Pediatric Drug Development: Reviewing Challenges and Opportunities by Tracking Innovative Therapies

Clinical data required for the approval of pediatric pharmaceuticals in Japan

BACKGROUND

In Japan, the number of pharmaceuticals with pediatric indications is low, and some are approved only in Europe or the USA but not in Japan. As the approval review report by the Japanese health authority contains any detailed items considered for drug approval, this study aimed to analyze the review reports and elucidate data types that facilitate the approval of pediatric drugs in Japan.

METHODS

We identified products approved in Japan, extracted relevant product- and review-related information, and summarized the characteristics of pediatric drug clinical data and drug approval procedures.

RESULTS

Among 625 products (approved 04/2019-02/2024), 171 with pediatric indications were analyzed. The approval review considered orphan drug designation for 56 products, public knowledge-based application for 16 products, mandatory post-marketing surveillance for 42 products, and investigator-initiated studies for 11 products. For only 10 products, confirmatory studies were completed exclusively in Japanese children. Among the other 161 products, extrapolation from non-Japanese children and Japanese adults and/or older children was discussed for 93 and 100 products, respectively. Extrapolation-based reviews focused on ethnic and population factors and consistency of exposure dose, efficacy, and safety. Statistical confirmation is not always necessary for approval. Administrative incentives are often applied, including for orphan drugs and Sakigake designation and public knowledge-based applications.

CONCLUSIONS

The appropriateness or sufficiency of the clinical data package can refer to the PMDA. By considering joining a multinational study and determining the required number of Japanese patients, a path toward the approval of pediatric drugs in Japan can be identified.

Melanoma and pediatric drug development: clinical progress vs. regulatory activism in minors - a narrative review

INTRODUCTION

Melanoma is the malignancy where, in recent years, drug treatment has massively improved prognosis and quality of life. Based on genetic analysis, we differentiate today melanomas caused by cumulative solar damage (CSD) from others.

AREAS COVERED

Conventional CSD-caused melanomas affect predominantly adults and occasionally adolescents. Spitz melanoma and melanoma arising in congenital nevi, the two other pediatric melanoma types, are not CSD-caused, are genetically different, have different prognoses, and need different treatment. In contrast to the improved situation in adult melanoma, regulatory demand for pediatric labels in minors has resulted in pointless and harmful studies and has obfuscated diagnosis and treatment. Modern communication facilitates a worldwide analysis of extremely rare diseases such as melanoma in minors. Regulatory demand for on-label treatment only is demonstrably wrong for pediatric melanomas. They are too rare for randomized controlled trials but nevertheless deserve effective treatment.

EXPERT OPINION

Adolescents with conventional, CSD-caused melanoma should be treated as adults. Their bodies are already mature. For other childhood melanomas, registries and consultations with clinical specialists are better options than dogmatically demanded regulatory studies.

Development and Characterization of Niaprazine-Loaded Xanthan Gum-Based Gel for Oral Administration

Niaprazine is a sedative-hypnotic drug initially developed as an antihistamine and used for its notable sedative effects, particularly in children. Following its withdrawal from the market by the producer, the drug has been administered as magistral formulations available in syrup form, but there are several important disadvantages to this, including instability, taste issues, lack of controlled release, and the potential for unreliable dosing due to incomplete swallowing. There is also an increased risk of dental caries, as well as the fact that these formulations are not suitable for children who suffer from diabetes. The purpose of the current investigation is to prepare and characterize xanthan gum-based gels for the oral administration of niaprazine. Niaprazine gels appear as transparent-whiteish, non-sticky substances, with the drug uniformly dispersed throughout the systems. They are also stable over time. Dynamic rheology revealed their advantageous shear-thinning properties, which enable the formulation to be flexibly dosed orally through administration via syringe. During experimentation, the evaluation of the mucoadhesion features and the in vitro drug release profile were also performed. The results demonstrate that the formulation may represent an alternative to niaprazine syrup, allowing easy preparation, administration, and increased compliance in various categories of patients, including pediatric.

