PTN featured in article on AAP News

The American Academy of Pediatrics (AAP) posted an article on the AAP News website to spotlight the work done by the Pediatric Trials Network (PTN) to provide much-needed dosing, safety and efficacy information for off-patent drugs used in children. The article was written by Perdita Taylor-Zapata of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and P. Brian Smith of the PTN and the Duke Department of Pediatrics.

Despite pediatric medicine’s long history of catastrophic events resulting from inadequate study of drugs prior to their widespread use, the majority of drugs used in children have undergone insufficient study to receive pediatric-specific labeling from the FDA. To fill this troubling information gap, the NICHD established the PTN at the Duke Clinical Research Institute. The PTN generates data to help regulators update drug labels for safer and more effective use of medications in infants and children, in keeping with the goals of the Best Pharmaceuticals for Children Act (BPCA).

BPCA became law in 2002 and provides a mechanism to study off-patent drugs through a collaborative effort of the National Institutes of Health (NIH) and the FDA. This effort includes identifying drugs and therapeutic areas that lack pediatric dosing, safety or efficacy data; sponsoring clinical trials for prioritized drugs; and submitting study results to the FDA for consideration of label modification.

PTN trials are conducted across the U.S. and other countries in partnership with the NIH, and eight clinical trials are ongoing. More than 100 clinical sites are enrolling children in PTN trials, and more than 7,000 children have been enrolled to date.

The PTN has submitted data to the FDA for 21 drugs and devices. To date, eight label changes have been made based on clinical trials sponsored by the NIH BPCA program, including recent label changes to lisinopril and meropenem.

Read the full article.

 

Red Book updated with fluconazole dosing information from PTN study

The American Academy of Pediatrics (AAP) has updated the 2018 edition of the Red Book to include fluconazole dosing information determined by a Pediatric Trials Network (PTN) study. The Red Book is the leading resource on pediatric infectious disease, providing the most up-to-date information on a wide variety of diseases that doctors see in children.

The updates include dosing information for the treatment of Cryptococcus neoformans and Cryptococcus gattii infections, as well as Cryptococcal meningitis in children. The updates, which can be viewed on Red Book Online, will enable doctors to provide a safer, more accurate dose of the antifungal drug fluconazole to treat these diseases in children.

The changes were based on a study conducted from 2008 to 2011 in collaboration with PTN that analyzed safety data on the use of fluconazole to treat infections caused by the Candida yeast. While Candida and Cryptococcus yeasts are not the same, they are treated similarly enough to allow dosing information for one to apply to the other. The study examined data from nearly 800 infants in three randomized trials.

The research was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

First site activated for LAPS study on antipsychotic use in children

The first site has been activated for the Long-term Antipsychotic Pediatric Safety (LAPS) Trial, which aims to determine the safety of long-term antipsychotic treatments in children. Dr. Ahmed Elmaadawi’s was the first site activated on Tuesday, Dec. 11. Dr. Elmaadawi is the director of the Interventional Psychiatry Program at Beacon Health System in South Bend, Ind.

The two-year LAPS study will follow children aged 3 to 17 who are already taking an antipsychotic (risperidone or aripiprazole) to treat disorders such as schizophrenia, bipolar disorder, and irritability associated with autism. The study will assess both the long-term health risks and quality-of-life benefits of these two drugs, which have been shown to be effective and may even prevent mental illness in adulthood.

Dr. Linmarie Sikich

“Antipsychotic treatment of children and adolescents has greatly increased over the past 20 years,” said Dr. Linmarie Sikich, principal investigator for the study and associate professor in the Department of Psychiatry and Behavioral Sciences at the Duke University School of Medicine. “At the same time, new evidence suggests an association between antipsychotic use and weight gain. In addition, the incidence of long-term adverse effects such as involuntary movements and hormonal changes is unknown.”

These findings have led to a growing concern that the potential benefits of long-term antipsychotic use may not outweigh the risks, especially for children.

While several antipsychotics are FDA-approved in children, it is common for these drugs to be prescribed without FDA approval for conditions such as attention-deficit disorder, obsessive-compulsive disorder, and major depression. Antipsychotics are also frequently used to promote weight gain and reduce anxiety in children and teens with eating disorders.

The ultimate goal of the study is to provide long-term safety data to the FDA to update the risperidone and aripiprazole labels to include correct safety and dosing information. This information will allow doctors to provide the safest, most effective dose to children who require treatment with antipsychotics.

