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Ithnin M, Mohd Rani MD, Abd Latif Z, Kani P, Syaiful A, Nor Aripin KN, Tengku Mohd TAM. Mobile App Design, Development, and Publication for Adverse Drug Reaction Assessments of Causality, Severity, and Preventability. JMIR Mhealth Uhealth 2017; 5:e78. [PMID: 28559222 PMCID: PMC5470006 DOI: 10.2196/mhealth.6261] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 01/27/2017] [Accepted: 03/15/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Adverse drug reactions (ADRs) cause significant morbidity and mortality. Improved assessment of ADRs to identify the causal relationship, the severity, and the preventability will aid ADRs prevention or reduce patient burden. OBJECTIVE The aim of this study was to develop mobile apps in assisting clinical decision in ADR assessments of causality, severity, and preventability using validated tools. The usability of the apps was assessed. METHODS We designed mobile apps using validated assessment tools for ADRs. They are the Liverpool ADRs Causality Assessment Tool, Hartwig's Severity Assessment Scale, and the Modified Schumock and Thronton Preventability Scale. The apps were named "Adverse Drug ReactionCausality," "Adverse Drug ReactionSeverity," and "Adverse Drug RxnPreventability." A survey was conducted using the System Usability Scale (SUS) to assess the usability of the developed apps among health care professionals. RESULTS These apps are available for download through Google Play Store for free since January 2015. From the survey, the mean SUS score was 70.9 based on 26 responses from the pediatric ward of Hospital Ampang, Malaysia. CONCLUSIONS The developed apps received an overall acceptable usability among health care professionals. The usage of these apps will improve detection, assessment, and avoidance of future ADRs. They will also contribute to future research on ADRs, thus increasing drug safety.
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Lindahl JR, Fisher NE, Cooper DJ, Rosen RK, Britton WB. The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in Western Buddhists. PLoS One 2017; 12:e0176239. [PMID: 28542181 PMCID: PMC5443484 DOI: 10.1371/journal.pone.0176239] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 04/02/2017] [Indexed: 11/18/2022] Open
Abstract
Buddhist-derived meditation practices are currently being employed as a popular form of health promotion. While meditation programs draw inspiration from Buddhist textual sources for the benefits of meditation, these sources also acknowledge a wide range of other effects beyond health-related outcomes. The Varieties of Contemplative Experience study investigates meditation-related experiences that are typically underreported, particularly experiences that are described as challenging, difficult, distressing, functionally impairing, and/or requiring additional support. A mixed-methods approach featured qualitative interviews with Western Buddhist meditation practitioners and experts in Theravāda, Zen, and Tibetan traditions. Interview questions probed meditation experiences and influencing factors, including interpretations and management strategies. A follow-up survey provided quantitative assessments of causality, impairment and other demographic and practice-related variables. The content-driven thematic analysis of interviews yielded a taxonomy of 59 meditation-related experiences across 7 domains: cognitive, perceptual, affective, somatic, conative, sense of self, and social. Even in cases where the phenomenology was similar across participants, interpretations of and responses to the experiences differed considerably. The associated valence ranged from very positive to very negative, and the associated level of distress and functional impairment ranged from minimal and transient to severe and enduring. In order to determine what factors may influence the valence, impact, and response to any given experience, the study also identified 26 categories of influencing factors across 4 domains: practitioner-level factors, practice-level factors, relationships, and health behaviors. By identifying a broader range of experiences associated with meditation, along with the factors that contribute to the presence and management of experiences reported as challenging, difficult, distressing or functionally impairing, this study aims to increase our understanding of the effects of contemplative practices and to provide resources for mediators, clinicians, meditation researchers, and meditation teachers.
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Affiliation(s)
- Jared R. Lindahl
- Cogut Center for the Humanities, Brown University, Providence, Rhode Island, United States of America
| | - Nathan E. Fisher
- Department of Religious Studies, University of California, Santa Barbara, California, United States of America
| | - David J. Cooper
- Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, Rhode Island, United States of America
| | - Rochelle K. Rosen
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, United States of America
| | - Willoughby B. Britton
- Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, Rhode Island, United States of America
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, United States of America
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Catatonia Secondary to Sudden Clozapine Withdrawal: A Case with Three Repeated Episodes and a Literature Review. Case Rep Psychiatry 2017; 2017:2402731. [PMID: 28396815 PMCID: PMC5370482 DOI: 10.1155/2017/2402731] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 02/26/2017] [Indexed: 02/06/2023] Open
Abstract
A literature search identified 9 previously published cases that were considered as possible cases of catatonia secondary to sudden clozapine withdrawal. Two of these 9 cases did not provide enough information to make a diagnosis of catatonia according to the Diagnostic and Statistical Manual, 5th Edition (DSM-5). The Liverpool Adverse Drug Reaction (ADR) Causality Scale was modified to assess ADRs secondary to drug withdrawal. From the 7 published cases which met DSM-5 catatonia criteria, using the modified scale, we established that 3 were definitive and 4 were probable cases of catatonia secondary to clozapine withdrawal. A new definitive case is described with three catatonic episodes which (1) occurred after sudden discontinuation of clozapine in the context of decades of follow-up, (2) had ≥3 of 12 DSM-5 catatonic symptoms and serum creatinine kinase elevation, and (3) required medical hospitalization and intravenous fluids. Clozapine may be a gamma-aminobutyric acid (GABA) receptor agonist; sudden clozapine withdrawal may explain a sudden decrease in GABA activity that may contribute to the development of catatonic symptoms in vulnerable patients. Based on the limited information from these cases, the pharmacological treatment for catatonia secondary to sudden clozapine withdrawal can include benzodiazepines and/or restarting clozapine.