Effects of the Paediatric Regulation funding on the development of off-patent medicines in children

Introduction

In paediatrics, medicines repurposing is a particularly advantageous approach, offering a route to address unmet medical needs and turn off-label use into evidence-based treatments for paediatric populations. This study analysed the effects of funds provided under the Seventh Framework Programme for Research (FP7-FRP), issued by the European Commission from 2007 to 2013 according to the European Paediatric Regulation, in terms of new paediatric marketing authorisations (MAs) including paediatric Use Marketing Authorisations (PUMAs). Additionally, we investigated which funded projects included repurposing initiatives.

Methods

Data was collected on paediatric Investigation Plans (PIPs), new MAs, and MAs variations from the EMA website, national medicine registers, and final project reports. A survey to project coordinators was also conducted to explore the challenges faced during paediatric drug development plans.

Results

The 20 FP7-funded projects studied 24 off-patent active substances. Eighteen substances had agreed PIPs with the European Medicines Agency paediatric Committee (PDCO). Positive compliance checks were granted for three PIPs, resulting in three new PUMAs. According to the adopted definition, 22 out of 24 (91.6%) paediatric development plans could be classified as repurposing. New conditions were proposed for eight substances, while 16 aimed to extend existing indications to broader paediatric populations. Additionally, 18 development plans included new age-appropriate formulations. The survey revealed that primary challenges in paediatric development plans included budgeting, lengthy regulatory processes, and recruitment.

Discussion

Taken together, these results highlighted on one hand that the FP7 programme had a positive impact, as three new PUMAs were effectively obtained, representing one third of the nine PUMAs obtained since the paediatric Regulation entered into force, and three out of 18 agreed PIPs were successfully completed within 3-10 years. In addition, repurposing existing drugs for paediatric use significantly contributed to addressing unmet medical needs in paediatrics. On the other hand, the gap between the number of agreed PIPs and those that have led to PUMAs is still considerable, due to regulatory barriers and financial constraints. This underscores the need for continued support and further initiatives to streamline public-private partnerships for paediatric drug development, ensuring that off-patent medicines can be safely and effectively repurposed for paediatric use.

Applications of Chitosan in Prevention and Treatment Strategies of Infectious Diseases

Chitosan is the most commonly investigated functional cationic biopolymer in a wide range of medical applications due to its promising properties such as biocompatibility, biodegradability, and bioadhesivity, as well as its numerous bioactive properties. Within the last three decades, chitosan and its derivatives have been investigated as biomaterials for drug and vaccine delivery systems, besides for their bioactive properties. Due to the functional groups in its structure, it is possible to tailor the delivery systems with desired properties. There has been a great interest in the application of chitosan-based systems also for the prevention and treatment of infectious diseases, specifically due to their antimicrobial, antiviral, and immunostimulatory effects. In this review, recent applications of chitosan in the prevention and treatment of infectious diseases are reviewed, and possibilities and limitations with regards to technical and regulatory aspects are discussed. Finally, the future perspectives on utilization of chitosan as a biomaterial are discussed.

Nanomedicine Therapies for Pediatric Diseases

In 2020, the top 10 causes of death among children and adolescents between the ages of 1 and 19 years old included cancer, congenital anomalies, heart disease, and chronic respiratory disease; all these conditions are potentially treatable with medical intervention. However, children exhibit specific physiological and developmental characteristics that can significantly impact drug pharmacokinetics, pharmacodynamics, and safety profile. These factors illustrate the importance of a heightened focus on pediatric drug development. Traditional drugs lack proper circulation, permeability, targeting, accumulation, and release, and they often require dose adjustments or modifications, which can result in suboptimal therapeutic outcomes and increased risks of adverse effects in pediatric patients. Nanomedicines have emerged as efficient drug delivery systems because of their unique properties, which can improve the solubility and stability of drugs by encapsulating them in different forms of nanoparticles. This review discusses the challenges of pediatric therapy, and the current state of nanomedicines for pediatric diseases in terms of Food and Drug Administration-approved nanomedicines, the types of diseases treated or diagnosed, and preclinical studies that have the potential to be translated to the clinic. In summary, nanomedicine holds significant potential for addressing the unique and pressing challenges associated with diagnosing and treating pediatric diseases.

