Академический Документы
Профессиональный Документы
Культура Документы
Medicines
for Children
From
Concept to
Reality
PROGRESS REPORT
ON THE PAEDIATRIC
REGULATION (EC)
N1901/2006
COM (2013) 443
FINAL
Health and
Consumers
REPORT
FROM THE
COMMISSION
TO THE
EUROPEAN
PARLIAMENT
AND THE
COUNCIL
Better Medicines
for Children
From Concept to Reality
General Report on
experience acquired as a
result of the application
of Regulation (EC)
n 1901/2006 on
medicinal products for
paediatric use
(text with EEA relevance)
1.
Introduction
Better Medicines for Children was the
ambitious title of a consultation paper
of February 2002, in which the European
Commission presented its vision for regulatory actions on paediatric medicinal
products1. At that time, many of the products used in children were not specifically
studied or authorised in children. Instead,
doctors often used products authorised
for adults, sometimes in different dosages, with the associated risks of inefficacy
and/or adverse reactions.
The consultation paper built on a 5-year
discussion process that started in 1997
with a round table meeting at the premises of the European Medicines Agency
(EMA) and was the blueprint for the subsequent legislative act. It outlined many
of the measures that are to be found in
the Paediatric Regulation (Regulation (EC)
No 1901/2006 of the European Parliament and of the Council on medicinal
products for paediatric use2, hereinafter
the Regulation).
The Regulation was adopted some five
years after the consultation paper, on 12
December 2006. It entered into force on
26January 2007 and its main provisions
were applicable from 26 July 2008 (Article 7) and 26 January 2009 (Article 8),
respectively.
Five years on, it is time to take stock of
developments and report to the European
Parliament and the Council on the experience acquired as a result of the Regulation, in accordance with its Article 50(2).
Are we already seeing the emergence of
better medicines for children?
This report does not yet provide comprehensive answer, as it is subject to certain
limitations; it should therefore be regarded as an interim report that presents a
first impression of the experience gained.
In view of the development cycles of medicinal products, it will take at least 10
years to gain a full understanding of the
impact of the legislation. This factor has
already been accounted for in the legislation which requires the Commission to
provide a second, more comprehensive
report in 2017 which, in accordance with
Article 50(3) of the Regulation, must include an analysis of the economic impact
of the rewards and incentives, together
with an analysis of the Regulations implications for public health, with a view to
proposing any necessary amendments.
However at this stage, some analyses and
interim conclusions can be made.
This document has been prepared in consultation with Member States, the EMA
and interested parties. The Commission
particularly values the 5-year Report to
the European Commission presenting the
views of the EMA and its Paediatric Committee3, and the responses to the public
consultation the Commission undertook
at the end of 20124.
1. http://ec.europa.eu/health/
files/pharmacos/docs/
doc2002/feb/cd_pediatrics_en.pdf.
2. OJ L 378, 27.12.2006,
p.1; amended by Regulation
(EC) No 1902/2006 of the
European Parliament and of
the Council of 20 December
2006, OJ L 378, 27.12.2006,
p.20.
3. 5-year report to the
European Commission
General report on experience
acquired as a result of the
application of the Paediatric Regulation, prepared
by the European Medicines
Agency with its Paediatric
Committee, http://ec.europa.
eu/health/files/paediatrics/2012-09_pediatric_report-annex1-2_en.pdf.
4. http://ec.europa.eu/health/
human-use/paediatric-medicines/developments/2013_
paediatric_pc_en.htm.
6
5. Regulation (EC)
N 141/2000 of the European Parliament and the
Council of 16 December
1999 on orphan medicinal
products, OJ L 18, 22.1.2000,
p.1.
2.
The Paediatric
Regulation
In 2010 around 21% of Europeans were
children, representing more than 100 million people. Children represent a vulnerable population group with developmental,
physiological and psychological differences from adults. They are not merely small
adults. Age- and development-related
research, and the availability of suitable
medicinal products, is consequently particularly important.
Studies carried out before the Regulation
was adopted showed that over 50% of the
medicines used for children had not been
tested for use in this specific age group.