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Mouton JP, Mehta U, Rossiter DP, Maartens G, Cohen K. Interrater agreement of two adverse drug reaction causality assessment methods: A randomised comparison of the Liverpool Adverse Drug Reaction Causality Assessment Tool and the World Health Organization-Uppsala Monitoring Centre system. PLoS One 2017; 12:e0172830. [PMID: 28235001 PMCID: PMC5325562 DOI: 10.1371/journal.pone.0172830] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 02/10/2017] [Indexed: 12/03/2022] Open
Abstract
Introduction A new method to assess causality of suspected adverse drug reactions, the Liverpool Adverse Drug Reaction Causality Assessment Tool (LCAT), showed high interrater agreement when used by its developers. Our aim was to compare the interrater agreement achieved by LCAT to that achieved by another causality assessment method, the World Health Organization-Uppsala Monitoring Centre system for standardised case causality assessment (WHO-UMC system), in our setting. Methods Four raters independently assessed adverse drug reaction causality of 48 drug-event pairs, identified during a hospital-based survey. A randomised design ensured that no washout period was required between assessments with the two methods. We compared the methods’ interrater agreement by calculating agreement proportions, kappa statistics, and the intraclass correlation coefficient. We identified potentially problematic questions in the LCAT by comparing raters’ responses to individual questions. Results Overall unweighted kappa was 0.61 (95% CI 0.43 to 0.80) on the WHO-UMC system and 0.27 (95% CI 0.074 to 0.46) on the LCAT. Pairwise unweighted Cohen kappa ranged from 0.33 to 1.0 on the WHO-UMC system and from 0.094 to 0.71 on the LCAT. The intraclass correlation coefficient was 0.86 (95% CI 0.74 to 0.92) on the WHO-UMC system and 0.61 (95% CI 0.39 to 0.77) on the LCAT. Two LCAT questions were identified as significant points of disagreement. Discussion We were unable to replicate the high interrater agreement achieved by the LCAT developers and instead found its interrater agreement to be lower than that achieved when using the WHO-UMC system. We identified potential reasons for this and recommend priority areas for improving the LCAT.
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Affiliation(s)
- Johannes P. Mouton
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ushma Mehta
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Dawn P. Rossiter
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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van der Wouden CH, Cambon-Thomsen A, Cecchin E, Cheung KC, Dávila-Fajardo CL, Deneer VH, Dolžan V, Ingelman-Sundberg M, Jönsson S, Karlsson MO, Kriek M, Mitropoulou C, Patrinos GP, Pirmohamed M, Samwald M, Schaeffeler E, Schwab M, Steinberger D, Stingl J, Sunder-Plassmann G, Toffoli G, Turner RM, van Rhenen MH, Swen JJ, Guchelaar HJ. Implementing Pharmacogenomics in Europe: Design and Implementation Strategy of the Ubiquitous Pharmacogenomics Consortium. Clin Pharmacol Ther 2017; 101:341-358. [DOI: 10.1002/cpt.602] [Citation(s) in RCA: 186] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/12/2016] [Accepted: 12/13/2016] [Indexed: 12/14/2022]
Affiliation(s)
- CH van der Wouden
- Department of Clinical Pharmacy and Toxicology; Leiden University Medical Center; Leiden The Netherlands
| | - A Cambon-Thomsen
- UMR Inserm U1027 and Université de Toulouse III Paul Sabatier; Toulouse France
| | - E Cecchin
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico; National Cancer Institute; Aviano Italy
| | - KC Cheung
- Royal Dutch Pharmacists Association (KNMP); The Hague The Netherlands
| | - CL Dávila-Fajardo
- Department of Clinical Pharmacy, Granada University Hospital; Institute for Biomedical Research; Granada Spain
| | - VH Deneer
- Department of Clinical Pharmacy; St Antonius Hospital; Nieuwegein The Netherlands
| | - V Dolžan
- Pharmacogenetics Laboratory, Institute of Biochemistry, Faculty of Medicine; University of Ljubljana; Slovenia
| | - M Ingelman-Sundberg
- Department of Physiology and Pharmacology, Section of Pharmacogenetics; Karolinska Institutet; Stockholm Sweden
| | - S Jönsson
- Department of Pharmaceutical Biosciences; Uppsala University; Uppsala Sweden
| | - MO Karlsson
- Department of Pharmaceutical Biosciences; Uppsala University; Uppsala Sweden
| | - M Kriek
- Center for Clinical Genetics; Leiden University Medical Center; Leiden The Netherlands
| | | | - GP Patrinos
- University of Patras, School of Health Sciences, Department of Pharmacy; University Campus; Rion Patras Greece
| | - M Pirmohamed
- Department of Molecular and Clinical Pharmacology; Royal Liverpool University Hospital and University of Liverpool; Liverpool United Kingdom
| | - M Samwald
- Center for Medical Statistics, Informatics, and Intelligent Systems; Medical University of Vienna; Vienna Austria
| | - E Schaeffeler
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart; Germany and University of Tübingen; Tübingen Germany
| | - M Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart; Germany and University of Tübingen; Tübingen Germany
- Department of Clinical Pharmacology; University Hospital Tübingen; Tübingen Germany
- Department of Pharmacy and Biochemistry; University of Tübingen; Tübingen Germany
| | - D Steinberger
- Bio.logis Center for Human Genetics; Frankfurt am Main Germany
| | - J Stingl
- Research Division; Federal Institute for Drugs and Medical Devices; Bonn Germany
| | - G Sunder-Plassmann
- Division of Nephrology and Dialysis, Department of Internal Medicine III; Medical University of Vienna; Vienna Austria
| | - G Toffoli
- Experimental and Clinical Pharmacology, Centro di Riferimento Oncologico; National Cancer Institute; Aviano Italy
| | - RM Turner
- Department of Molecular and Clinical Pharmacology; Royal Liverpool University Hospital and University of Liverpool; Liverpool United Kingdom
| | - MH van Rhenen
- Royal Dutch Pharmacists Association (KNMP); The Hague The Netherlands
| | - JJ Swen
- Department of Clinical Pharmacy and Toxicology; Leiden University Medical Center; Leiden The Netherlands
| | - H-J Guchelaar
- Department of Clinical Pharmacy and Toxicology; Leiden University Medical Center; Leiden The Netherlands