State of the art in pediatric nanomedicines

In recent years, the continuous development of innovative nanopharmaceuticals is expanding their biomedical and clinical applications. Nanomedicines are being revolutionized to circumvent the limitations of unbound therapeutic agents as well as overcome barriers posed by biological interfaces at the cellular, organ, system, and microenvironment levels. In many ways, the use of nanoconfigured delivery systems has eased challenges associated with patient differences, and in our opinion, this forms the foundation for their potential usefulness in developing innovative medicines and diagnostics for special patient populations. Here, we present a comprehensive review of nanomedicines specifically designed and evaluated for disease management in the pediatric population. Typically, the pediatric population has distinguishing needs relative to those of adults majorly because of their constantly growing bodies and age-related physiological changes, which often need specialized drug formulation interventions to provide desirable therapeutic effects and outcomes. Besides, child-centric drug carriers have unique delivery routes, dosing flexibility, organoleptic properties (e.g., taste, flavor), and caregiver requirements that are often not met by traditional formulations and can impact adherence to therapy. Engineering pediatric medicines as nanoconfigured structures can potentially resolve these limitations stemming from traditional drug carriers because of their unique capabilities. Consequently, researchers from different specialties relentlessly and creatively investigate the usefulness of nanomedicines for pediatric disease management as extensively captured in this compilation. Some examples of nanomedicines covered include nanoparticles, liposomes, and nanomicelles for cancer; solid lipid and lipid-based nanostructured carriers for hypertension; self-nanoemulsifying lipid-based systems and niosomes for infections; and nanocapsules for asthma pharmacotherapy.

Paediatric Drug Development in China: Current Status and Future Prospects

For more than two decades, regulatory agencies throughout the world released guidelines, rules and laws to stimulate and assist in paediatric drug development. In 2014, the National Health and Family Planning Commission (now known as the National Health Commission, NHC) and five other departments in China jointly issued 'Several Opinions on Safeguarding Medication for Children', after which several policies and regulations were issued to implement the priority review and approval of paediatric medicinal products and support the development of new drugs, including new dosage forms and strengths, for children. A total of 172 special medicinal products for children were approved from 2018 to 2022. Since 2016, the NHC, together with relevant administrative departments, has formulated and issued four paediatric drug lists containing 129 medicinal products to encourage research and development. At present, approximately 25 of these drugs (at exactly the same dosage forms and strengths as on the lists) have been approved for marketing, including antitumour drugs and immunomodulators, nervous system drugs, drugs for mental disorders and drugs for rare diseases. In this review, we analysed the regulations issued for promoting paediatric drug development in China, including the priority review and approval system, technical guidelines, data protection and financial support policies and general profiles of paediatric drug approval, clinical trials and the addition of information for children in the labels of marketed medicinal products. Finally, we discussed the challenges and possible strategies in the research and development of paediatric drugs in China.

A Narrative Review of Scoring Methods in Disseminated Intravascular Coagulation: Evaluating Diagnostic Accuracy and Clinical Utility

Disseminated intravascular coagulation (DIC) is a critical, life-threatening disorder characterized by widespread activation of the coagulation cascade, leading to microthrombi formation, consumption of clotting factors and platelets, and a paradoxically increased risk of bleeding. Accurate and timely diagnosis is crucial for effective management and improved patient outcomes. This narrative review aims to evaluate the diagnostic accuracy and clinical utility of various scoring systems used to assess DIC. We examine prominent systems, including the International Society on Thrombosis and Haemostasis (ISTH) scoring system, the Japanese Association for Acute Medicine (JAAM) DIC criteria, and other regional or institutional criteria such as the Chinese DIC scoring system (CDSS). The review compares these systems based on their criteria, sensitivity, specificity, and accuracy across different patient populations and discusses their strengths and limitations. Additionally, we explore the impact of these scoring systems on patient management and therapeutic decisions, identify challenges and limitations, and highlight emerging trends and future directions in DIC diagnosis. By providing a comprehensive analysis, this review aims to enhance understanding of DIC scoring methods and inform clinical practice to improve patient care.