What is more, only a limited number of
medicinal products had been developed
specifically with children in mind. Companies had already developed a range of
products against a number of diseases
prior to the Paediatric Regulation, particularly in sectors such as childhood immunisation by means of vaccines. However, the
availability of child-appropriate medicines
was generally unsatisfactory. Accordingly,
the Regulation was seen as a response to
the absence of sufficient numbers of suitable, authorised medicinal products, with
appropriate dosages and pharmaceutical
forms, to treat conditions in children in the
European Union (EU).
There are several reasons for the lack
of paediatric medicines. It would, however, be too simplistic to pin the blame
on pharmaceutical companies for not carrying out enough research and development (R&D) to adapt medicinal products
to the needs of the paediatric population. This reluctance has long mirrored a
general social and ethical paradigm that
children should be protected from clinical
research. Only in the last two decades has
there been a shift to the current consensus of better protecting children through
clinical research.
to ensure, over time, that the majority of medicines used by children are
specifically authorised for such use
with appropriate forms and formulations;
3.
Major
milestones in
Implementing
the
Regulation
To implement the Paediatric Regulation
successfully, complementary measures
needed to be adopted and supplementary
action taken as stipulated in the legislation.
The Agency implemented the Regulation
in a timely manner. The Paediatric Committee was duly established and held
its first meeting on 1-2 July 2007, and
has met monthly since. The Commission
guideline on the format and content of
applications for a paediatric investigation
plan (Article 10) was published in September 20086. The Agency put in place
the necessary procedures and database
for the scientific evaluation of paediatric
investigation plans and for the adoption
of decisions under the Regulation.
The European Network for Paediatric Research at the EMA (Enpr-EMA) was set up
after the EMA Management Board adopted the implementing strategy in 2008,
launched in 2009 and has met regularly
since 2010 (Article 44).
The results of the survey of all existing
uses of medicinal products in the EU paediatric population were published in December 20107 (Article 42) and were used
as a basis for the inventory of therapeutic
needs (Article 43).
In March 2011, the European Union Database on Clinical Trials (EudraCT) was
modified and made publicly accessible
via the public website clinicaltrialregister.eu, for protocol-related information
on paediatric trials included in paediatric
investigation plans or submitted under
10
15. http://www.ema.
europa.eu/docs/en_GB/document_library/Other/2009/10/
WC500004017.pdf.
4.
Main
achievements
4.1. Better and safer research
Before the Paediatric Regulation entered
into force, many pharmaceutical companies considered the adult population their
key market. Research into the potential
use of an adult product in the paediatric
population was often side-lined or not
considered at all. With the obligations introduced by the Regulation, forcing companies to screen every new (adult) product for its potential paediatric use, the
situation has been turned around. Feedback from companies confirms a fundamental change of culture: undertakings
now consider paediatric development to
be an integral part of the overall development of a product.
The requirement to develop and discuss
with the Paediatric Committee a paediatric investigation plan, which normally
should be submitted not later than upon
completion of the human pharmaco-kinetic studies in adults, obliges companies
to think about paediatric use early on so
as to avoid any delays in general product development. The plan brings with it
a research and development programme
which aims to ensure that the necessary
data are generated for the authorisation
of paediatric indications.
By the end of 2012 the Agency had
agreed 600 paediatric investigation plans
(see Table1). Of these, 453 were for
medicines that were not yet authorised
in the EU (Article 7), while the remainder
related to new indications for patent-protected products (Article 8) or paediatricuse marketing authorisations (Article 30).
These plans cover a broad range of therapeutic areas. At the forefront are Endocrinology-Gynaecology-Fertility-Metabolism
(11%), Infectious diseases (11%) and
Oncology (11%), but no particular area
dominates (see Table3).
11
12
16. http://www.who.int/childmedicines/paediatric_regulators/en/.
13
14
19. Case T-52/09 Nycomed v
EMA, not yet published.
