Pediatric Drugs最新文献

Background: Carbamazepine and valproic acid (VPA) are long-standing treatments for epilepsy in children. Interestingly, they display unique drug disposition characteristics, and maturation of drug metabolizing enzymes further complicates personalized dosing. Physiologically based pharmacokinetic (PBPK) modeling includes these mechanisms so is a promising tool to optimize dosing. Our aim was to better support pediatric drug dosing of carbamazepine and VPA.

Methods: All carbamazepine and VPA dosing simulations were conducted with Simcyp, using available carbamazepine and VPA compound models linked with adult and pediatric population models. To verify model adequacy, adult and pediatric pharmacokinetic data were retrieved from the literature to compare predicted carbamazepine and VPA concentrations with observed data. Current Dutch national dosing strategies were then simulated to evaluate their appropriateness to achieve therapeutic levels. Where doses could be optimized, alternative dosing strategies were proposed based on simulations. In addition, the effect of altered albumin levels in children on VPA was explored through simulations under conditions of +20%, average, - 20%, and - 35% age normalized reference albumin levels.

Results: Therapeutic levels of carbamazepine and VPA will be reached after 1 or 2 weeks of treatment with the current dosing strategies. Simulations suggest a carbamazepine starting dose of 10 mg/kg/day for neonates rather than 7 mg/kg/day. In addition, children aged 12-18 years may receive a higher starting dose (e.g., 400 mg/day instead of 200 mg/day) to reach therapeutic levels more quickly. For VPA, mean total VPA concentrations dropped below the therapeutic target with reduced albumin levels (i.e., - 20% and - 35%), whereas unbound levels remained within the therapeutic window.

Conclusion: Our PBPK simulations support the current pediatric drug dosing recommendations of carbamazepine and VPA. In patients with hypoalbuminemia and when higher VPA doses are needed (i.e., ≥ 30 mg/kg/day), routine determination of unbound VPA concentrations is advised to monitor free VPA concentrations. We demonstrate that PBPK modeling is a valuable tool to confirm and further optimize dosing recommendations in children. PBPK modeling provides valuable comprehensive evidence for guiding clinical practice and potentially informing pediatric drug labeling.

Background and objective: Wound catheter infusion (WCI) with local anesthetics provides effective postoperative analgesia in adults, without adverse effects on wound healing. Studies on WCI in infants are scarce. The aim of this study was to investigate the efficacy and safety of WCI with ropivacaine as treatment for postoperative pain in infants.

Methods: We conducted a prospective, randomized, double-blind, placebo-controlled trial including children aged < 1 year undergoing open abdominal surgery. Informed consent was obtained. All children received a wound catheter at the end of surgery and were randomized for treatment with either ropivacaine (bolus dose of 2 mg/kg and continuous infusion of 0.2 mg/kg/h) (R-group) or placebo (C-group), for 72 h postoperatively. The C-group received morphine 100 mcg/kg intravenously at the end of surgery, the R-group received placebo. Standard analgesia postoperatively was paracetamol intravenously and rescue morphine intravenously. Primary outcome was the cumulative amount of morphine (mcg/kg) administered in the first 48 hours postoperatively. Secondary outcomes were the number of patients needing morphine, area under the curve over 24 hours of COMFORT-B and Numeric Rating Scale pain scores, incidence of adverse events, and plasma concentrations of ropivacaine.

Results: After inclusion of 30 patients, the study was discontinued because of slow recruitment. In two cases, the wound catheter was accidentally displaced directly after surgery, therefore data of 28 children were analyzed (14 R-group, 14 C-group). Median [interquartile range] cumulative amount of morphine (mcg/kg) administered within 48 hours postoperatively was 0.0 [0.0-642.2] in the R-group, compared with 240.1 [15.1-759.0] in the C-group (P = 0.068). In the R-group, 6/14 children required morphine compared with 13/14 in the C-group (P = 0.013). Pain scores were not significantly different between groups. Plasma concentrations of ropivacaine stayed below toxic thresholds.

Conclusions: Cumulative morphine use postoperatively was not significantly different between infants receiving WCI with ropivacaine or placebo, although a lower number in the R-group required morphine. Wound catheter infusion provided adequate analgesia, with no signs of local anesthetic toxicity. The study may have been underpowered because of early discontinuation.

