Pediatric cardiovascular safety: challenges in drug and device development and clinical application.
Development of pediatric medications and devices is complicated by differences in pediatric physiology and pathophysiology (both compared with adults and within the pediatric age range), small patient populations, and practical and ethical challenges to designing clinical trials. This article summarizes the discussions that occurred at a Cardiac Safety Research Consortium-sponsored Think Tank convened on December 10, 2010, where members from academia, industry, and regulatory agencies discussed important issues regarding pediatric cardiovascular safety of medications and cardiovascular devices. Pediatric drug and device development may use adult data but often requires additional preclinical and clinical testing to characterize effects on cardiac function and development. Challenges in preclinical trials include identifying appropriate animal models, clinically relevant efficacy end points, and methods to monitor cardiovascular safety. Pediatric clinical trials have different ethical concerns from adult trials, including consideration of the subjects' families. Clinical trial design in pediatrics should assess risks and benefits as well as incorporate input from families. Postmarketing surveillance, mandated by federal law, plays an important role in both drug and device safety assessment and becomes crucial in the pediatric population because of the limitations of premarketing pediatric studies. Solutions for this wide array of issues will require collaboration between academia, industry, and government as well as creativity in pediatric study design. Formation of various epidemiologic tools including registries to describe outcomes of pediatric cardiac disease and its treatment as well as cardiac effects of noncardiovascular medications, should inform preclinical and clinical development and improve benefit-risk assessments for the patients. The discussions in this article summarize areas of emerging consensus and other areas in which consensus remains elusive and provide suggestions for additional research to further our knowledge and understanding of this topic.
Children's Hospital of Philadelphia, Division of Cardiology, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA. bateske1@email.chop.edu
Katherine E
KE
Bates
Victoria L
VL
Vetter
Jennifer S
JS
Li
Susan
S
Cummins
Fernando
F
Aguel
Christopher
C
Almond
Anne M
AM
Dubin
Josephine
J
Elia
John
J
Finkle
Elizabeth A
EA
Hausner
Francesca
F
Joseph
Abraham M
AM
Karkowsky
Matthew
M
Killeen
Jodi
J
Lemacks
Lisa
L
Mathis
Ann W
AW
McMahon
Ellen
E
Pinnow
Ignacio
I
Rodriguez
Norman L
NL
Stockbridge
Margaret
M
Stockwell
Melissa
M
Tassinari
Mitchell W
MW
Krucoff
D000818:Animals; D026688:Bioethical Issues; D002318:Cardiovascular Diseases / Q000628:therapy*; D013504:Cardiovascular Surgical Procedures / Q000295:instrumentation*; D002648:Child; D002657:Child Development / Q000187:drug effects / Q000502:physiology*; D002986:Clinical Trials as Topic / Q000941:ethics; D018795:Device Approval / Q000331:legislation & jurisprudence; D004305:Dose-Response Relationship, Drug; D015195:Drug Design; D004353:Drug Evaluation, Preclinical; D004562:Electrocardiography; D004867:Equipment Design; D033161:Government Regulation; D006801:Humans; D023421:Models, Animal; D061214:Patient Safety / Q000331:legislation & jurisprudence; D011358:Product Surveillance, Postmarketing