unlicensed medicine use among South African children is limited. This is a concern as the prescribing of off-label and unlicensed medicines can lead to issues of effectiveness and safety as well as raise liability issues in the event of adverse events. This potentially exposes physicians to legal penalties. Consequently, we sought to determine the prevalence of off-label and unlicensed medicine use among paediatric patients in South Africa to provide future direction. METHODS This study retrospectively examined the use of medicine in a point-prevalence survey study (PPS) involving paediatric patients aged (0-2 years) admitted to selected public hospitals in Gauteng Province, South Africa. Data were collected per hospital over two days between February 2022 and July 2022. Demographics, duration of treatment, diagnosis, and medicines prescribed were collected from patient medical records using a mobile application. Prescribed medicines were reviewed against the medicine formularies and other databases to assess their appropriateness. RESULTS From three academic hospitals, 184 patient records were reviewed. A total of 592 medicines were dispensed, of which 379 (64.0%) were licensed and 213 (36.0%) were used off-label/unlicensed for paediatric patients 0-2 years of age. The most prevalent off-label and unlicensed medicines were multivitamins (n = 32, 15.0%) and ampicillin injections (n = 15, 7.0%). CONCLUSION The frequency of unlicensed and off-label medicine prescribing shown in this study is consistent with the literature and can be considered high. This practice can pose a risk because it adversely affects patients if not properly regulated. Attention is needed to ensure future high-quality, safe, and effective use of medicines.
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Affiliation(s)
- Hlayiseka Mathevula
- School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria 0204, South Africa; (B.G.); (M.M.)
| | - Natalie Schellack
- Department of Pharmacology, University of Pretoria, Pretoria 0084, South Africa;
| | - Samuel Orubu
- Pharmacy Department, Niger Delta University, Yenagoa P.O. BOX 72, Nigeria;
- Global Strategy Lab, York University, Toronto, ON 4700, Canada
| | - Brian Godman
- School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria 0204, South Africa; (B.G.); (M.M.)
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Science (SIPBS), University of Strathclyde, Glasgow G4 0RE, UK
| | - Moliehi Matlala
- School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria 0204, South Africa; (B.G.); (M.M.)
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Johnson AL, Torgerson T, Adewumi MT, Kee M, Farahani C, Wehrmann DJ, Francis CL, Vassar M. Discontinuation and nonpublication of pediatric otolaryngology clinical trials. Int J Pediatr Otorhinolaryngol 2021; 151:110972. [PMID: 34773883 DOI: 10.1016/j.ijporl.2021.110972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/16/2021] [Accepted: 11/08/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Randomized controlled trial (RCT) discontinuation and nonpublication are potential mechanisms of waste in resources and lead to decreased advancement of medical science and compromised ethical issues in all specialties. However, the prevalence of discontinued or unpublished RCTs regarding common pediatric otolaryngology disorders and interventions remains unclear. STUDY DESIGN Cross-sectional analysis. METHODS Retrospective analysis of common pediatric otolaryngology RCTs registered in ClinicalTrials.gov up until November 2, 2018. Data were collected from the registry, and publication status was identified. If a reason for trial discontinuation or nonpublication was not identified through a systematic search, corresponding trialists were contacted through email. RESULTS After exclusion, 260 RCTs were included for analysis. Analysis found 198 (76%) RCTs were completed, and 62 (24%) trials were discontinued. The most commonly reported reasons for RCT discontinuation were program termination by sponsor or management (7/24; 29.2%), lack of participant enrollment, difficulty recruiting, or slow accrual (7/24; 29.2%). A total of 192 (192/260; 73.8%) published RCTs and 68 (68/260; 26.2%) unpublished RCTs were identified. Twenty-six (26/62; 42%) of the discontinued RCTs reached publication, while 36 (58%) remained unpublished. Regarding the completed RCTs, 166 of 198 (83.8%) completed trials reached publication, while 32 (32/198; 16.2%) remained unpublished after trial completion. CONCLUSIONS Approximately 1 in 4 of included RCTs were discontinued or did not reach publication. Findings suggest further guidance is needed for RCTs regarding common pediatric otolaryngology disorders and interventions. LEVEL OF EVIDENCE NA.
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Affiliation(s)
- Austin L Johnson
- Oklahoma State University Center for Health Sciences, Tulsa, OK, USA.
| | - Trevor Torgerson
- Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | | | - Micah Kee
- Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Clay Farahani
- Oklahoma State University Medical Center, Department of Otolaryngology, Tulsa, OK, USA
| | - Daniel J Wehrmann
- University of Nebraska Medical Center, Department of Otolaryngology, Omaha, NE, USA
| | - Carrie L Francis
- University of Kansas Medical Center, Department of Otolaryngology, Kansas City, KS, USA
| | - Matt Vassar
- Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
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French pediatricians' views on industry-sponsored clinical trials: Toward stronger research on ethics? Arch Pediatr 2021; 28:459-463. [PMID: 34244025 DOI: 10.1016/j.arcped.2021.05.003] [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: 05/11/2020] [Revised: 02/19/2021] [Accepted: 05/16/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION There is a crucial need to perform clinical trials in pediatrics due to an increased prescription rate of unapproved drugs. Since pediatricians are the gatekeepers of clinical trials, the primary objective of the current study was to evaluate, for the first time in France, pediatricians' views on performing clinical trials. The second objective was to identify the factors that influence their perceptions. MATERIAL AND METHODS In 2017, pediatricians who were members of the French Pediatric Society completed an online survey comprising 27 questions. Fisher's exact test was performed to evaluate possible correlations between pediatrician characteristics (age, sex, parenthood, professional experience, status, type of practice, previous participation in clinical trials, ethics education) and personal views on clinical trials. A value of P≤0.001 was considered statistically significant. RESULTS Overall, 207 pediatricians completed the questionnaire. Almost all participants (96.6%) were in favor of performing clinical trials. Pediatricians with teaching experience at university hospitals were more reluctant to propose children's participation in clinical trials for fear of increasing parental stress (P<0.001), or the occurrence of serious adverse reactions (P<0.001). Pediatricians with coordinator or investigator experience considered that one of the ethical drifts in pediatric clinical trials is the risk of child exploitation (P<0.001). CONCLUSION Our findings suggest a favorable position of pediatricians concerning clinical trials, despite numerous concerns. Another outcome is the need to create an educational system of research in ethics in France dedicated to pediatricians in order to guarantee good clinical practice in research.