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106
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Bracken LE, Nunn AJ, Kirkham JJ, Peak M, Arnott J, Smyth RL, Pirmohamed M, Turner MA. Development of the Liverpool Adverse Drug Reaction Avoidability Assessment Tool. PLoS One 2017; 12:e0169393. [PMID: 28046035 PMCID: PMC5207751 DOI: 10.1371/journal.pone.0169393] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 12/13/2016] [Indexed: 11/27/2022] Open
Abstract
Aim To develop and test a new tool to assess the avoidability of adverse drug reactions that is suitable for use in paediatrics but which is also applicable to a variety of other settings. Methods The study involved multiple phases. Preliminary work involved using the Hallas scale and a modification of the existing Hallas scale, to assess two different sets of adverse drug reaction (ADR) case reports. Phase 1 defined, modified and refined a new tool using multidisciplinary teams. Phase 2 involved the assessment of 50 ADR case reports from a prospective study of paediatric inpatients by individual assessors. Phase 3 compared assessments with the new tool for individuals and groups in comparison to the ‘gold standard’ (the avoidability outcome set by a panel of senior investigators: an experienced clinical pharmacologist, paediatrician and pharmacist). Main Outcome Measures Inter-rater reliability (IRR), measure of disagreement and utilization of avoidability categories. Results Preliminary work—Pilot phase: results for the original Hallas cases were fair and pairwise kappa scores ranged from 0.21 to 0.36. Results for the modified Hallas cases were poor, pairwise kappa scores ranged from 0.06 to 0.16. Phase 1: on initial use of the new tool, agreement between the two multidisciplinary groups was found on 13/20 cases with a kappa score of 0.29 (95% CI -0.04 to 0.62). Phase 2: the assessment of 50 ADR case reports by six individual reviewers yielded pairwise kappa scores ranging from poor to good 0.12 to 0.75 and percentage exact agreement (%EA) ranged from 52–90%. Phase 3: Percentage exact agreement ranged from 35–70%. Overall, individuals had better agreement with the ‘gold standard’. Conclusion Avoidability assessment is feasible but needs careful attention to methods. The Liverpool ADR avoidability assessment tool showed mixed IRR. We have developed and validated a method for assessing the avoidability of ADRs that is transparent, more objective than previous methods and that can be used by individuals or groups.
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Affiliation(s)
- Louise E. Bracken
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- * E-mail:
| | - Anthony J. Nunn
- Department of Women’s & Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jamie J. Kirkham
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Matthew Peak
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- School of Health, University of Central Lancashire, Preston, United Kingdom
| | - Janine Arnott
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- School of Health, University of Central Lancashire, Preston, Lancashire, United Kingdom
| | - Rosalind L. Smyth
- Institute of Child Health, University College London, London, United Kingdom
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Mark A. Turner
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- Department of Women’s & Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
- Liverpool Women’s NHS Foundation Trust, Liverpool, United Kingdom
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107
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Lonergan M, Senn SJ, McNamee C, Daly AK, Sutton R, Hattersley A, Pearson E, Pirmohamed M. Defining drug response for stratified medicine. Drug Discov Today 2017; 22:173-179. [DOI: 10.1016/j.drudis.2016.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 09/10/2016] [Accepted: 10/27/2016] [Indexed: 12/21/2022]
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108
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Gupta SK, Kumar KD. An assessment of reported adverse drug reactions in a Tertiary Care Hospital in South India: A retrospective cross-sectional study. Int J Pharm Investig 2017; 7:193-197. [PMID: 29692979 PMCID: PMC5903024 DOI: 10.4103/jphi.jphi_81_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective: The primary objective of this study was to assess the causality of ADRs using World Health Organization-Uppsala Monitoring Centre (WHO–UMC), Naranjo and Liverpool ADR Causality Assessment Tool (LCAT). Other primary objective was to assess the agreement between the WHO-UMC criterion, Naranjo algorithm and LCAT. The secondary objective was to assess the reported adverse drug reactions in a tertiary care hospital in South India. Materials and Methods: This was a cross-sectional retrospective study. All the ADRs which were reported by the Pharmacovigilance Unit between July 2016 and March 2017 were assessed. Causality assessment was performed by two well-trained independent pharmacologists by applying the three methods–WHO, Naranjo and LCAT. Concurrence between the two algorithms was compared using the Cohen's weighted kappa statistic. Results: Causality assessment of adverse reactions according to Naranjo criteria shows that 81% cases were of probable type, 9.5% cases were possible and 9.5% cases were unlikely. Causality assessment of adverse reactions according to WHO-UMC criteria shows that 85.7% cases were of probable type, 4.8% cases were possible, 4.8% cases were unlikely and 4.8% cases were definite. Causality assessment of adverse reactions according to Liverpool criteria shows that 61.9% cases were of probable type, 4.8% cases were possible and 33.3% cases were definite. Cohen's kappa test shows that negative and poor concurrence was seen between WHO and Naranjo causality comparison (κ = −0.161). Positive but poor concurrence based on kappa values was seen between Liverpool and Naranjo's causality comparison (κ = 0.133). Negative and poor concurrence based on kappa values was seen between WHO and Liverpool causality comparison (κ = −0.161). Conclusion: The most frequent causality category observed by the WHO-UMC criteria, Naranjo as well as the Liverpool algorithm was “Probable.” Full concurrence was not found between any of two scales of causality assessment.