FDA changes lithium label to reflect appropriate dosing for children

The U.S. Food and Drug Administration (FDA) recently updated the label for the drug lithium to include appropriate dosing for children. The change was made after a trial supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) showed that lithium was safe and effective for children with bipolar disorder. Prior to this change, lithium had no safety or dosing information for anyone under age 18.

Researchers enrolled 81 children ages 7 to 17, who were divided into two groups. Fifty-three received lithium for a period of 8 weeks, and 28 received a placebo. Based on a questionnaire, researchers found that children receiving lithium experienced improved symptoms over those in the placebo group. In addition, children taking lithium did not experience significant metabolic side effects such as weight gain, as compared to other medications for bipolar disorder.

The Best Pharmaceuticals for Children Act (BPCA), which became law in 2002, funds research on medications for infants and children. The PTN was created by NICHD to make these pediatric trials more efficient. Read more on the NICHD website.

Database locked for SCAMP study

The Pediatric Trials Network (PTN) has locked the database for the Antibiotic Safety in Infants with Complicated Intra-abdominal Infections (SCAMP) study. The study, which enrolled its first patient in 2014, is designed to assess the safety, efficacy, and pharmacokinetics of three commonly prescribed antibiotic regimens for infants with intra-abdominal infections.

Complicated intra-abdominal infections (cIAIs) are common and often fatal in premature infants. The most common cIAI in neonates is necrotizing enterocolitis (NEC), a devastating disease that causes inflammation and can eventually destroy the wall of the bowel.

“In extremely low-birth-weight infants, the death rate for NEC can be as high as 50 percent,” said Dr. Michael Smith, investigator for the SCAMP study and associate professor of pediatrics at the Duke University School of Medicine. “Even survivors can suffer from lifelong complications such as short bowel-syndrome and poor neurodevelopmental outcomes.”

The most commonly used antibiotics in infants with cIAI include ampicillin, metronidazole, clindamycin, piperacillin-tazobactam, and gentamicin. However, since safety and efficacy data are lacking, these drugs are not labeled for use in infants with cIAI.

The PTN is filling this information gap with SCAMP, a partially randomized, multicenter, open-label study to determine the safety of these drug regimens in this specific and highly vulnerable population. Nearly 300 infants participated in the study at 58 sites in the U.S. and Canada. The infants were enrolled for 100 days, including 10 days of treatment and up to 90 days of follow-up assessments.

As a next step, the results of the SCAMP study will be submitted to the FDA for potential drug label changes.

PTN intern credits experience in STAR Program with passion for medical research

Daniel Gorham was a 17-year-old high school student when his mother, a data scientist at the Duke Clinical Research Institute, showed him an article about the Summer Training in Academic Research (STAR) Program.

Although he dismissed the idea at first, he began reading up on the program and became more intrigued. He applied in 2016, and it is a decision he doesn’t regret.

“I always knew I wanted to do something in the sciences, but I didn’t know which route I wanted to take,” he said. “Learning about the different career fields and meeting different doctors and professionals, I ended up learning more about myself.”

The annual STAR Program gives high school students, college students, and middle and high school teachers hands-on experience conducting an original research project. It also provides classroom training in epidemiology, global health, medical ethics, statistics, and writing.

Although Gorham was initially more interested in cancer research than pediatrics, the eight-week program changed his mind. He spent the summer researching bronchopulmonary dysplasia (BPD), a dangerous lung disease that affects approximately 17,500 premature infants in the U.S. every year, often leading to life-long medical problems and even death.

His research on how BPD impacts the lives of premature infants, along with lectures in neonatology and tours of the neonatal intensive care unit (NICU), quickly instilled a love of pediatrics. The fact that Gorham’s older brother had been born preterm made the research hit even closer to home.

“I had always heard these stories about how tiny and sick he was, and how his chances of life were so slim,” Gorham said. “After spending time on rounds and being around these babies and their families, I realized how important this work really is.”

After graduating from the program, Gorham kept in close contact with program director Dr. Danny Benjamin. When an opening became available for a summer intern at the Pediatric Trials Network (PTN), where Benjamin is principal investigator, Gorham jumped at the chance.

For the entire summer, he conducted research on blood plasma stability, or how certain drugs stay stable in the blood of infants and children. At the end of his internship, he presented his findings on 70 different drugs to an audience of doctors and other professionals at the DCRI.