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Gates A, Caldwell P, Curtis S, Dans L, Fernandes RM, Hartling L, Kelly LE, Vandermeer B, Williams K, Woolfall K, Dyson MP. Reporting of data monitoring committees and adverse events in paediatric trials: a descriptive analysis. BMJ Paediatr Open 2019; 3:e000426. [PMID: 31206076 PMCID: PMC6542427 DOI: 10.1136/bmjpo-2018-000426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/13/2019] [Accepted: 02/18/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES For 300 paediatric trials, we evaluated the reporting of: a data monitoring committee (DMC); interim analyses, stopping rules and early stopping; and adverse events and harm-related endpoints. METHODS For this cross-sectional evaluation, we randomly selected 300 paediatric trials published in 2012 from the Cochrane Central Register of Controlled Trials. We collected data on the reporting of a DMC; interim analyses, stopping rules and early stopping; and adverse events and harm-related endpoints. We reported the findings descriptively and stratified by trial characteristics. RESULTS Eighty-five (28%) of the trials investigated drugs, and 18% (n=55/300) reported a DMC. The reporting of a DMC was more common among multicentre than single centre trials (n=41/132, 31% vs n=14/139, 10%, p<0.001) and industry-sponsored trials compared with those sponsored by other sources (n=16/50, 32% vs n=39/250, 16%, p=0.009). Trials that reported a DMC enrolled more participants than those that did not (median [range]): 224 (10-60480) vs 91 (10-9528) (p<0.001). Only 25% of these trials reported interim analyses, and 42% reported stopping rules. Less than half (n=143/300, 48%) of trials reported on adverse events, and 72% (n=215/300) reported on harm-related endpoints. Trials that reported a DMC compared with those that did not were more likely to report adverse events (n=43/55, 78% vs 100/245, 41%, p<0.001) and harm-related endpoints (n=52/55, 95% vs. 163/245, 67%, p<0.001). Only 32% of drug trials reported a DMC; 18% and 19% did not report on adverse events or harm-related endpoints, respectively. CONCLUSIONS The reporting of a DMC was infrequent, even among drug trials. Few trials reported stopping rules or interim analyses. Reporting of adverse events and harm-related endpoints was suboptimal.
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Affiliation(s)
- Allison Gates
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
| | - Patrina Caldwell
- Discipline of Child and Adolescent Health and Centre for Kidney Research, University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Sarah Curtis
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Leonila Dans
- Department of Medicine, University of the Philippines, Manila, Philippines
| | | | - Lisa Hartling
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
| | - 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
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
| | - Katrina Williams
- Developmental Medicine, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Kerry Woolfall
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Michele P Dyson
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
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Joseph PD, Caldwell PH, Barnes EH, Hynes K, Choong CS, Turner S, Vosk C, White J, Richichi K, Craig JC. Completeness of protocols for clinical trials in children submitted to ethics committees. J Paediatr Child Health 2019; 55:291-298. [PMID: 30161286 DOI: 10.1111/jpc.14189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/20/2018] [Accepted: 07/23/2018] [Indexed: 12/11/2022]
Abstract
AIM Studies of published clinical trials involving children have shown frequent omissions in key aspects of design and conduct, but these problems may be artefactual and due to editorial processes and space limitations. To determine actual design and conduct, we analysed the completeness of key domains in trial protocols involving children submitted to Human Research Ethics Committees. METHODS The ethics committees of all eight children's hospitals in Australia were invited to participate. De-identified trial protocols submitted for review in 2012 were evaluated using a checklist derived from Consolidated Standards of Reporting Trials, the Cochrane Risk of Bias Tool and Good Clinical Practice guidelines. RESULTS Four ethics committees agreed to participate, and 69 protocols were analysed. The domains almost always reported were clustered around the background and trial plan (planned interventions for each group (99%), specific objectives (97%) and scientific background (96%)). Risk-of-bias domains such as random sequence generation and blinding of participants were often reported (75-90%). Domains least reported were clustered around the statistical analysis plan (66%), specified intention-to-treat analysis (54%), the justification for the proposed trial based upon a systematic review (48%) and age-specific outcomes (48%). CONCLUSIONS Protocols of trials involving children assessed by ethics committees generally include details on background and basic design, but many key domains in trial design and conduct are not covered. Despite widespread recognition of how problems in the design and conduct of trials may lead to unreliable results, investigators still appear to be omitting key elements in trial protocols.