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Affiliation(s)
- Sandeep Kumar Gupta
- Department of Pharmacology, Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - K Deva Kumar
- Department of Pharmacology, Dhanalakshmi Srinivasan Medical College and Hospital, Perambalur, Tamil Nadu, India
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109
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Rieder M, Hawcutt D. Design and conduct of early phase drug studies in children: challenges and opportunities. Br J Clin Pharmacol 2016; 82:1308-1314. [PMID: 27353241 PMCID: PMC5061783 DOI: 10.1111/bcp.13058] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/03/2016] [Accepted: 06/12/2016] [Indexed: 12/14/2022] Open
Abstract
It has historically been very difficult to conduct early phase drug studies in children for a number of reasons related to ethics, acceptability, rarity, standardization, end points, safety, dosing and feasibility. Over the past decade there have been a number of developments including novel clinical trial design, in silico pharmacology and microdosing that have significantly enhanced the ability of investigators to conduct early phase drug studies in children. While the evolution of drug therapy is creating a series of new challenges, there has never been a better time for conducting drug studies in children.
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Affiliation(s)
- Michael Rieder
- Department of Paediatrics, Robarts Research Institute, University of Western Ontario, Canada.
- Department of Paediatrics, Western University, London, Ontario, Canada.
| | - Daniel Hawcutt
- NIHR Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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Chan SL, Ang X, Sani LL, Ng HY, Winther MD, Liu JJ, Brunham LR, Chan A. Prevalence and characteristics of adverse drug reactions at admission to hospital: a prospective observational study. Br J Clin Pharmacol 2016; 82:1636-1646. [PMID: 27640819 PMCID: PMC5099543 DOI: 10.1111/bcp.13081] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 07/20/2016] [Accepted: 08/01/2016] [Indexed: 01/11/2023] Open
Abstract
Aims Adverse drug reactions (ADRs) contribute to poorer patient outcomes and additional burden to the healthcare system. However, data on the true burden, relevant types and drugs causing ADRs are lacking. The aim of this study was to determine the prevalence of ADR‐related hospitalization in the general adult population in Singapore and to investigate their characteristics. Methods We prospectively recruited 1000 adult patients with unplanned admission to a large tertiary‐care hospital. Two independent reviewers evaluated all suspected ADRs for causality, type, severity and avoidability. The prevalence of ADR‐related hospitalization was calculated based on ‘definite’ and ‘probable’ ADRs. Logistic regression was used to evaluate predictors for having an ADR at admission. Results The prevalence of all ADRs at admission was 12.4% (95% CI: 10.5–14.6%) and ADRs causing admission was 8.1% (95% CI: 6.5–10.0%). The most common ADRs were gastrointestinal‐related. The most common drug category causing ADRs were cardiovascular drugs. Patients with ADRs had a longer length of stay than those who did not (median 4 vs. 3 days, P = 1.70 × 10−3). About 30% of ADRs at admission were caused by at least one drug with a clinical annotation in the Pharmacogenomics KnowledgeBase (PharmGKB), suggesting that some of these ADRs may have been predicted by pharmacogenetic testing. Conclusions We have quantified the burden and characteristics of clinically impactful ADRs in the Singaporean general adult population. Our results will provide vital information for efforts in reducing ADRs through targeted vigilance, patient education and pharmacogenomics in Singapore.
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Affiliation(s)
- Sze Ling Chan
- Translational Laboratory in Genetic Medicine, Agency for Science, Technology and Research, Singapore and the National University of Singapore
| | - Xiaohui Ang
- Genome Institute of Singapore, Agency for Science, Technology and Research, Singapore
| | - Levana L Sani
- Genome Institute of Singapore, Agency for Science, Technology and Research, Singapore
| | - Hong Yen Ng
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Michael D Winther
- Genome Institute of Singapore, Agency for Science, Technology and Research, Singapore
| | - Jian Jun Liu
- Genome Institute of Singapore, Agency for Science, Technology and Research, Singapore
| | - Liam R Brunham
- Translational Laboratory in Genetic Medicine, Agency for Science, Technology and Research, Singapore and the National University of Singapore.,Centre for Molecular Medicine and Therapeutics, Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Alexandre Chan
- Department of Pharmacy, National University of Singapore, Singapore.,Oncology Pharmacy, National Cancer Centre Singapore, Singapore
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111
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Awdishu L, Nievergelt CM, Davenport A, Murray PT, Macedo E, Cerda J, Chakaravarthi R, Ramachandra Rao SP, Holden A, Goldstein SL, Mehta RL. Rationale and Design of the Genetic Contribution to Drug Induced Renal Injury (DIRECT) Study. Kidney Int Rep 2016; 1:288-298. [PMID: 29142931 PMCID: PMC5678673 DOI: 10.1016/j.ekir.2016.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/10/2016] [Accepted: 08/14/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction Nephrotoxicity from drugs accounts for 18% to 27% of cases of acute kidney injury. Determining a genetic predisposition may potentially be important in minimizing risk. The aims of this study are as follows: to determine whether a genetic predisposition exists for the development of drug-induced kidney disease (DIKD), using genome-wide association and whole-genome sequencing studies; to describe the frequency, course, risk factors, resolution and outcomes of DIKD cases; to investigate the role of ethnic/racial variability in the genetics of DIKD; and to explore the use of different tools establishing causality of DIKD. Methods A total of 800 patients will be enrolled worldwide and blood samples for DNA collected. Data on the patient risk factors, vital signs, laboratory parameters, drug exposure, and DIKD course will be recorded. A panel of nephrologists will adjudicate all cases. Genome-wide association studies will be conducted using population controls matched on biogeographic ancestry to determine whether there is a genetic predisposition to DIKD. The primary endpoint is the identification of specific drug-related polymorphisms associated with DIKD. Secondary endpoints include the following: frequency of DIKD by causal drug and drug combinations; DIKD genetic variability; exploration of causality assessment tools; risk factor identification; description of the course of DIKD, including mortality and dialysis dependency at hospital discharge and 28 and 90 days post-event. Results Data are currently being analyzed. Results are pending. Discussion The Genetic Contribution to Drug Induced Renal Injury (DIRECT) study will be the first observational cohort study to investigate the genetic determinants of DIKD. If the trial is positive, its findings will potentially translate into safer patient outcomes, by genotypic individualization of therapy and minimization of harm.