See the results of the public
consultation conducted by
the Commission in preparation of this Report.
proved medicinal products. The summaries of product characteristics of 12 medicinal products were changed following
the assessment.
5.
Lessons
learnt
15
16
22. Directive 2001/83/EC of
the European Parliament and
of the Council of 6 November
2001 on the Community
code relating to medicinal
products for human use, OJ L
311, 28.11.2001, p. 67.
23. Regulation (EC) No
726/2004 of the European
Parliament and of the Council of 31 March 2004 laying
down Community procedures
for the authorisation and
supervision of medicinal
products for human and
veterinary use and establishing a European Medicines
Agency, OJ L 136, 30.4.2004,
p.1.
17
18
nies may decide to stop the corresponding adult development. It is too early still
to obtain reliable statistics that show
the ratio between completed and noncompleted paediatric investigation plans,
but in the current context not all approved
plans will eventually result in an approved
medicine with a paediatric indication.
In terms of output, this entails some unnecessary effort in compiling and screening paediatric investigation plans. To what
extent this is offset by the benefit of early
submission, which ensures that the paediatric development fits smoothly into the
overall product development, need further monitoring.
A further point of concern is the high
number of modifications to paediatric investigation plans. Figures seem to
suggest that nearly all plans have to
be modified at least once. Conceptually
though this does not come as a surprise,
in view of the early submission of paediatric investigation plans, the length of
adult and paediatric developments and
the substantial deferrals granted. An
R&D plan frequently has to be adapted
or amended to take account of initial results. Recruitment problems or necessary
design changes in the trials may also lead
to modifications. While it is acknowledged
that substantial amendments or modifications to the plan have to be subject to
discussions with the Paediatric Committee, this is less obvious for minor changes.
In this context, the level of detail required
by the EMA has been repeatedly criticised.
In the past five years, the EMA and its
Paediatric Committee have made efforts
to provide for some flexibility in the plan
so to allow a margin of manoeuvre that
takes account of uncertainties in relation
to certain parameters of a trial.
In any case, the Commission intends to
review its Communication on the format
and content of applications for agreement or modification of a paediatric investigation plan to take into account the
experience gained, including the considerable number of modification requests.
On a positive note, it can be noted that
companies are applying for the rewards
19
6.
Outlook
A fairy-tale
ending ahead?
Better Medicines for Children From
Concept to Reality is the title of this report. Readers may suggest that, based on
the evaluation referred to above, it would
be more appropriate to add a question
mark. It is evident that it is too early still
to make a firm statement. Despite more
than five years of experience, the true impact of the Regulation on the health of
children will only become apparent over
time as experience is accumulated in the
longer term.
There are encouraging signs though.
Paediatric development has become a
more integral part of the overall development of medicinal products in the EU. A
number of new products with paediatric
indications and age-appropriate pharmaceutical forms have been authorised and
made available to patients. A high number of agreed paediatric investigation
plans indicates that further products are
in the pipeline.
However, it needs to be pointed out that it
would be wrong to expect the Regulation
to be able to solve all problems. Instead,
it is a major catalyst to improve the situation of young patients.
Finally, some weaknesses and deficits
have also become apparent in the last
five years. Their impact on the overall
performance of the Regulation has to be
closely monitored. On the basis of the actions outlined above, the Commission intends to fine-tune the current implementation together with the EMA.
Even if better medicines for children are
not yet a reality, it should be the ambition
of all stakeholders involved that this piece
of legislation will be for the greater good
of children, so that in the 2017 report,
the discussion will focus not on whether a
question mark should be added to the title of the report, but on whether it should
be an exclamation mark instead!
21
ANNEXES
Figures and Tables
22
23
ANNEX I
250
200
150
100
50
0
2007
2008
2009
2010
2011
2012
Table 2:
Agreed paediatric investigations plans (PIPs) compared to full waivers and modifications 2007-2012
250
200
150
100
50
0
2007
2008
2009
2010
2011
2012
24
Table 3:
HaematologyHaemostaseology
8%
Cardiovascular
Diseases
8%
Oto-rhino-laryngology
3%
Pain, Anaesthesiology
3%
Uro-nephrology
3%
Psychiatry
2%
Other
19%
Neonatology** Intensive
Care 2%
ImmunologyRheumatologyTransplantation
9%
Oncology
10%
Infectious
Diseases
10%
Other
7%
EndocrinologyGynaecology-FertilityMetabolism
10%
Table 4:
10
9
8
7
6
5
4
3
2
1
0
2008
Source: EMA Paediatric database.