Gorham is now returning to East Carolina University, where he will be a junior this year. After completing his degree, he plans to come back to Durham to take the next steps toward a career in pediatric research.

“When I say the STAR Program changed my life, it sounds cliché,” he said. “But without it, I would have ended up approaching a career that I didn’t have much passion for.”

He recommends the STAR Program to others, and has even encouraged three of his friends to apply.

“It takes you out of the mindset of a high school student and turns you into an adult,” Gorham said. “My outlook on science completely transformed from, ‘I need to get an A in this class’ to ‘This actually saves lives.’”

PTN creates data repository to aid in pediatric research

Dr. Christoph Hornik

Randomized clinical trials are considered the gold standard in clinical research. However, they often require a great deal of time and cost, and may not be feasible to conduct in vulnerable populations such as premature infants.

To overcome these difficulties, the Pediatric Trials Network (PTN) developed a repository of electronic health record (EHR) data gathered from nearly 265,000 pediatric patients to better guide research.

“This real-world data can be used to target drugs, conditions, and subpopulations for clinical studies that will maximize public health benefit and help identify areas for future study,” said Dr. Christoph Hornik of the Duke Department of Pediatrics, who led the development of the data repository.

The Best Pharmaceuticals for Children Act (BPCA) mandates the National Institutes of Health to prioritize areas where there is a critical need for information to guide medical treatments in children. With funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the PTN conducts studies designed to determine the dosing, safety, and efficacy of drugs that have been approved for adults but lack information for the pediatric population.

The repository, which includes data collected from 9 participating sites from 2013 to 2017, will aid in PTN’s mission by providing a multicenter data source to support its studies. It will facilitate both trial planning and the analysis of the uses and effects of a variety of medications in infants and children.

“Findings from this initiative will benefit children receiving care by not only shedding light on existing treatment practices, but also determining best practices for the future,” Hornik said.

The data collection, validation, and storage process was managed by Duke Health Technology Services and conducted in accordance with the Federal Information Security Management Act.

PTN to present at PAS 2018 Meeting in Toronto

The Pediatric Trials Network (PTN) will be presenting its research at the Pediatric Academic Societies (PAS) Meeting May 5-8 at the Metro Toronto Convention Centre in Toronto, Canada.

The annual PAS Meeting brings together thousands of researchers, academics, and clinical care providers united by a common mission: to improve the health and well-being of children worldwide. It is supported by the American Pediatric Society, the Society for Pediatric Research, the Academic Pediatric Association, and the American Academy of Pediatrics.

During the annual meeting, PTN investigators will share information on a variety of studies involving antibiotic safety, treatment of hospital-associated and ventilator-acquired bacterial pneumonia, infant weight estimation, personal protective equipment, and the development of a data repository to aid in pediatric research. See a detailed schedule of PTN-related presentations below or view the online program guide on the PAS website.

Saturday, May 5

  •  1:15 p.m. – Validation and Human Factors Evaluation of a New Device for Infant Weight Estimation – Dr. Susan Abdel-Rahman, Children’s Mercy Kansas City (Poster)
  •  1:15 p.m. – The Use of PPE during Pediatric Resuscitation: Which Tasks are Most Affected? The Results of a Survey during a Simulation Trial – Dr. Aaron Donoghue, Children’s Hospital of Philadelphia (Poster)

Sunday, May 6

  •  11 a.m. – The Impact of Personal Protective Equipment on Performing Critical Procedures for Pediatric Patients in the Pre-Hospital Setting – Dr. Maybelle Kou, Inova Fairfax Hospital (Platform)
  •  3:45 p.m. – Population Pharmacokinetics of Milrinone in Infants and Children – Dr. Christoph Hornik, Duke University (Platform)
  •  4:45 p.m. – Development of an Electronic Health Record Derived Multicenter Inpatient Pediatric Data Repository – Dr. Christoph Hornik, Duke University (Platform)
  •  5:45 p.m. – Hospital Associated and Ventilator Acquired Bacterial Pneumonias in Infants and Children – Dr. Jessica Ericson, Penn State Milton S. Hershey Medical Center (Poster)
  •  5:45 p.m. – Population Pharmacokinetics and Safety of Sildenafil in Premature Infants – Dr. Daniel Gonzalez, UNC Eshelman School of Pharmacy (Poster)