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Affiliation(s)
- Linda Awdishu
- Department of Clinical Pharmacy, University of California, La Jolla, California, USA
- Department of Medicine, University of California, La Jolla, California, USA
- Correspondence: Linda Awdishu, 9500 Gilman Drive, La Jolla, California 92093, USA.9500 Gilman DriveLa JollaCalifornia 92093USA
| | | | | | | | | | - Jorge Cerda
- Albany Medical College, Albany, New York, USA
| | | | - Satish P. Ramachandra Rao
- Department of Medicine, University of California, La Jolla, California, USA
- Sri Devaraj Urs Academy of Higher Education and Research, India
| | | | - Stuart L. Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ravindra L Mehta
- Department of Medicine, University of California, La Jolla, California, USA
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112
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Two Sudden and Unexpected Deaths of Patients with Schizophrenia Associated with Intramuscular Injections of Antipsychotics and Practice Guidelines to Limit the Use of High Doses of Intramuscular Antipsychotics. Case Rep Psychiatry 2016; 2016:9406813. [PMID: 27597919 PMCID: PMC5002457 DOI: 10.1155/2016/9406813] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/03/2016] [Indexed: 12/12/2022] Open
Abstract
Intravenous haloperidol has been associated with torsades de pointes (TdP). These two sudden deaths were probable adverse drug reactions (ADRs) following intramuscular (IM) antipsychotics. The autopsies described lack of heart pathology and were highly compatible with the possibility of TdP in the absence of risk factors other than the accumulation of antipsychotics with a high serum peak after the last injection, leading to death within hours. The first case was a 27-year-old African-American male with schizophrenia but no medical issues. His death was probably caused by repeated IM haloperidol injections of 10 mg (totaling 35 mg in 2 days). The second case involves a 42-year-old African-American female with metabolic syndrome. Her probable cause of death was the last ziprasidone IM injection of 20 mg in addition to (1) three extra haloperidol doses (2 hours before the ziprasidone injection, 5 mg oral haloperidol; approximately 21 hours earlier, 5 mg oral haloperidol; and 2 days prior, one 10 mg IM haloperidol injection), (2) 10 mg/day of scheduled oral haloperidol for 6 days before death, and (3) a long-acting paliperidone injection of 156 mg 18 days before death. The study of haloperidol glucuronidation and its impairment in some African-Americans is urgently recommended.
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Prolonged drug-induced myoclonus: is it related to palonosetron? J Anesth 2016; 30:1063-1066. [PMID: 27510560 DOI: 10.1007/s00540-016-2228-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
Abstract
We report a case of drug-induced myoclonus possibly related to palonosetron, a second-generation 5-hydroxytryptamine-3 receptor antagonist which was administered as a prophylaxis for postoperative nausea and vomiting in a 28-year-old female. The recurrent episodes of myoclonus jerk involving the head, neck and shoulder persisted for a period of 4 days. The patient also exhibited an episode of severe bradycardia leading to hypotension 7 h after surgery. To our knowledge, this is the first report presenting these adverse events potentially associated with the use of palonosetron.
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Nakatani M, Tsukino M, Takahashi R, Ikeda A. [Periodic synchronous discharge occurred in an elderly with acute valacyclovir-associated encephalopathy]. Rinsho Shinkeigaku 2016; 56:504-507. [PMID: 27356736 DOI: 10.5692/clinicalneurol.cn-000892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
An 81-year-old woman suffering from sarcoidosis, chronic renal failure caused by hypertention was treated by valacyclovir 500 mg/day, for the diagnosis of herpes zoster of her right back. Her consciousness gradually became worse, and 3 days after taking the drug, she was sent to the emergency department of the hospital. Her conscious level was E2V2M5 (Glasgow Coma Scale) and myoclonus especially in her lower extremities occurred. Head CT and MRI show no obvious, acute abnormal findings other than chronic ischemic lesions, while an electroencephalogram (EEG) shows periodic synchronous discharges (PSDs) and disorganized background activity. Based on these findings, she was diagnosed as valacyclovir-associated acute encephalopathy. After conservative therapy of maintenance hemodialysis, her consciousness gradually improved, and PSDs disappeared accordingly and background activity of EEG became improved. In this case report, we presented valacyclovir-associated neurotoxicity with PSDs in EEG as potentially a surrogate marker. We should be cautious to use valaciclovir which may cause drug-induced encephalopathy especially in elderly or patients with renal failure even though the dose was adjusted in advance.