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Affiliation(s)
- Pathma D Joseph
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia.,Pharmacy Department, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Patrina Hy Caldwell
- Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Elizabeth H Barnes
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Kay Hynes
- Pharmacy Department, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Catherine S Choong
- Department of Diabetes and Endocrinology, Princess Margaret Hospital, Perth, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Sean Turner
- Pharmacy Department, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Claire Vosk
- Pharmacy Department, Monash Health, Melbourne, Victoria, Australia
| | - Jessie White
- Clinical Research and Education, Princess Margaret Hospital, Perth, Western Australia, Australia
| | - Kate Richichi
- Flinders Medical Centre and Repatriation General Hospital, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Jonathan C Craig
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, New South Wales, Australia.,School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Chong LSH, Sautenet B, Tong A, Hanson CS, Samuel S, Zappitelli M, Dart A, Furth S, Eddy AA, Groothoff J, Webb NJA, Yap HK, Bockenhauer D, Sinha A, Alexander SI, Goldstein SL, Gipson DS, Raman G, Craig JC. Range and Heterogeneity of Outcomes in Randomized Trials of Pediatric Chronic Kidney Disease. J Pediatr 2017; 186:110-117.e11. [PMID: 28449820 DOI: 10.1016/j.jpeds.2017.03.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/07/2017] [Accepted: 03/10/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine the range and heterogeneity of outcomes reported in randomized controlled trials of interventions for children with chronic kidney disease (CKD). STUDY DESIGN The Cochrane Kidney and Transplant Specialized Register was searched to March 2016. Randomized trials involving children across all stages of CKD were selected. All outcome domains and measurements were extracted from included trials. The frequency and characteristics of the outcome domains and measures were evaluated. RESULTS From 205 trials included, 6158 different measurements of 100 different outcome domains were reported, with a median of 22 domains per trial (IQR 13-41). Overall, 52 domains (52%) were surrogate, 38 (38%) were clinical, and 10 (10%) were patient-reported. The 5 most commonly reported domains were blood pressure (76 [37%] trials), relapse/remission (70 [34%]), kidney function (66 [32%]), infection (61 [30%]), and height/pubertal development (51 [25%]). Mortality (14%), cardiovascular disease (4%), and quality of life (1%) were reported infrequently. The 2 most frequently reported outcomes, blood pressure and relapse/remission, had 56 and 81 different outcome measures, respectively. CONCLUSIONS The outcomes reported in clinical trials involving children with CKD are extremely heterogeneous and are most often surrogate outcomes, rather than clinical and patient-centered outcomes such as cardiovascular disease and quality of life. Efforts to ensure consistent reporting of outcomes that are important to patients and clinicians will improve the value of trials to guide clinical decision-making. In our study, non-English articles were excluded.
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Affiliation(s)
- Lauren S H Chong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Benedicte Sautenet
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia; University Francois Rabelais, Tours, France; Department of Nephrology and Clinical Immunology, Tours Hospital, Tours, France; INSERM (U1153), Paris, France
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia.
| | - Camilla S Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Susan Samuel
- Department of Pediatrics, Section of Nephrology, University of Calgary, Calgary, Canada
| | - Michael Zappitelli
- Department of Pediatrics, Division of Pediatric Nephrology, Montreal Children's Hospital, McGill University Health Centre, McGill University, Montreal, Canada
| | - Allison Dart
- Department of Pediatrics and Child Health, The Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Canada
| | - Susan Furth
- Departments of Pediatrics and Epidemiology, Perelman School of Medicine, Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Allison A Eddy
- Department of Pediatrics, University of British Columbia and the British Columbia Children's Hospital, Vancouver, Canada
| | - Jaap Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Nicholas J A Webb
- Department of Pediatric Nephrology and National Institute for Health Research/Wellcome Trust Clinical Research Facility, University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Hui-Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Detlef Bockenhauer
- University College London Centre for Nephrology, Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, United Kingdom
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, India
| | - Stephen I Alexander
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Debbie S Gipson
- Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI
| | - Gayathri Raman
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
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Hoppu K. Data monitoring committees should be used more frequently and appropriately to monitor paediatric clinical trials, particularly those involving neonates. Acta Paediatr 2017; 106:7-8. [PMID: 27943437 DOI: 10.1111/apa.13628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kalle Hoppu
- Children's Hospital and Department of Clinical Pharmacology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
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Egberts K, Karwautz A, Plener PL, Mehler-Wex C, Kölch M, Dang SY, Taurines R, Romanos M, Gerlach M. [Pharmacovigilance in child and adolescent psychiatry]. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2015; 43:21-8. [PMID: 25536893 DOI: 10.1024/1422-4917/a000329] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Rational pharmacotherapy is a challenging task in child and adolescent psychiatry. Increasing prescription numbers contrast with the uncertainties of safety and efficacy issues. The lack of clinical (authorization) trials often implies a non- age-specific use of drugs. However, young patients show particular metabolic conditions and a higher vulnerability for adverse drug reactions. Thus it seems mandatory to create age-specific pharmacological data about efficacy and safety of psychotropic drug use in minors. Legislation authorities became aware of this situation and introduced European and national scientific pharmacovigilance regulations and programmes accordingly in order to continuously evaluate the benefit-risk-ratio, detect, collect, minimize, and prevent adverse effects of drugs by appropriate measures, e.g., therapeutic drug monitoring. In this paper the principles and needs of pharmacovigilance in child and adolescent psychiatry are discussed. Furthermore a large multicenter clinical trial («TDM-VIGIL»), funded by the German Federal Institute for Drugs and Medical Devices, is presented, which appeals to collect epidemiological prescription and safety data of psychotropic drugs in children and adolescents using an internet-based data infrastructure (patient registry).
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Affiliation(s)
- Karin Egberts
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg Arbeitsgruppe «Therapeutisches Drug Monitoring» der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Nürnberg Arbeitsgemeinschaft «Kinder- und jugendpsychiatrische Pharmakologie» der AGNP, Nürnberg
| | | | - Paul L Plener
- Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm
| | - Claudia Mehler-Wex
- Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm HEMERA Klinik, Privatklinik für Seelische Gesundheit, Jugendliche und junge Erwachsene, Bad Kissingen
| | - Michael Kölch
- Arbeitsgemeinschaft «Kinder- und jugendpsychiatrische Pharmakologie» der AGNP, Nürnberg Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm Vivantes Klinikum, Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik, Berlin
| | - Su-Yin Dang
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg
| | - Regina Taurines
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg
| | - Marcel Romanos
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg
| | - Manfred Gerlach
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg Arbeitsgruppe «Therapeutisches Drug Monitoring» der Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP), Nürnberg Arbeitsgemeinschaft «Kinder- und jugendpsychiatrische Pharmakologie» der AGNP, Nürnberg
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Joseph PD, Craig JC, Caldwell PHY. Clinical trials in children. Br J Clin Pharmacol 2015; 79:357-69. [PMID: 24325152 PMCID: PMC4345947 DOI: 10.1111/bcp.12305] [Citation(s) in RCA: 222] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/28/2013] [Indexed: 12/31/2022] Open
Abstract
Safety and efficacy data on many medicines used in children are surprisingly scarce. As a result children are sometimes given ineffective medicines or medicines with unknown harmful side effects. Better and more relevant clinical trials in children are needed to increase our knowledge of the effects of medicines and to prevent the delayed or non-use of beneficial therapies. Clinical trials provide reliable evidence of treatment effects by rigorous controlled testing of interventions on human subjects. Paediatric trials are more challenging to conduct than trials in adults because of the paucity of funding, uniqueness of children and particular ethical concerns. Although current regulations and initiatives are improving the scope, quantity and quality of trials in children, there are still deficiencies that need to be addressed to accelerate radically equitable access to evidence-based therapies in children.