Monday, May 7

  • 2 p.m. – Antibiotic Safety and Efficacy in Infants with Complicated Intra-Abdominal Infections (cIAIs) – Dr. Michael Smith, Duke University (Platform)
  • 5:45 p.m. – Dosing-Safety Relationship for Acyclovir in the Treatment of Neonatal Herpes Simplex Virus Disease – Dr. Jessica Ericson, Penn State Milton S. Hershey Medical Center (Poster)
  • 5:45 p.m. – Impact of Personal Protective Equipment on Pediatric Cardiopulmonary Resuscitation Performance – Dr. Aaron Donoghue, Children’s Hospital of Philadelphia (Poster)
  • 5:45 p.m. – Weight Gain and Metabolic Syndrome in Children Exposed to Second-Generation Antipsychotic Medications – Dr. Angela Czaja, Children’s Hospital Colorado (Platform)

Tuesday, May 8

  • 7:30 a.m. – Correlating Pulmonary Hypertension by Echocardiogram with Mortality in Premature Infants – Dr. Rachel Torok, Duke University (Platform)

PTN welcomes first sites in Australia

The Pediatric Trials Network (PTN) welcomed its first two Australian sites in February. Sydney Children’s Hospitals Network and the Royal Children’s Hospital in Melbourne are now participating in PTN’s Pharmacokinetics of Understudied Drugs in Infants and Children (POPS) study.

The sites are currently involved in the Paediatric Trials Network Australia (PTNA), a counterpart of PTN that brings together pediatric researchers from across Australia who are committed to improving child health through the facilitation of pediatric clinical trials.

“These sites bring considerable experience in pediatric research and will make a significant contribution to PTN’s work,” said Dr. Danny Benjamin, principal investigator for the PTN. “In addition, their involvement will expand PTN’s global footprint, allowing us to gather data from a more diverse and widespread group of children and infants that can better inform our research.”

The POPS study is designed to assess the pharmacokinetics of a variety of commonly used drugs in children and infants that have limited safety and dosing information in the pediatric population. More than 70 drugs used to treat nearly 50 diseases and conditions have been studied so far.

Sydney Children’s Hospital, Randwick
Kids Research Institute, Westmead
Royal Children’s Hospital, Melbourne

Groundbreaking study to assess safety of drugs passed through breastmilk

The Pediatric Trials Network (PTN) is undertaking a groundbreaking study to assess the safety of commonly used off-patent medications when they are given to breastfeeding mothers. The study will track how different drugs are passed through breastmilk to determine dosing levels that are safe for both mom and baby.

Although the U.S. Food and Drug Administration (FDA) has implemented a guidance document on conducting lactation studies, off-patent drugs are not included in that rule. The PTN seeks to fill this knowledge gap.

Dr. Kevin Watt

“Although the benefits of breastfeeding are well-documented, we still don’t know enough about the effects of many prescription and over-the-counter off-patent drugs when they are passed to infants through their mother’s breastmilk,” said Dr. Kevin Watt, an assistant professor of pediatrics at Duke University who is leading the study. “As a rule, we discourage unnecessary drug use during lactation, but it’s quite common for new mothers to have symptoms or medical conditions that must be treated with drugs.”

“Many breastfeeding moms struggle with the decision to take medications because of the fear that these drugs will harm their children,” Watt said. “In the end, it often comes down to either stopping breastfeeding or discontinuing needed medications. We want to take the guesswork out of this decision and allow moms to breastfeed without worry.”

The study is expected to begin in April of 2018 and will enroll approximately 50 lactating women, along with their breastfed infants, for each drug studied. Initially 10 off-patent drugs will be studied, including medications used to treat bacterial infections, depression and anxiety, high blood pressure, diabetes, and chronic pain. Mothers will be enrolled in the study only if they are already taking one of the study drugs as part of their routine care.

Mothers who participate in the study will provide samples of breastmilk, their blood, their infants’ blood, or a combination to help researchers measure drug levels and determine the safest dose. Mothers and infants are expected to remain in the study until the infants reach 180 days of age.

The study, supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), will also explore the effects of maternal obesity on drug exposure and long-term outcomes of breastfed infants exposed to drugs in breastmilk.

See the NIH LactMed database for more information on the levels of various substances in breastmilk and infant blood, and possible adverse effects.