Ensuring safety and efficacy in combination products: regulatory challenges and best practices

Combination products, amalgamating drugs, biologics, and medical devices, have revolutionized the healthcare landscape with their potential for innovative therapies. However, the intersection of diverse components within these products presents a complex regulatory environment, demanding rigorous attention to safety and efficacy. This article delves into the intricate landscape of regulatory considerations, safety, and efficacy assessments pertaining to combination products-a category at the intersection of drugs, devices, and biologics. The regulatory framework, primarily governed by the U.S. Food and Drug Administration (FDA), necessitates a nuanced classification determining the regulatory pathway. Collaboration between diverse regulatory centers, such as the Center for Drug Evaluation and Research (CDER) and the Center for Devices and Radiological Health (CDRH), underscores the integrated approach required for these innovative healthcare solutions. Safety considerations unravel the potential risks and adverse events associated with combining diverse components, emphasizing the need for robust risk assessment and mitigation strategies. The evaluation of efficacy involves sophisticated methodologies, clinical trials, and post-market surveillance, with recent advancements incorporating digital technologies. This comprehensive exploration aims to contribute to the evolving understanding and best practices in the regulatory and scientific realms, fostering collaboration and innovation in the development and assessment of combination products.

How the French national authority for health assesses medicines for use in pediatrics

Children deserve to be treated with appropriate medicines based on robust assessments. Despite the introduction of new regulations, the availability of medicines for children is suboptimal because of the frequent lack of relevant clinical trials due to the difficulty of conducting such trials. Thus, the Transparency Committee (TC) of the French National Authority for Health, who oversees the assessment of medicinal products in France, set up a pediatric working group with two aims: (1) The first aim was to review all opinions on medicines for pediatric use. Out of 536 opinions delivered between 2020 and 2022, 181 (34 %) concerned medicines for pediatric use. Whereas oncology largely dominated the medicines for adults, medicines for infectious diseases, endocrinology/metabolism, neurology, and hematology mostly prevailed for children. (2) The second aim was to clarify the evaluation criteria assessed by the TC, namely, the clinical benefit (CB), the clinical added value (CAV), and the public health impact (PHI) for pediatric medicinal products. An important CB was given to 113 out of 161 (71 %) opinions on medicines for pediatric use when it concerned pathologies with a severe prognosis. The quality of the demonstration (e.g., double-blind randomized trial vs. placebo or another active medicine) played a major role in the CB level. Clinical pediatric studies were also consistently associated with higher CAV levels: levels I (major) to III (moderate) in 26 out of 42 (62 %) opinions, level IV (minor) and level V (no therapeutic progress) in 43 out of 84 (51 %) and 30 out of 43 (70 %) opinions granting a sufficient CB, respectively. Conversely, 22 out of 30 (73 %) dossiers based only on literature reviews were given a level V. The main criteria leading to the qualification of a medicine for pediatric use as providing a PHI included a significant change in the morbidity and mortality of the disease and an improvement in the care pathway. Assessments were mostly aligned on the adults in the case of subsequent extensions of indications to children. Lastly, new measures were taken aimed at shortening median delays in the assessment process in order to reduce off-label use of medicines in France.

Pediatric Pharmacology for the Primary Care Provider: Advances and Limitations

Despite >1 in 5 children taking prescription drugs in the United States, off-label drug use is common. To increase the study of drugs in children, regulatory bodies have enacted legislation to incentivize and require pediatric drug studies. As a result of this legislation, novel trial approaches, and an increase in personnel with pediatric expertise, there have been numerous advancements in pediatric drug development. With this review, we aim to highlight developments in pediatric pharmacology over the past 6 years for the most common disease processes that may be treated pharmacologically by the pediatric primary care provider. Using information extracted from label changes between 2018 and 2023, the published literature, and Clinicaltrials.gov, we discuss advances across multiple therapeutic areas relevant to the pediatric primary care provider, including asthma, obesity and related disorders, mental health disorders, infections, and dermatologic conditions. We highlight instances in which new drugs have been developed on the basis of a deeper mechanistic understanding of illness and instances in which labels have been expanded in older drugs on the basis of newly available data. We then consider additional factors that affect pediatric drug use, including cost and nonpharmacologic therapies. Although there is work to be done, efforts focused on pediatric-specific drug development will increase the availability of evidence-based, labeled guidance for commonly prescribed drugs and improve outcomes through the safe and effective use of drugs in children.