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Affiliation(s)
- Pathma D Joseph
- The Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
| | - Jonathan C Craig
- School of Public Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
| | - Patrina HY Caldwell
- The Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, The University of SydneyWestmead, NSW, Australia
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10
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Van't Hoff W, Offringa M. StaR Child Health: developing evidence-based guidance for the design, conduct and reporting of paediatric trials. Arch Dis Child 2015; 100:189-92. [PMID: 25260517 DOI: 10.1136/archdischild-2012-303094] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
There has been a huge upsurge in clinical research in children in the last decade, stimulated in England by dedicated research infrastructure and support through the National Institute for Health Research. This infrastructure offering research design, expert review, trial management, research nurse, data support and dedicated facilities enables paediatricians to conduct more and better research. The challenge is how to design and conduct trials that will make a real difference to children's health. Standards for Research (StaR) in Child Health was founded in 2009 to address the paucity and shortcomings of paediatric clinical trials. This global initiative involves methodologists, clinicians, patient advocacy groups and policy makers dedicated to developing practical, evidence-based standards for enhancing the reliability and relevance of paediatric clinical research. In this overview, we highlight the contribution of StaR to this agenda, describe the international context, and suggest how StaR's future plans could be integrated with new and existing support for research.
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Affiliation(s)
- William Van't Hoff
- Somers Clinical Research Facility, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Martin Offringa
- Child Health Evaluative Sciences (CHES), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Abstract
Paediatric clinical pharmacology is the scientific study of medicines in children and is a relatively new subspecialty in paediatrics in the UK. Training encompasses both the study of the effectiveness of drugs in children (clinical trials) and aspects of drug toxicity (pharmacovigilance). Ethical issues in relation to clinical trials and also studies of the pharmacokinetics and drug metabolism in children are crucial. Paediatric patients require formulations that young children in particular are able to take. The scientific evidence generated from clinical trials, pharmacokinetic studies and studies of drug toxicity all need to be applied in order to ensure that medicines are used rationally in children.
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Affiliation(s)
- Imti Choonara
- Academic Unit of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Helen Sammons
- Academic Unit of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
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12
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Lathyris D, Panagiotou OA, Baltogianni M, Ioannidis JP, Contopoulos-Ioannidis DG. Safety of medical interventions in children versus adults. Pediatrics 2014; 133:e666-73. [PMID: 24567023 PMCID: PMC9923602 DOI: 10.1542/peds.2013-3128] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Compare the risk of harm from pharmacologic interventions in pediatric versus adult randomized controlled trials (RCTs). METHODS We used systematic reviews from the Cochrane Database of Systematic Reviews. We considered separately 7 categories of harms/harm-related end points: severe harms, withdrawals due to harms, any harm, organ system-level harms, specific harms, withdrawals for any reason, and mortality. Systematic reviews with quantitative synthesis from at least 1 adult and 1 pediatric RCT for any of those end points were eligible. We calculated the summary odds ratio (experimental versus control intervention) in adult and pediatric trials/meta-analysis; the relative odds ratio (ROR) in adults versus children per meta-analysis; and the summary ROR (sROR) across all meta-analyses for each end point. ROR <1 means that the experimental intervention fared worse in children than adults. RESULTS We identified 176 meta-analyses for 52 types of harms/harm-related end points with 669 adult and 184 pediatric RCTs. Of those, 165 had sufficient data for ROR estimation. sRORs showed statistically significant discrepancy between adults and children only for headache (sROR 0.82; 95% confidence interval 0.70-0.96). Nominally significant discrepancies for specific harms were identified in 12 of 165 meta-analyses (RORs <1 in 7, ROR >1 in 5). In 36% of meta-analyses, the ROR estimates suggested twofold or greater differences between children and adults, and the 95% confidence intervals could exclude twofold differences only in 18% of meta-analyses. CONCLUSIONS Available evidence on harms/harm-related end points from pharmacologic interventions has large uncertainty. Extrapolation of evidence from adults to children may be tenuous. Some clinically important discrepancies were identified.
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Affiliation(s)
- Dimitrios Lathyris
- Intensive Care Unit, General Hospital G. Gennimatas, Thessaloniki, Greece
| | - Orestis A. Panagiotou
- Clinical Trials and Evidence-Based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Maria Baltogianni
- Neonatal Intensive Care Unit, University Hospital of Ioannina, Ioannina, Greece
| | - John P.A. Ioannidis
- Stanford Prevention Research Center, Department of Medicine,,Department of Health Research and Policy, and
| | - Despina G. Contopoulos-Ioannidis
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California; and,Palo Alto Medical Foundation Research Institute, Palo Alto, California,Address correspondence to Despina G. Contopoulos-Ioannidis, MD, Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, Room G312, 300 Pasteur Dr, Stanford, CA 94305. E-mail:
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Choonara I. Educational Paper: Aspects of clinical pharmacology in children--pharmacovigilance and safety. Eur J Pediatr 2013; 172:577-80. [PMID: 23111760 DOI: 10.1007/s00431-012-1871-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 10/15/2012] [Indexed: 10/27/2022]
Abstract
Adverse drug reactions (ADRs) are a significant problem in children, affecting one in ten children in hospital. Within the community, one in 500 children will experience an adverse drug reaction each year. Pharmacovigilance has been useful in detecting suspected ADRs. However, most ADRs are unreported and often not suspected. Education of health professionals in relation to drug toxicity improves the reporting rate of suspected ADRs. Clinical trials are useful to evaluate the efficacy of drugs. They are, however, not the best way of looking at ADRs where surveillance following the widespread use of a drug is more appropriate. Alongside work by the regulatory agencies, independent investigators have helped collate data. This information has been useful in developing guidelines to prevent further cases of drug toxicity. Greater awareness and understanding of drug toxicity in children should result in more rational prescribing.