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Thaker SJ, Sinha RS, Gogtay NJ, Thatte UM. Evaluation of inter-rater agreement between three causality assessment methods used in pharmacovigilance. J Pharmacol Pharmacother 2016; 7:31-3. [PMID: 27127394 PMCID: PMC4831488 DOI: 10.4103/0976-500x.179361] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Saket J Thaker
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Rahul S Sinha
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nithya J Gogtay
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Urmila M Thatte
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Heap GA, So K, Weedon M, Edney N, Bewshea C, Singh A, Annese V, Beckly J, Buurman D, Chaudhary R, Cole AT, Cooper SC, Creed T, Cummings F, de Boer NK, D'Inca R, D'Souza R, Daneshmend TK, Delaney M, Dhar A, Direkze N, Dunckley P, Gaya DR, Gearry R, Gore S, Halfvarson J, Hart A, Hawkey CJ, Hoentjen F, Iqbal T, Irving P, Lal S, Lawrance I, Lees CW, Lockett M, Mann S, Mansfield J, Mowat C, Mulgrew CJ, Muller F, Murray C, Oram R, Orchard T, Parkes M, Phillips R, Pollok R, Radford-Smith G, Sebastian S, Sen S, Shirazi T, Silverberg M, Solomon L, Sturniolo GC, Thomas M, Tremelling M, Tsianos EV, Watts D, Weaver S, Weersma RK, Wesley E, Holden A, Ahmad T. Clinical Features and HLA Association of 5-Aminosalicylate (5-ASA)-induced Nephrotoxicity in Inflammatory Bowel Disease. J Crohns Colitis 2016; 10:149-58. [PMID: 26619893 DOI: 10.1093/ecco-jcc/jjv219] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 10/08/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Nephrotoxicity is a rare idiosyncratic reaction to 5-aminosalicylate (5-ASA) therapies. The aims of this study were to describe the clinical features of this complication and identify clinically useful genetic markers so that these drugs can be avoided or so that monitoring can be intensified in high-risk patients. METHODS Inflammatory bowel disease patients were recruited from 89 sites around the world. Inclusion criteria included normal renal function prior to commencing 5-ASA, ≥50% rise in creatinine any time after starting 5-ASA, and physician opinion implicating 5-ASA strong enough to justify drug withdrawal. An adjudication panel identified definite and probable cases from structured case report forms. A genome-wide association study was then undertaken with these cases and 4109 disease controls. RESULTS After adjudication, 151 cases of 5-ASA-induced nephrotoxicity were identified. Sixty-eight percent of cases were males, with nephrotoxicity occurring at a median age of 39.4 years (range 6-79 years). The median time for development of renal injury after commencing 5-ASA was 3.0 years (95% confidence interval [CI] 2.3-3.7). Only 30% of cases recovered completely after drug withdrawal, with 15 patients requiring permanent renal replacement therapy. A genome-wide association study identified a suggestive association in the HLA region (p = 1×10(-7)) with 5-ASA-induced nephrotoxicity. A sub-group analysis of patients who had a renal biopsy demonstrating interstitial nephritis (n = 55) significantly strengthened this association (p = 4×10(-9), odds ratio 3.1). CONCLUSIONS This is the largest and most detailed study of 5-ASA-induced nephrotoxicity to date. It highlights the morbidity associated with this condition and identifies for the first time a significant genetic predisposition to drug-induced renal injury.
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Affiliation(s)
- Graham A Heap
- IBD Pharmacogenetics, Royal Devon and Exeter Foundation Trust, Exeter, UK Precision Medicine Exeter, University of Exeter, Exeter, UK
| | - Kenji So
- IBD Pharmacogenetics, Royal Devon and Exeter Foundation Trust, Exeter, UK Precision Medicine Exeter, University of Exeter, Exeter, UK
| | - Mike Weedon
- Precision Medicine Exeter, University of Exeter, Exeter, UK
| | - Naomi Edney
- Exeter Kidney Unit, Royal Devon and Exeter Foundation Trust, Exeter, UK
| | - Claire Bewshea
- IBD Pharmacogenetics, Royal Devon and Exeter Foundation Trust, Exeter, UK Precision Medicine Exeter, University of Exeter, Exeter, UK
| | - Abhey Singh
- IBD Pharmacogenetics, Royal Devon and Exeter Foundation Trust, Exeter, UK Precision Medicine Exeter, University of Exeter, Exeter, UK
| | - Vito Annese
- University Hospital AOU, Department of Emergency, 2nd Gastroenterology Unit, Florence, Italy
| | - John Beckly
- Royal Cornwall Hospital NHS Trust, Penventinnie Lane, Truro, UK
| | - Dorien Buurman
- Department of Gastroenterology and Hepatology, University of Groningen, Groningen, The Netherlands University Medical Center Groningen, Groningen, The Netherlands
| | - Rakesh Chaudhary
- Department of Gastroenterology, West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Watford, UK
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Are We Growing Psychotropics in Our Backyards?: A Case Report and Literature Review of Coleus blumei. J Addict Med 2015; 10:68-9. [PMID: 26690294 DOI: 10.1097/adm.0000000000000189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
There have been very limited reports of the euphoria experienced under the influence of Coleus blumei--part of a large genus with similarities to various mints and herbs, naturally found in abundance and popular in home gardens. There have been reports of similar properties to Salvia divinorum, which contains the psychoactive neocleordane diterpene salvinorin-A. We present a case of a man in his twenties, with no significant known personal or family psychiatric history, presenting to an emergency room with a psychotic episode after the ingestion of C. blumei. He had chewed leaves of this plant, with the intention of obtaining a euphoric experience, as learned through social media posts. Comprehensive laboratory work-up drug screening and diagnostic imaging were negative. Vital signs were stable and physical examination was unremarkable. His mental status improved significantly after treatment with risperidone 2 mg twice daily, during a 5-day psychiatric hospitalization. This case draws attention to a potential psychotropic that warrants clinical consideration and further investigation.
