1. The Best Pharmaceuticals for Children Act Anne Zajicek, M.D., Pharm.D. Pediatric Medical Officer National Institute of Child Health and Human Development National Institutes of Health

2. Best Pharmaceuticals for Children Act Enacted January 2002, exclusivity provision will sunset October 2007 Continues exclusivity provision of FDAMA Purpose: pediatric labeling

3. Pediatric Labeling Pre-approval: Pediatric Research Equity Act On-patent: Best Pharmaceuticals for Children Act which continues the exclusivity provisions of FDAMA Studies supported by the Foundation for the NIH Off-patent: Best Pharmaceuticals for Children Act

4. Best Pharmaceuticals for Children Act In pediatric oncology prioritize new drugs for study assure timely access to new treatments develop pre-clinical models of pediatric cancers

5. Master List of all Off-Patent Drugs which lack adequate pediatric labeling N=200 Consultation with experts in pediatric practice and research Develop, prioritize, publish an Annual List N=5-15 Consider for prioritizing:  Availability of S/E data  Are additional data needed?  Will new studies produce health benefits?  Reformulation?

6. Priority List Developed by NIH In consultation with Institutes and Centers of the National Institutes of Health Federal Agencies  Food and Drug Administration  Centers for Disease Control and Prevention Pediatric subspecialists and subspecialty groups Advocacy groups

7. Drugs on the Priority List: January 2003 FR 68: 13; Jan 21, 2003 Azithromycin Baclofen* Bumetanide Dobutamine Dopamine Furosemide Heparin Lithium Lorazepam Rifampin Sodium nitroprusside Spironolactone

8. Drugs on the Priority List: August 2003 FR 68: 156; Aug 13, 2003 Ampicillin/sulbactam Diazoxide Isoflurane Lindane Meropenem Metoclopramide* Piperacillin/ tazobactam Promethazine

9. Drugs on the Priority List: February 2004 FR 69:30; February 13, 2004 Ampicillin Ketamine Vincristine Actinomycin-D Metolazone

10. Drugs on the Priority List: January 2005 FR 70:17; January 27, 2005 Ivermectin Hydrocortisone valerate Hydrochlorothiazide Ethambutol Griseofulvin Methadone Hydroxychloroquine Sevelamer* Morphine*

11. Drugs on the Priority List: April 2006 FR 70:79; April 25, 2006 ADHD: methylphenidate Hypertension: diuretics Parasitic Diseases: albendazole, mebendazole Influenza: amantidine, rimantidine Cancer: methotrexate, daunomycin Poisonings: pralidoxime Sickle Cell Anemia: hydroxyurea

12. Drugs on the Priority List: March 2007 FR 72: 14588; March 28, 2007 Infectious Diseases: Methicillin-resistant Staph aureus infection Clindamycin, tetracyclines, trimethoprim- sulfamethoxazole Hypertension: clinical trial designs Neonatal Research: clinical trial designs Cancer: Neuroblastoma 13-cis retinoic acid Asthma: clinical trial designs in young children

13. FDA Issues a Written Request: On-Patent From Priority List FDA issues Written Request (WR) WR sent to Holder of NDA Accept Decline Referred to FNIH for funding

14. FDA Issues a Written Request: Off-Patent From Priority List FDA issues Written Request (WR) WR sent to Holders of NDA/ aNDA Accept Decline Referred to NIH for contract

15. Contracting Process WR referred to NIH RFC* RFP* FedBizOpps Proposals peer-reviewed Contract(s) awarded *RFC=request for contract *RFP=request for proposal

16. Results So Far…

17. Studies On-Going under BPCA Lorazepam: Clinical studies for treatment of status epilepticus Study 1: PK Study 2: Efficacy, safety study comparing lorazepam to diazepam Lorazepam: Clinical studies of sedation of children on ventilators in an intensive care unit Nitroprusside: Clinical studies to reduce blood pressure during surgery to reduce blood loss Lithium: Clinical studies to define treatment of mania in children with bipolar disorder Baclofen: Clinical studies of oral baclofen to treat spasticity, most commonly from cerebral palsy

18. Studies On-Going Ketamine - Preclinical studies to evaluate the scientific and safety concerns about the use as an anesthetic in children Hydroxyurea- Clinical studies to improve treatment of children with sickle cell disease (NHLBI) Methylphenidate – Preclinical and clinical evaluation of pharmacokinetics and safety to understand reports of cytogenetic toxicity (NIEHS) Morphine – preclinical basic science evaluations of the developmental expression of opioid receptors to better understand management of pain in children of different developmental stages and safety issues in treating pain in neonates

19. Studies On-Going under BPCA Vincristine: Studies to evaluate neurotoxicity, PK in children (NCI-COG) Actinomycin-D: Studies to evaluate hepatotoxicity/ VOD, PK in children (NCI-COG) Methotrexate: Clinical studies to evaluate neurocognitive outcomes of pediatric patients with high risk acute lymphoblastic leukemia (NCI-COG) Daunomycin: Pharmacokinetics, safety, efficacy of daunomycin to treat childhood cancers and relationship to body weight (NCI-COG)

20. Vincristine and Actinomycin-D Retrospective chart review of Demographics Treatment history Toxicity  Neurotoxicity  Veno-occlusive disease Line-clearing method Pharmacokinetic modeling Prospective PK study

21. Summary Partnership with FDA NIH responsible for prioritizing list of drugs for study sponsoring clinical studies in children that will improve pediatric therapeutics