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Affiliation(s)
- Imti Choonara
- Academic Division of Child Health, Derbyshire Children's Hospital, University of Nottingham, Derby, UK.
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14
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Yuill K, Carandang C. Safety methodology in pediatric psychopharmacology trials. J Child Adolesc Psychopharmacol 2013; 23:148-62. [PMID: 23607408 DOI: 10.1089/cap.2011.0142] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In recent years, there has been an increase in pediatric clinical trials as the result of an identified need for greater research with this population. Given the potential risks, and the vulnerability of the population, there has also been an identified need for greater safety elicitation and monitoring in pediatric psychopharmacology trials, for example, through the use of a data and safety monitoring board (DSMB). However, research indicates that pediatric trials and psychiatric trials are less likely to use a DSMB. The rationale for the current study was to determine what safety methodologies have been reported in pediatric psychopharmacology trials over the past 10 years. A literature review was conducted of all pediatric psychopharmacology trials published since 2001. Results indicated that the most common elicitation method was collecting laboratory information and vital signs. Six percent of trials solely relied on spontaneous reporting of adverse events, and only 11.8% reported using a DSMB. These results suggest that elicitation methods and use of DSMBs are still low. Practical considerations, affected stakeholders, and barriers are discussed. Recommendations for moving forward include the use of multiple elicitation methods and automatic requirement of a DSMB for pediatric psychopharmacology trials, required completion of a standardized safety reporting form, and engaging multiple interested parties in these processes.
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Affiliation(s)
- Kathryn Yuill
- Faculty of Health Professions, Dalhousie University, Halifax, Nova Scotia, Canada
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Affiliation(s)
- Sandeep B Bavdekar
- Department of Pediatrics, TN Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India
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16
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Downing HJ, Pirmohamed M, Beresford MW, Smyth RL. Paediatric use of mycophenolate mofetil. Br J Clin Pharmacol 2013; 75:45-59. [PMID: 22519685 PMCID: PMC3555046 DOI: 10.1111/j.1365-2125.2012.04305.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 04/16/2012] [Indexed: 01/14/2023] Open
Abstract
A number of medications do not have a licence, or label, for use in the paediatric age group nor for the specific indication for which they are being used in children. Over recent years, mycophenolate mofetil has increasingly been used off-label (i.e. off-licence) in adults for a number of indications, including autoimmune conditions; progressively, this wider use has been extended to children. This review summarizes current use of mycophenolate mofetil (MMF) in children, looking at how MMF works, the pharmacokinetics, the clinical conditions for which it is used, the advantages it has when compared with other immunosuppressants and the unresolved issues remaining with use in children. The review aims to focus on off-label use in children so as to identify areas that require further research and investigation. The overall commercial value of MMF is limited because it has now come off patent in adults. Given the increasing knowledge of the pharmacodynamics, pharmacokinetics and pharmacogenomics demonstrating the clinical benefits of MMF, new, formal, investigator-led studies, including trials focusing on the use of MMF in children, would be of immense value.
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Affiliation(s)
- Heather J Downing
- Department of Women's and Children's Health, Institute of Translational Medicine, The University of Liverpool, Alder Hey Children's NHS Foundation TrustEaton Road, Liverpool L12 2AP, UK
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, The University of LiverpoolAshton Street, Liverpool L69 3GE, UK
| | - Michael W Beresford
- Department of Women's and Children's Health, Institute of Translational Medicine, The University of Liverpool, Alder Hey Children's NHS Foundation TrustEaton Road, Liverpool L12 2AP, UK
| | - Rosalind L Smyth
- Department of Women's and Children's Health, Institute of Translational Medicine, The University of Liverpool, Alder Hey Children's NHS Foundation TrustEaton Road, Liverpool L12 2AP, UK
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Outcome measures and serious asthma exacerbation in clinical trials of asthma controller medications. Ann Allergy Asthma Immunol 2012; 108:448-53. [PMID: 22626599 DOI: 10.1016/j.anai.2012.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 04/04/2012] [Accepted: 04/10/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND With the introduction and approval of several new asthma controller medications for pediatric use, the risk-benefit ratio of these medications has not been fully evaluated. OBJECTIVE To determine whether physiologic pulmonary measurements are superior to other measures in evaluating outcomes and to determine whether asthmatic children have a higher risk of serious adverse events than adults. METHODS We obtained data on asthma controller medications approved between 1997 and 2010 from the US Food and Drug Administration archives. Six medications were approved for use in children and adults during this time. Of these, we were able to analyze 23 trials of 5 medications. Nine of the trials were conducted in pediatric patients and 14 in adults. RESULTS We determined whether the primary outcome measure was a physiologic pulmonary measure or another measure and compared trial outcomes. We also evaluated serious adverse events, including mortality rates for both adult and pediatric trials. The frequency of successfully demonstrating efficacy was far superior using physiologic pulmonary measures (13/14 [93%]) compared with other outcome measures (4/9 [44%]). The frequency of serious asthma exacerbations, although less than 1%, was higher in the pediatric group of patients (18/1,948 [0.9%]) compared with adults (4/2,460 [0.2%]), regardless of assignment to placebo or drug. CONCLUSION These results suggest that physiologic pulmonary function measures should be used in evaluating the efficacy of asthma controller medications. These data also indicate that pediatric patients may be more prone to serious asthma exacerbations during clinical trials.