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Ide K, Yamada H, Kitagawa M, Kawasaki Y, Buno Y, Matsushita K, Kaji M, Fujimoto K, Waki M, Nakashima M, Umegaki K. Methods for estimating causal relationships of adverse events with dietary supplements. BMJ Open 2015; 5:e009038. [PMID: 26608636 PMCID: PMC4663420 DOI: 10.1136/bmjopen-2015-009038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Dietary supplement use has increased over past decades, resulting in reports of potentially serious adverse events. The aim of this study was to develop optimised methods to evaluate the causal relationships between adverse events and dietary supplements, and to test these methods using case reports. DESIGN Causal relationship assessment using prospectively collected data. SETTING AND PARTICIPANTS 4 dietary supplement experts, 4 pharmacists and 11 registered dietitians (5 men and 14 women) examined 200 case reports of suspected adverse events using the modified Naranjo scale and the modified Food and Drug Administration (FDA) algorithm. PRIMARY OUTCOME MEASURES The distribution of evaluation results was analysed and inter-rater reliability was evaluated for the two modified methods employed using intraclass correlation coefficients (ICC) and Fleiss' κ. RESULTS Using these two methods, most of the 200 case reports were categorised as 'lack of information' or 'possible' adverse events. Inter-rater reliability among entire assessors ratings for the two modified methods, based on ICC and Fleiss' κ, were classified as more than substantial (modified Naranjo scale: ICC (95% CI) 0.873 (0.850 to 0.895); Fleiss' κ (95% CI) 0.615 (0.615 to 0.615). Modified FDA algorithm: Fleiss' κ (95% CI) 0.622 (0.622 to 0.622). CONCLUSIONS These methods may help to assess the causal relationships between adverse events and dietary supplements. By conducting additional studies of these methods in different populations, researchers can expand the possibilities for the application of our methods.
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Affiliation(s)
- Kazuki Ide
- Department of Drug Evaluation & Informatics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Hiroshi Yamada
- Department of Drug Evaluation & Informatics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Mamoru Kitagawa
- Department of Drug Evaluation & Informatics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Yohei Kawasaki
- Department of Drug Evaluation & Informatics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Yuma Buno
- Department of Drug Evaluation & Informatics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | | | | | | | - Masako Waki
- Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | | | - Keizo Umegaki
- Information Center, National Institutes of Biomedical Innovation, Health and Nutrition, Tokyo, Japan
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Conroy EJ, Kirkham JJ, Bellis JR, Peak M, Smyth RL, Williamson PR, Pirmohamed M. A pilot randomised controlled trial to assess the utility of an e-learning package that trains users in adverse drug reaction causality. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2015; 23:447-55. [PMID: 26032626 PMCID: PMC4755231 DOI: 10.1111/ijpp.12197] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 03/27/2015] [Indexed: 11/28/2022]
Abstract
Objectives Causality assessment of adverse drug reactions (ADRs) by healthcare professionals is often informal which can lead to inconsistencies in practice. The Liverpool Causality Assessment Tool (LCAT) offers a systematic approach. An interactive, web‐based, e‐learning package, the Liverpool ADR Causality Assessment e‐learning Package (LACAeP), was designed to improve causality assessment using the LCAT. This study aimed to (1) get feedback on usability and usefulness on the LACAeP, identify areas for improvement and development, and generate data on effect size to inform a larger scale study; and (2) test the usability and usefulness of the LCAT. Methods A pilot, single‐blind, parallel‐group, randomised controlled trial hosted by the University of Liverpool was undertaken. Participants were paediatric medical trainees at specialty training level 1+ within the Mersey and North‐West England Deaneries. Participants were randomised (1 : 1) access to the LACAeP or no training. The primary efficacy outcome was score by correct classification, predefined by a multidisciplinary panel of experts. Following participation, feedback on both the LCAT and the LACAeP was obtained, via a built in survey, from participants. Key findings Of 57 randomised, 35 completed the study. Feedback was mainly positive although areas for improvement were identified. Seventy‐four per cent of participants found the LCAT easy to use and 78% found the LACAeP training useful. Sixty‐one per cent would be unlikely to recommend the training. Scores ranged from 4 to 13 out of 20. The LACAeP increased scores by 1.3, but this was not significant. Conclusions Improving the LACAeP before testing it in an appropriately powered trial, informed by the differences observed, is required. Rigorous evaluation will enable a quality resource that will be of value in healthcare professional training.