2009
2010
2011
2012
25
Table 5:
Scientific advice and protocol assistance, including follow-ups (provided by the EMA Scientific Advice Working
Party and the Committee for Human Medicinal Products, per year)
500
400
300
420
321
277
259
433
400
388
200
74 68
100
0
2006
21
32
2007
80 80
91 94
57 67
2008
2009
2010
2011
2012
Table 6:
2006
2007
2008
2009
2010
2011
2012
Paediatric trials
(number)
254
316
355
342
404
379
334
332
Paediatric trials
that are part of an
agreed PIP*
16
30
76
76
Proportion of
paediatric trials
that are part of an
agreed PIP among
paediatric trials*
1%
0%
1%
2%
4%
8%
23%
23%
Total number
of trials (adults
and/or children)
3350
3979
4749
4512
4445
4026
3809
3698
Proportion of
paediatric trials of
all trials
8%
8%
7%
8%
9%
10%
9%
9%
Source: EudraCT Data Warehouse using a predefined query on 6 March 2013 and counting the first authorised trial only, in the case of more than
one Member State.
* This partial information requires sponsors to use a Clinical Trial Application form that was only available from November 2009, for use with version 8 of EudraCT
(available from 2011).
26
Table 7:
2006
2007
2008
2009
2010
2011
2012
Preterm
newborns
207
82
2281
1712
Newborns
64
169
1105
1172
Infants and
toddlers
330
21
20
59
351
2788
3141
Children
2142
181
200
2230
2055
10325
20677
Adolescents
368
111
205
1577
2861
9054
13193
Sum of
above
2840
313
430
4137
5517
25553
39895
Reference:
number of
paediatric
trials
316
355
342
404
379
334
332
Source: EudraCT Data Warehouse using a pre-defined query on 6 March 2013, modified by excluding studies for immunological medicinal products
Table 8:
2007
2008
2009
2010
2011
2012
27
Table 9:
Percentage of European Medicines Agencys human resources working in the paediatric area from 2006 (inner
circle) to 2012 (outer circle)
0,52% (2006)
7,33% (2012)
Table 10:
Member States acting as rapporteurs for the assessment of studies submitted in accordance with Article 46
(paediatric work-sharing procedures)
60
50
40
30
20
10
0
UK DE SE NL FR DK IT BE PL ES NO SK FI
Study included in worksharing
IE RO AT HU EL CZ PT LV BG
Rapporteur appointed
28
Table 11:
Member States acting as rapporteur for the assessment of studies submitted in accordance with Article 45
(paediatric work-sharing procedures)
60
50
40
30
20
10
0
UK DE NL DK AT FR PL SE ES IE CZ MT IT BE SI EE FI HU NO RO BG EL LV PT IS SK
Wave 1
Wave 2
Wave 3
Wave 4
Wave 5
Wave 6
Wave 7
Wave 8
Wave 9
Wave 10
Wave 11
Wave 12
Wave 13
Wave 14
Wave 15
Wave 16
Wave 17
Wave 18
Table 12:
Member States acting as rapporteurs/peer reviewers in EMAs Paediatric Committee procedures (initial PIP/
waiver or modification of an agreed PIP)
500
450
400
350
300
250
200
150
100
50
0
United Kingdom
The Netherlands
Sweden
Spain
Slovenia
Slovakia
Romania
Portugal
Poland
Patients' Organisation
Norway
Malta
Luxembourg
Lithuania
Latvia
Italy
Ireland
Iceland
Hungary
Healthcare and Academia
Greece
Germany
France
Finland
Estonia
Denmark
Czech Republic
Cyprus
Bulgaria
Belgium
Austria
PIP modifications
29
ANNEX II
Medicinal products authorised centrally since 2007, which include a paediatric indication
Requirement
to fulfil
Paediatric
Regulation
at first
authorisation?