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Hartling L, Wittmeier KDM, Caldwell P, van der Lee H, Klassen TP, Craig JC, Offringa M. StaR child health: developing evidence-based guidance for the design, conduct, and reporting of pediatric trials. Pediatrics 2012; 129 Suppl 3:S112-7. [PMID: 22661756 DOI: 10.1542/peds.2012-0055c] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Lisa Hartling
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
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Hartling L, Wittmeier KDM, Caldwell PH, van der Lee JH, Klassen TP, Craig JC, Offringa M. StaR Child Health: developing evidence-based guidance for the design, conduct, and reporting of pediatric trials. Clin Pharmacol Ther 2011; 90:727-31. [PMID: 21993427 DOI: 10.1038/clpt.2011.212] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Standards for Research in (StaR) Child Health was founded in 2009 to address the paucity and shortcomings of pediatric clinical trials. This initiative involves international experts who are dedicated to developing practical, evidence-based standards to enhance the reliability and relevance of pediatric clinical research. Through a systematic "knowledge to action" plan, StaR Child Health will make efforts to improve and expand the evidence base for child health across the world.
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Affiliation(s)
- L Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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20
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Fernandes RM, van der Lee JH, Offringa M. Data monitoring committees, interim analysis and early termination in paediatric trials. Acta Paediatr 2011; 100:1386-92. [PMID: 21434998 DOI: 10.1111/j.1651-2227.2011.02282.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIM To evaluate whether paediatric randomized clinical trials (RCTs) adopt recent guidance on Data Monitoring Committees (DMCs), interim analysis and early termination. METHODS We reviewed paediatric RCTs that reported on DMCs, interim analysis or early termination, published in eight general medical and paediatric journals (2005-2007). We searched full-text databases for eligible trials and recorded predefined parameters on each item. Reported activities were compared with current scientific guidance. RESULTS A total of 110 of 648 paediatric trials (17%) reported on DMC, interim analysis or early stopping. Various approaches for convening a DMC were identified; information on DMC composition and independence was limited. Strict predefined statistical stopping 'rules' were reported in 10 of 23 trials, and interim analyses were more frequently performed on efficacy than on safety outcomes (39/45 vs 27/45). No adjustment for repeated testing was reported in 11 of 33 trials reporting monitoring methods and in 7 of 17 early terminated trials. Validity of results from early stopped trials was threatened by small sample sizes. Incomplete reporting hampered a full analysis. CONCLUSION Few paediatric trials report on DMCs' roles, interim analysis or early stopping. Heterogeneous practices and apparent shortcomings jeopardize the validity of trial results. Easily accessible guidelines for the design, conduct and reporting of paediatric DMCs are needed.
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Affiliation(s)
- Ricardo M Fernandes
- Departamento da Criança e da Família (Child and Family Department), Hospital de Santa Maria, Centro Hospitalar Lisboa Norte EPE, and Farmacologia Clínica e Terapêutica (Therapeutics and Clinical Pharmacology), Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
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Nor Aripin KNB, Choonara I, Sammons HM. Systematic review of safety in paediatric drug trials published in 2007. Eur J Clin Pharmacol 2011; 68:189-94. [PMID: 21858432 PMCID: PMC3256313 DOI: 10.1007/s00228-011-1112-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 07/27/2011] [Indexed: 10/31/2022]
Abstract
BACKGROUND There is now greater involvement of children in drug trials to ensure that paediatric medicines are supported by sound scientific evidence. The safety of the participating children is of paramount importance. Previous research shows that these children can suffer moderate and severe adverse drug reactions (ADRs) in clinical trials, yet very few of the trials designated a data safety monitoring board (DSMB) to oversee the trial. METHODS Safety data from a systematic review of paediatric drug randomised controlled trials (RCTs) published in 2007 were analysed. All reported adverse events (AEs) were classified and assessed to determine whether an ADR had been experienced. ADRs were then categorised according to severity. Each trial report was examined as to whether an independent DSMB was in place. RESULTS Of the 582 paediatric drug RCTs analysed, 210 (36%) reported that a serious AE had occurred, and in 15% mortality was reported. ADRs were detected in more than half of the RCTs (305); 66 (11%) were severe, and 79 (14%) were moderate. Severe ADRs involved a wide range of organ systems and were frequently associated with cytotoxic drugs, antiparasitics, anticonvulsants and psychotropic drugs. Two RCTs reported significantly higher mortality rates in the treatment group. Only 69 (12%) of the RCTs stated there was a DSMB. DSMBs terminated five RCTs and changed the protocol in one. CONCLUSIONS Children participating in drug RCTs experience a significant amount and a wide range of ADRs. DSMBs are needed to ensure the safety of paediatric participants in clinical drug trials.
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Kemper EM, Merkus M, Wierenga PC, Van Rijn PC, Van der Werff D, Lie-A-Huen L, Offringa M. Towards evidence-based pharmacotherapy in children. Paediatr Anaesth 2011; 21:183-9. [PMID: 21199133 DOI: 10.1111/j.1460-9592.2010.03493.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In daily practice, it is difficult to find a registered drug for children, because about 70% of the drugs prescribed in children are not studied, off-label or unlicensed in this age group. Clinical trials have usually been performed in adults, and then in daily practice dosages are adjusted for children without proper studies in that age group. In some countries, national formularies are being established to overcome the existing variance in prescribing between physicians. Complicating factors in finding the correct dosage for children include the heterogeneity between different age groups in the developmental stages of the organs influencing the absorption, distribution, metabolism, and excretion as well as differences in body composition during growth. Growth may also influence the effects and adverse effects of a drug used in a child. For oral administration of drugs in children, the bioavailability, the taste, the composition, and the absence of toxic ingredients for that age group are additional important factors. The EU has recently introduced legislation to stimulate the pharmaceutical industry to investigate the pharmacological effect and safety of new medicines in children. In response to this legislation, research networks are being established to provide the optimal infrastructure for pediatric drug investigation. The goals of this paper are to review the current problems in daily practice and to address the needs for evidence based pharmacotherapy in children.