Clinical trial registration: The study was registered in EudraCT (2015-002209-12), and the Dutch Trial Registry NTR6130 on 23 November, 2016 (International Clinical Trials Registry Platform NL-OMON20504).

Background and objectives: Takayasu arteritis (TAK) is a rare large-vessel vasculitis primarily affecting young female patients, with pediatric cases being even rarer. Biologic therapies, such as anti-tumor necrosis factor (anti-TNF) and anti-interleukin-6 (anti-IL-6) agents, have become integral to TAK treatment; however, their use in children is not well supported by robust data due to the rarity of the disease. This systematic review aimed to evaluate the use, effectiveness, and safety of anti-TNF drugs and tocilizumab in the treatment of pediatric TAK.

Methods: We conducted a systematic literature search in PubMed/MEDLINE and Scopus databases from their inception until 15 December 2024. Studies were eligible if they included pediatric patients with TAK (diagnosed before 18 years of age) treated with anti-TNF or anti-IL-6 drugs and reported clinical outcomes. Clinical trials, observational studies, case series, and reports were included. Data were extracted independently by two reviewers. Only English articles were analyzed. Due to heterogeneity in study designs and reporting, a narrative synthesis was performed.

Results: A total of 94 reports involving 225 pediatric patients with TAK who received 262 treatment courses of biologic treatment were included. Anti-TNF drugs were more frequently used than tocilizumab (74.2% versus 36.9%, p < 0.001). Both groups showed comparable effectiveness, with clinical improvement observed in 64.9% of anti-TNF drug and 70.9% of tocilizumab treatment courses (p = 0.438). The frequency of relapse was also similar between the two groups (~50% in both groups, p = 0.472). Hypertension was more prevalent in the anti-TNF group (p = 0.004), while concurrent glucocorticoid administration was more frequent in the tocilizumab group (p = 0.024). Infliximab was the most frequently used anti-TNF drug, with a higher proportion of patients showing improvement compared with adalimumab (71.1% versus 45.5%). Adverse events were only reported with infliximab (n = 3), including allergic and infusion reactions.

Limitations: The evidence is primarily based on case reports and series, which might have introduced selection and publication bias. Additionally, heterogeneity in diagnostic criteria, treatment protocols, and outcome definitions limits the comparability of results across studies.

Conclusion: Despite the higher frequency of anti-TNF drug use, both therapies exhibit similar clinical outcomes, highlighting the potential of tocilizumab as an equally effective alternative in pediatric TAK management. Long-term head-to-head studies are needed to optimize the data regarding biologic treatment strategies in pediatric TAK.

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most frequent periodic fever syndrome in non-Mediterranean children, usually manifesting before the age of 5 years. It is characterized by clockwork episodes of fever lasting 3-7 days, accompanied by aphthous stomatitis, pharyngitis, and/or cervical adenitis. Typically, patients with PFAPA are generally well between episodes and exhibit normal growth and development. Although PFAPA often resolves spontaneously, its recurrent nature can significantly impact quality of life, and symptoms may persist into adulthood. This narrative review aimed to consolidate current knowledge on PFAPA epidemiology, pathogenesis, clinical presentation, diagnostic considerations, and therapeutic options. A structured literature search was performed using PubMed, Cochrane Library, and Scopus, focusing on relevant articles specifically addressing PFAPA. Increasing evidence suggests multifactorial pathogenesis involving innate immune dysregulation, activation of the NLRP3 inflammasome, and Th1-driven inflammation. Genetic analysis studies suggest a polygenic inheritance of PFAPA, linking it to immune pathways shared with familial Mediterranean fever and Behçet's disease. Diagnosis remains clinical, though genetic testing may be warranted in specific cases. Management strategies vary owing to the absence of standardized guidelines. Oral corticosteroids are highly effective for acute episodes but may shorten the interval between flares. Among preventive therapies, colchicine appears to reduce attack frequency, although evidence of its efficacy is limited, while tonsillectomy is often considered curative but recommended for patients with refractory disease or when there is a concurrent otolaryngologic indication. Further research is needed to refine diagnostic criteria and optimize treatment strategies, ultimately improving patients' and caregivers' quality of life.