Indication is
paediatric-only
or mixed (adult
and paediatric)?
Active
substance(s)
Trade
name
Year
of
authorisation
Retapamulin
Altargo
2007
No
Mixed
Nelarabine
Atriance
2007
No
Mixed
Cervarix
2007
No
Mixed
Hydroxocobalamin
Cyanokit
2007
No
Mixed
Idursulfase
Elaprase
2007
No
Mixed
Gadoversetamide
Optimark
2007
No
Mixed
Betaine anhydrous
Cystadane
2007
No
Mixed
Stiripentol
Diacomit
2007
No
Paediatric only
Mecasermin
Increlex
2007
No
Paediatric only
Rufinamide
Inovelon
2007
No
Mixed
Hydroxycarbamide
Siklos
2007
No
Mixed
Human normal
immunoglobulin (ivig)
Flebogamma DIF
2007
No
Mixed
Fluticasone furoate
Avamys
2008
No
Mixed
Privigen
2008
No
Mixed
Lacosamide
Vimpat
2008
No
Mixed
Micafungin
Mycamine
2008
No
Mixed
Sapropterin
Kuvan
2008
No
Mixed
Sugammadex
Bridion
2008
No
Mixed
Tocofersonal d-alpha
tocopheryl polyethylene glycol
succinate
Vedrop
2009
No
Paediatric only
Mifamurtide
Mepact
2009
No
Mixed
Rilonacept
Rilonacept Regeneron
2009
No
Mixed
Tacrolimus
Modigraf
2009
No
Mixed
Pneumoccocal polysaccharide
conjugate vaccine (adsorbed)
Synflorix
2009
No
Paediatric only
Canakinumab
2009
Yes
Mixed
30
Requirement
to fulfil
Paediatric
Regulation
at first
authorisation?
Indication is
paediatric-only
or mixed (adult
and paediatric)?
Active
substance(s)
Trade
name
Year
of
authorisation
Pneumoccocal polysaccharide
conjugate vaccine (13-valent,
adsorbed)
2009
Yes
Paediatric only
Meningococcal group a, c,
w135 and y conjugate vaccine
Menveo
2010
Yes
Mixed
Velaglucerase alfa
2010
Yes
Mixed
Fluenz (Waiver)
2011
Yes
Paediatric only
C1 inhibitor, human
2011
Yes
Mixed
Dihydroartemisinin /
piperaquine phosphate
2011
Yes
Mixed
Midazolam
Buccolam
2011
Yes (PUMA)
Paediatric only
Everolimus
Votubia
(PIP not yet completed)
2011
Yes
Mixed
Tobramycin
2011
Yes
Mixed
Nomegestrol / estradiol
Ioa, Zoely
2011
Yes
Mixed
Colistimethate sodium
Colobreathe
2012
Yes
Mixed
Mercaptopurine
Xaluprine
2012
No
Mixed
Catridecacog
NovoThirteen
2012
Yes
Mixed
Efavirenz
Efavirenz Teva
2012
No
Mixed
Ivacaftor
Kalydeco
2012
Yes
Mixed
Desloratadine
Desloratadine ratiopharm
2012
No
Mixed
Desloratadine
Desloratadine Actavis
2012
No
Mixed
Perampanel
Fycompa
2012
Yes
Mixed
31
Table 14:
List of centrally authorised medicinal products for which the therapeutic indication was extended to or amended for the paediatric population
Active substance(s)
Levetiracetam
Trade
name
Keppra
Prevenar
Infliximab
Remicade
Darbepoetin alfa
Fosamprenavir
Aranesp
Telzir
Date
2007/
2009
Extension of the indication to include adjunctive therapy in the treatment of primary generalised tonicclonic (PGTC) seizures in adults and adolescents from
12 years of age with idiopathic generalised epilepsy;
Extension of indication to include the adjunctive
treatment of partial seizures with or without secondary generalisation in children from 1 month to <4
years old
2007
Extension of the indication to include new information on efficacy against disease caused by Streptococcus pneumoniae serotypes 4, 6B, 9V, 14, 18C, 19F