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Affiliation(s)
- Elles Marleen Kemper
- Department of Pharmacy, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Knellwolf AL, Bauzon S, Alberighi ODC, Lutsar I, Bácsy E, Alfarez D, Panei P. Framework conditions facilitating paediatric clinical research. Ital J Pediatr 2011; 37:12. [PMID: 21345195 PMCID: PMC3055809 DOI: 10.1186/1824-7288-37-12] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 02/23/2011] [Indexed: 12/05/2022] Open
Abstract
The use of unlicensed and "off-label" medicines in children is widespread. Between 50-80% of the medicines currently administered to children have neither been tested nor authorized for their use in the paediatric population which represents approximately 25% of the whole European population. On 26 January 2007, entered into force the European Regulation of Paediatric Medicines. It aims at the quality of research into medicines for children but without subjecting the paediatric population to unnecessary clinical trial. This article addresses ethical and legal issues arising from the regulation and makes recommendations for the framework conditions facilitating the development of clinical research with children.
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Affiliation(s)
- Anne-Laure Knellwolf
- Dept. of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Stéphane Bauzon
- Storia e Teoria del Diritto, Facoltà di Giurisprudenza, University of Rome "Tor Vergata", Rome, Italy
| | | | - Irja Lutsar
- Dept. of Microbiolgoy, University of Tartu, Tartu, Estonia
| | - Ernö Bácsy
- Medical Research Council of Hungary, Budapest, Hungary
| | - Deborah Alfarez
- ERA-NET Priority Medicines for Children Coordination, The Netherlands Organization for Health Research and Development, The Hague, The Netherlands
| | - Pietro Panei
- Dept. of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy
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Ligi I, Boubred F, Grandvuillemin I, Simeoni U. Clinical research in newborn infants: difficulties and specificity. Eur J Clin Pharmacol 2010; 67 Suppl 1:29-32. [PMID: 21085938 DOI: 10.1007/s00228-010-0921-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 10/10/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical trials are essential in neonates to evaluate scientifically the efficacy and safety of drugs. However, major specificities condition clinical research in human neonates. OBJECTIVE To review specific constraints to be taken into account in neonatal research studies. METHODS A review of the literature and contribution of authors' opinions was carried out. RESULTS AND CONCLUSION Neonatal specificities that induce obstacles in neonatal studies and proposals are detailed. This review also looks at recommendations recently developed by the European Commission to promote safe and ethical research in neonatology.
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Affiliation(s)
- Isabelle Ligi
- Division of Neonatology, La Conception Hospital, Assistance Publique-Hôpitaux de Marseille and Faculté de Médecine, Université de la Méditerranée, Marseille, France
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26
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Nor Aripin KNB, Sammons HM, Choonara I. Published pediatric randomized drug trials in developing countries, 1996-2002. Paediatr Drugs 2010; 12:99-103. [PMID: 20218746 DOI: 10.2165/11316260-000000000-00000] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND The greatest burden of disease in children lies in the developing world; however, previous reviews have suggested that few randomized controlled trials (RCTs) involving children take place in developing countries. Children in developing countries deserve the same standard of medicines as those in developed countries, i.e. appropriate medications for the specific diseases that occur. OBJECTIVE To elucidate published pediatric therapeutic RCTs that have taken place in the developing world and to determine whether they are appropriate for the major diseases occurring there, and to explore their approach to safety monitoring. METHODS A previously assembled database of pediatric RCTs published between 1996 and 2002, from journals indexed in MEDLINE, was analyzed. The main country of setting of the RCTs was categorized as having low, medium or high development status according to the Human Development Index (HDI). Articles were read to add the WHO International Classification of Diseases 10th Revision (ICD-10) category of the disease studied, the WHO Collaborating Centre for Drug Statistics Methodology Anatomical Therapeutic Chemical (ATC) classification system category of the main drug therapy studied, the source of funding, and ethical approval to the variables already recorded in the database. RESULTS One hundred and fifty-eight (22%) of the 733 RCTs analyzed took place in medium and low HDI (developing) countries. The disease areas studied seemed appropriate, with 89 (56%) of the 158 RCTs studying infectious and parasitic diseases. Ninety-nine (63%) RCTs from developing countries were trials of antiparasitic and anti-infective drugs. Compared with studies from high HDI countries, a significantly lower proportion of articles from medium and low HDI countries mentioned ethical committee or institutional review board approval, and safety monitoring. Only one paper from low and medium HDI countries mentioned the presence of a safety monitoring committee/data safety monitoring board. CONCLUSIONS Published pediatric drug RCTs conducted in developing countries appear to study appropriate diseases but the results show that fewer RCTs are undertaken compared with the developed world. The standard of reporting for RCTs from developing countries needs attention to ensure that adequate information can be obtained, especially with regard to safety monitoring.
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Affiliation(s)
- Khairun N B Nor Aripin
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby DE22 3DT, UK.