Kawasaki disease (KD) is a common pediatric vasculitis, with coronary artery lesions (CALs) representing its most severe complication. Early identification of high-risk patients, including those with disease resistant to first-line treatments, is essential to guide personalized therapeutic approaches. Given the limited reliability of current scoring systems, there has been growing interest in the development of new prognostic models based on machine learning algorithms and artificial intelligence (AI). AI has the potential to revolutionize the management of KD by improving patient stratification and supporting more targeted treatment strategies. This narrative review examines recent applications of AI in stratifying patients with KD, with a particular focus on the ability of models to predict intravenous immunoglobulin resistance and the risk of CALs. We analyzed studies published between January 2019 and April 2024 that incorporated AI-based predictive models. In total, 21 papers met the inclusion criteria and were subject to technical and statistical review; 90% of these were conducted in patients from Asian hospitals. Most of the studies (18/21; 85.7%) were retrospective, and two-thirds included fewer than 1000 patients. Significant heterogeneity in study design and parameter selection was observed across the studies. Resistance to intravenous immunoglobulin emerged as a key factor in AI-based models for predicting CALs. Only five models demonstrated a sensitivity > 80%, and four studies provided access to the underlying algorithms and datasets. Challenges such as small sample sizes, class imbalance, and the need for multicenter validation currently limit the clinical applicability of machine-learning-based predictive models. The effectiveness of AI models is heavily influenced by the quantity and quality of data, labeling accuracy, and the completeness of the training datasets. Additionally, issues such as noise and missing data can negatively affect model performance and generalizability. These limitations highlight the need for rigorous validation and open access to model code to ensure transparency and reproducibility. Collaboration and data sharing will be essential for refining AI algorithms, improving patient stratification, and optimizing treatment strategies.

Background: Fibro-adipose vascular anomaly (FAVA) is a rare and complex vascular malformation that, to date, has hardly been studied, especially in children. The diagnosis and management of FAVA is complicated, and no treatment guidelines have yet been published.

Objectives: This study aimed to analyze the clinical manifestations and diagnostic and genetic evidence of FAVA and to explore safe and effective treatment with sirolimus in pediatric patients.

Methods: We retrospectively analyzed the clinical manifestations and examination data of 18 pediatric patients with FAVA who presented at the Vascular Anomaly Center from September 2019 to February 2023 and summarized the basis on which a diagnosis of FAVA was made. A genetic examination was completed in five cases. A total of 12 cases were treated with oral sirolimus. We analyzed changes in skin lesions before and after treatment and recorded the occurrence of adverse reactions.

Results: Of the 18 patients, 15 were girls and 3 were boys. Most lesions (15 cases) were in the lower extremities, accompanied by varying degrees of chronic pain, functional impairment, contractures, and other functional disorders. Imaging findings can be divided into three categories: focal, focal infiltrative, and diffuse. Histopathological manifestations were malformed vascular fibro-adipose tissue. A genetic examination of five cases identified a PIK3CA somatic mutation. After oral sirolimus treatment, pain and dysfunction associated with the lesions were significantly improved, the lesion volume dramatically diminished, and no obvious adverse reactions occurred.

Conclusions: With the help of imaging, and histopathological and somatic genetic examinations, FAVA can be promptly diagnosed and treated to avoid serious dysfunction. The efficacy and safety of oral sirolimus in the treatment of FAVA deserves further study.

Ceftazidime/avibactam (CAZ/AVI) is effective against a wide range of carbapenem-resistant Enterobacterales and multidrug-resistant Pseudomonas. The European Medicines Agency (EMA) approved its use in children from 3 months of age for urinary tract (UTI) and intra-abdominal infections (IAI). Published data in children are limited. We performed a review of existing literature on the use of CAZ/AVI in children. Our search identified a phase I dose-exploratory trial, two registrational phase II clinical trials and nine real-world case series. The efficacy, adverse effects and pharmacokinetics of CAZ/AVI in children were summarized. We also describe the experience of the use of CAZ/AVI in a tertiary hospital in Madrid, Spain. Up to March 2023, 22 episodes of treatment with CAZ/AVI were recorded in 14 patients (50% female, with a median age of 4 years [interquartile range (IQR) 3.5-9]). UTI, bacteraemia or sepsis were the most common clinical conditions for which CAZ/AVI was prescribed. CAZ/AVI was started as targeted therapy in 10 paediatric patients and as empirical therapy in 12 (54.5%) children. The treatment indication was reviewed and adapted according to microbiological results by a paediatric infectious diseases team. Effectiveness of CAZ/AVI was adequate, and there were no discontinuations in any case because of adverse effects.