and 23F in otitis media;
Extension of indication from active immunisation
against bacteraemic pneumonia to active immunisation against pneumonia
2007
2007
2007
Lamivudine / zidovudine
Combivir
2007
Desloratadine
Aerius
2007
Insulin glulisine
Apidra
2007
Gardasil
2008
Adalimumab
Humira
2008/2011
Caspofungin
Cancidas
2008
32
Active substance(s)
Etanercept
Miglustat
Tacrolimus
Tipranavir
Trade
name
Enbrel
Zavesca
Protopic
Aptivus
Date
2008/2011
2009
2009
2009
Omalizumab
Xolair
2009
Aripiprazole
Abilify
2009
Peginterferon alfa-2b
PegIntron
2009
2009
2010
Ribavirin
Abatacept
Rebetol
Orencia
Atazanavir sulphate
Reyataz
2010
M-MRVAXPRO
2010
2011
Nitric oxide
Inomax
Tenofovir disoproxil
fumarate
Viread
2011
Paliperidone
Invega
2011
2011
2011
Extension of indication to include treatment of multifocal motor neuropathy and hypogammaglobulinaemia in patients after allogeneic haematopoietic stem
cell transplantation in adults and children
Sildenafil
Revatio
Kiovig
33
Active substance(s)
Trade
name
Date
Tocilizumab
Roactemra
2011
Extension of indication to include treatment of active systemic juvenile idiopathic arthritis in patients
2 years of age and older, who have responded
inadequately to previous therapy with NSAIDs and
systemic corticosteroids
Synflorix
2011
2011
Insulin detemir
Levemir
Eculizumab
Soliris
2011
Human papillomavirus
vaccine [types 16, 18]
(recombinant, adjuvanted, adsorbed)
Cervarix
2011
2012
2012
Extension of the age range in the indication to children from 9 months of age onwards under special
circumstances, i.e. outbreak control
Etanercept
Measles, mumps,
rubella and varicella
vaccine (live)
Enbrel
Proquad
For a more detailed inventory, including information on nationally authorised products and new routes of
administration or new pharmaceutical forms, please refer to Annex II of the 5year Report to the European
Commission of the EMA.
34
ANNEX III
Table 15:
Funded off-patent medicines projects (beginning up to 1 January 2012) and agreed PIPs, if available.
No.
Acronym
KIEKIDS
NEO-CIRC
TAIN
GRIP
Year
start
Objectives
Agreed
PIP
2011
NA
2011
EMEA-001262PIP01-12
2011
EMEA-001283PIP01-12
2011
NA
EMEA-001126PIP01-10
DEEP
2011
TINN2
2011
EMEA-001298PIP01-12
2010
NA / EMEA-001105PIP01-10
2010
EMEA-001034PIP01-10
2010
European multicentre network to evaluate pharmacokinetics, safety and efficacy of meropenem in neonatal sepsis
and meningitis
EMEA-000898PIP01-10
HIP Trial
PERS
NeoMero
35
No.
10
Acronym
NEMO
Year
start
Objectives
Agreed
PIP
2009
NA
EMEA-001120PIP01-10
11
NEUROSIS
2009
12
EPOC
2009
NA
13
LOULLA &
PHILLA
2008
NA / NA
EMEA-000712PIP01-09
14
NeoOpioid
2008
15
O3K
2008
EMEA-000530PIP02-11 / NA
16
TINN
2008
NA
Table 16:
No.
Acronym
Year
start
Objectives
Agreed PIP
MAGICBULLET
2012
NA
2011
Assessment of clinical efficacy by a pharmacokinetic / pharmacodynamic approach to optimise effectiveness and reduce
resistance for off-patent antibiotics.
NA
AIDA
NA = not available