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Fernandes RM, van der Lee JH, Offringa M. A systematic review of the reporting of Data Monitoring Committees' roles, interim analysis and early termination in pediatric clinical trials. BMC Pediatr 2009; 9:77. [PMID: 20003383 PMCID: PMC2801486 DOI: 10.1186/1471-2431-9-77] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 12/13/2009] [Indexed: 12/15/2022] Open
Abstract
Background Decisions about interim analysis and early stopping of clinical trials, as based on recommendations of Data Monitoring Committees (DMCs), have far reaching consequences for the scientific validity and clinical impact of a trial. Our aim was to evaluate the frequency and quality of the reporting on DMC composition and roles, interim analysis and early termination in pediatric trials. Methods We conducted a systematic review of randomized controlled clinical trials published from 2005 to 2007 in a sample of four general and four pediatric journals. We used full-text databases to identify trials which reported on DMCs, interim analysis or early termination, and included children or adolescents. Information was extracted on general trial characteristics, risk of bias, and a set of parameters regarding DMC composition and roles, interim analysis and early termination. Results 110 of the 648 pediatric trials in this sample (17%) reported on DMC or interim analysis or early stopping, and were included; 68 from general and 42 from pediatric journals. The presence of DMCs was reported in 89 of the 110 included trials (81%); 62 papers, including 46 of the 89 that reported on DMCs (52%), also presented information about interim analysis. No paper adequately reported all DMC parameters, and nine (15%) reported all interim analysis details. Of 32 trials which terminated early, 22 (69%) did not report predefined stopping guidelines and 15 (47%) did not provide information on statistical monitoring methods. Conclusions Reporting on DMC composition and roles, on interim analysis results and on early termination of pediatric trials is incomplete and heterogeneous. We propose a minimal set of reporting parameters that will allow the reader to assess the validity of trial results.
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Affiliation(s)
- Ricardo M Fernandes
- Departamento da Criança e da Família, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte-EPE, Laboratório de Farmacologia Clínica e Terapêutica, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Portugal.
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Abstract
Clinical trials in neonates are essential in order to provide scientific evidence in relation to the efficacy and safety of medicines. European legislation has recently been passed in order to stimulate clinical research in this area. This should hopefully result in more licensed medicines in the neonatal period. It is essential that the clinical trials are performed safely and ethically and one therefore needs to be aware of predisposing factors for drug toxicity in the neonatal period.
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Affiliation(s)
- Imti Choonara
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby DE22 3DT, UK.
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Shilling V, Young B. How do parents experience being asked to enter a child in a randomised controlled trial? BMC Med Ethics 2009; 10:1. [PMID: 19220889 PMCID: PMC2652490 DOI: 10.1186/1472-6939-10-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Accepted: 02/16/2009] [Indexed: 11/22/2022] Open
Abstract
Background As the number of randomised controlled trials of medicines for children increases, it becomes progressively more important to understand the experiences of parents who are asked to enrol their child in a trial. This paper presents a narrative review of research evidence on parents' experiences of trial recruitment focussing on qualitative research, which allows them to articulate their views in their own words. Discussion Parents want to do their best for their children, and socially and legally their role is to care for and protect them yet the complexities of the medical and research context can challenge their fulfilment of this role. Parents are simultaneously responsible for their child and cherish this role yet they are dependent on others when their child becomes sick. They are keen to exercise responsibility for deciding to enter a child in a trial yet can be fearful of making the 'wrong' decision. They make judgements about the threat of the child's condition as well as the risks of the trial yet their interpretations often differ from those of medical and research experts. Individual parents will experience these and other complexities to a greater or lesser degree depending on their personal experiences and values, the medical situation of their child and the nature of the trial. Interactions at the time of trial recruitment offer scope for negotiating these complexities if practitioners have the flexibility to tailor discussions to the needs and situation of individual parents. In this way, parents may be helped to retain a sense that they have acted as good parents to their child whatever decision they make. Summary Discussing randomised controlled trials and gaining and providing informed consent is challenging. The unique position of parents in giving proxy consent for their child adds to this challenge. Recognition of the complexities parents face in making decisions about trials suggests lines for future research on the conduct of trials, and ultimately, may help improve the experience of trial recruitment for all parties.
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Affiliation(s)
- Valerie Shilling
- Division of Clinical Psychology, School of Population, Community and Behavioural Sciences, University of Liverpool, Liverpool, UK.
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van der Lee JH, Tanck MWT, Wesseling J, Offringa M. Pitfalls in the design and analysis of paediatric clinical trials: a case of a 'failed' multi-centre study, and potential solutions. Acta Paediatr 2009; 98:385-91. [PMID: 18826493 PMCID: PMC2659390 DOI: 10.1111/j.1651-2227.2008.01048.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Aim: To increase awareness of possible pitfalls in the design and analysis of a multi-centre randomized clinical trial and to give an overview of alternative study designs and their consequences for power analyses in case of limited availability of trial participants. Methods: Investigation of the assumptions in the power calculation and re-analysis of the original data of a ‘failed’ trial on the effect of dexamethasone on the duration of mechanical ventilation in young children with respiratory syncytial virus infection. Use of ‘boundaries approach’ is explored using the data from this trial. A comprehensive overview of the various modern solutions for the design of a subsequent trial in this field is given. Results: Two frequent major deficiencies of trial design and data analysis are reviewed in depth, i.e. too optimistic assumptions for the sample size calculation and failure to adjust for centre effects. Conclusion: Critical review of trial assumptions and if necessary sample size recalculation based on an internal pilot by a data monitoring committee is recommended to maximize the probability of obtaining conclusive results.
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Affiliation(s)
- Johanna H van der Lee
- Department of Paediatric Clinical Epidemiology, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, The Netherlands.
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Bitter medicine. New regulations aim to address the dearth of clinical safety trials for drugs used in children. EMBO Rep 2008; 9:505-8. [PMID: 18516084 DOI: 10.1038/embor.2008.95] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Klassen TP, Hartling L, Craig JC, Offringa M. Children are not just small adults: the urgent need for high-quality trial evidence in children. PLoS Med 2008; 5:e172. [PMID: 18700813 PMCID: PMC2504487 DOI: 10.1371/journal.pmed.0050172] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Terry Klassen and colleagues discuss a new study examining whether children and adults with drug-resistant partial epilepsy respond differently to antiepileptic drugs.
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Affiliation(s)
- Terry P Klassen
- Alberta Research Center for Health Evidence, Stollery Children's Hospital, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Howie S, Mueller J, Whittle H. Assuring trial safety for children. Lancet 2008; 372:30. [PMID: 18603156 DOI: 10.1016/s0140-6736(08)60988-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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