The testing of antihypertensive medications in children: report of the Antihypertensive Agent Guidelines Subcommittee of the Pediatric Pharmacology Research Units

[Key drugs and doses in the hypertension's treatment in child in France]

The prescription drug for hypertension in children remains difficult because of the lack of pharmacological data validated for this age of life. The Food and Drug Administration (FDA) has recently proposed some antihypertensive regimens orally. The authors found it useful to reproduce a table by adding all the necessary data for its use in France. Here is a list of French medicines and doses applied to children. Similarly, they made a second table for injectable antihypertensive treatment based on American recommendations--but not yet validated by FDA.

A multicenter study of the pharmacokinetics of lisinopril in pediatric patients with hypertension

The pharmacokinetic (PK) parameters of lisinopril were obtained in 46 children aged 6 months to 15 years. A lisinopril suspension (0.15 mg/kg per day) was administered to patients <6 years of age; the remaining children received lisinopril tablets, the daily dose being adjusted according to body weight, i.e., 2.5 mg if <25 kg, 5 mg if 25-45 kg, and 10 mg if >45 kg. Blood was drawn predose and on eight occasions postdose in children aged 4-15 years, and on five occasions in those aged <4 years. PK data are reported for the 46 children in terms of age groups: Group I (n=9), aged 6-23 months; Group II (n=8), aged 2-5 years; Group III (n=12), aged 6-11 years; Group IV (n=17), aged 12-15 years. The dose of lisinopril ranged from 3.07 mg/m(2) per day in Group I to 4.78 mg/m(2) per day in Group IV. C(max) of lisinopril, which occurred 5-6 h postdose, varied from 22 ng/ml in Groups I and II to 44 ng/ml in Groups III and IV; AUC(0-24 h) ranged from 301-311 ng.h/ml in Groups I and II to 550-570 ng.h/ml in Groups III and IV. No serious adverse events related to lisinopril were reported.

¿Son los niños hipertensos españoles huérfanos terapéuticos?

INTRODUCTION

According to current guidelines, hypertension in children should be treated with the same drugs as those used in adults, with adjustment of the dose to their body size. The term therapeutic orphans refers to the lack of information on how to use drugs in children. The aim of this study was to investigate whether the information in the International Vademecum (I-V) is sufficient for the correct use of antihypertensive drugs in children.

MATERIAL AND METHOD

We reviewed the data on pediatric dosages of antihypertensive drugs in the I-V (44th and 45th editions). When there were several drugs for the same molecule, the last one marked with the Spanish Ministry of Health and Consumption's logo was selected. When information on a particular drug was not available, the entries for other drugs with the same active principle were reviewed. The information was compared with that provided by the Fourth Report of the National High Blood Pressure Education Program Working Group (NHBPEP).

RESULTS

A total of 111 entries for 41 antihypertensive drugs were reviewed. Information on use in children is available for only 3 diuretics and 2 angiotensin converting enzyme inhibitors. The remaining entries either contain no information or indicate that the effectiveness and safety in children has not been evaluated. Some drugs are contraindicated in children. The Fourth Report of the NHBPEP includes pediatric dosages for 28 antihypertensive drugs. The Food and Drug Administration has authorized 10 antihypertensive drugs for use in children.

CONCLUSIONS

The information in the V-I can be used to determine the correct dosage of only 5 antihypertensive drugs in children, making this age group authentic therapeutic orphans.

Ethics of placebo use in pediatric clinical trials: the case of antihypertensive drug studies

Industry-sponsored pediatric clinical trials of antihypertensive medications have greatly increased in number since passage of the Food and Drug Modernization Act of 1997. This development should ultimately benefit the treatment of hypertensive children by increasing the amount of scientific knowledge regarding the efficacy and safety of antihypertensive agents in children. However, the designs of many of these trials raise ethical questions related to the inclusion of placebo controls, a practice that has largely been abandoned in trials of antihypertensives in adults because of the well-known adverse consequences of untreated hypertension. This is an especially important issue in pediatric hypertension, as many hypertensive children have either secondary forms of hypertension or hypertension-induced target organ damage, potentially increasing the risk of harm during exposure to placebo. Against this background, and with a strong emphasis on protection of this vulnerable patient population, a strict set of conditions for use of placebos in pediatric antihypertensive trials is proposed.

Clinical trial of extended-release felodipine in pediatric essential hypertension

Essential hypertension in pediatric patients may require pharmacological treatment. There is a need for efficacious, safe, and well-tolerated antihypertensive agents with a once-a-day dosing regimen in children and adolescents. The aim of the trial was to evaluate the dose-response and tolerability of the dihydropyridine calcium channel blocker, felodipine extended-release tablets (felodipine ER), given once daily to pediatric patients with essential hypertension. A randomized double-blind, parallel-group, multi-center clinical study comparing felodipine ER (2.5, 5, or 10 mg once daily) and placebo was performed on pediatric patients with a baseline systolic (SBP) or diastolic blood pressure (DBP) above the 95th percentile for age, sex, and height. Of 133 randomized patients, 128 (96.2%) completed the 3 weeks of double-blind treatment. The study population included 50% children 6-12 years of age or Tanner stage <or=3, 39% black, and 40% female patients. All doses of felodipine ER and placebo decreased both SBP and DBP. The 5-mg dose of felodipine ER resulted in a significant decline in trough sitting, standing, and supine DBP (placebo-adjusted, -4.6, -5.06, and -5.05 mmHg, respectively, P<0.05) compared with placebo. However, there was no significant decline in SBP. The 2.5- and 10-mg doses showed no significant differences compared with placebo in lowering BP. The effect of felodipine ER was comparable in patient subgroups by age, race, and gender. The drug was well tolerated. The study failed to show a dose response of felodipine ER in pediatric patients with essential hypertension. This finding might be explained in part by the limitations of study design. The spectrum of side effects in pediatric patients was comparable with that in adults, except for a lower incidence of peripheral edema. Further studies are needed to clarify the role of felodipine ER in the management of children and adolescents with essential hypertension.

Cardiac risk factors and participation guidelines for youth sports

Accurate assessment of the cardiac system in pediatric and adolescent youth is important. The hemodynamic demands associated with exercise, training, and sport participation are usually positive and beneficial; however, when an underlying cardiac problem exists, it is imperative that such cardiac problems be identified. Safe sport-related cardiac participation guidelines should be provided for young athletes and their families and coaches. This chapter provides a physician perspective on the recognition and current cardiac management considerations for young athletes participating in both static and dynamic types of sports. The most recent guidelines for hypertension in youth are also provided.