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Affiliation(s)
| | - Jamie J Kirkham
- Department of Biostatistics, University of Liverpool, Liverpool
| | - Jennifer R Bellis
- Research and Development, Alder Hey Children's NHS Foundation Trust, Liverpool
| | - Matthew Peak
- Research and Development, Alder Hey Children's NHS Foundation Trust, Liverpool
| | | | | | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool
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Abstract
Forgetting history, which frequently repeats itself, is a mistake. In General Psychopathology, Jaspers criticised early 20th century psychiatrists, including those who thought psychiatry was only neurology (Wernicke) or only abnormal psychology (Freud), or who did not see the limitations of the medical model in psychiatry (Kraepelin). Jaspers proposed that some psychiatric disorders follow the medical model (Group I), while others are variations of normality (Group III), or comprise schizophrenia and severe mood disorders (Group II). In the early 21st century, the players' names have changed but the game remains the same. The US NIMH is reprising both Wernicke's brain mythology and Kraepelin's marketing promises. The neo-Kraepelinian revolution started at Washington University, became pre-eminent through the DSM-III developed by Spitzer, but reached a dead end with the DSM-5. McHugh, who described four perspectives in psychiatry, is the leading contemporary representative of the Jaspersian diagnostic approach. Other neo-Jaspersians are: Berrios, Wiggins and Schwartz, Ghaemi, Stanghellini, Parnas and Sass. Can psychiatry learn from its mistakes? The current psychiatric language, organised at its three levels, symptoms, syndromes, and disorders, was developed in the 19th century but is obsolete for the 21st century. Scientific advances in Jaspers' Group III disorders require collaborating with researchers in the social and psychological sciences. Jaspers' Group II disorders, redefined by the author as schizophrenia, catatonic syndromes, and severe mood disorders, are the core of psychiatry. Scientific advancement in them is not easy because we are not sure how to delineate between and within them correctly.
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Schmiedl S, Rottenkolber M, Hasford J, Rottenkolber D, Farker K, Drewelow B, Hippius M, Saljé K, Thürmann P. Self-medication with over-the-counter and prescribed drugs causing adverse-drug-reaction-related hospital admissions: results of a prospective, long-term multi-centre study. Drug Saf 2015; 37:225-35. [PMID: 24550104 DOI: 10.1007/s40264-014-0141-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Self-medication, including both the use of over-the-counter (OTC) drugs and the use of formerly prescribed drugs taken without a current physician's recommendation, is a public health concern; however, little data exist regarding the actual risk. OBJECTIVE We aimed to analyse self-medication-related adverse drug reactions (ADRs) leading to hospitalisation. METHODS In a multi-centre, observational study covering a hospital catchment area of approximately 500,000 inhabitants, we analysed self-medication-related ADRs leading to hospital admissions in internal medicine departments. Data of patients with ADRs were comprehensively documented, and ADR causality was assessed using Bégaud's algorithm. The included ADRs occurred between January 2000 and December 2008 and were assessed to be at least 'possibly' drug related. RESULTS Of 6,887 patients with ADRs, self-medication was involved in 266 (3.9 %) patients. In 143 (53.8 %) of these patients, ADRs were due to OTC drugs. Formerly prescribed drugs and potential OTC drugs accounted for the remaining ADRs. Most self-medication-related ADRs occurred in women aged 70-79 years and in men aged 60-69 years. Self-medication-related ADRs were predominantly gastrointestinal complaints caused by non-steroidal anti-inflammatory drugs (most frequently OTC acetylsalicylic acid [ASA, aspirin]). In 102 (38.3 %) of the patients with self-medication-related ADRs, a relevant drug-drug interaction (DDI), occurring between a self-medication and a prescribed medication, was present (most frequently ASA taken as an OTC drug and prescribed diclofenac). CONCLUSION In the general population, self-medication plays a limited role in ADRs leading to hospitalisation. However, prevention strategies focused on elderly patients and patients receiving interacting prescribed drugs would improve patient safety.
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Affiliation(s)
- Sven Schmiedl
- Philipp-Klee Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Heusnerstraße 40, 42283, Wuppertal, Germany
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Khan LM, Al-Harthi SE, Osman AMM, Sattar MAAA, Ali AS. Dilemmas of the causality assessment tools in the diagnosis of adverse drug reactions. Saudi Pharm J 2015; 24:485-93. [PMID: 27330379 PMCID: PMC4908100 DOI: 10.1016/j.jsps.2015.01.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 01/01/2015] [Indexed: 01/30/2023] Open
Abstract
Importance: Basic essence of Pharmacovigilance is prevention of ADRs and its precise diagnosis is crucially a primary step, which still remains a challenge among clinicians. Objective: This study is undertaken with the objective to scrutinize and offer a notion of commonly used as well as recently developed methods of causality assessment tools for the diagnosis of adverse drug reactions and discuss their pros and cons. Evidence review: Overall 49 studies were recognized for all assessment methods with five major decisive factors of causality evaluation, all the information regarding reasons allocating causality, the advantages and limitations of the appraisal methods were extracted and scrutinized. Findings: From epidemiological information a past prospect is designed and subsequent possibility merged this background information with a clue in the individual case to crop up with an approximation of causation. Expert judgment is typically based on the decisive factor on which algorithms are based, nevertheless in imprecise manner. The probabilistic methods use the similar principle; however connect probabilities to each measure. Such approaches are quite skeptical and liable to generate cloudy causation results. Causation is quite intricate to ascertain than correlation in Pharmacovigilance due to numerous inherent shortcomings in causality assessment tools. Conclusions and relevance: We suggest that there is a need to develop a high quality assessment tool which can meticulously establish suitable diagnostic criteria for ADRs with universal acceptance to improvise the fundamental aspect of drug safety and evade the impending ADRs with the motive to convert Pharmacovigilance into a state of art.
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Affiliation(s)
- Lateef M Khan
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Sameer E Al-Harthi
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Abdel-Moneim M Osman
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Saudi Arabia; National Cancer Institute, Cairo University, Egypt
| | - Mai A Alim A Sattar
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Saudi Arabia; Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed S Ali
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Saudi Arabia
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Bellis JR, Kirkham JJ, Nunn AJ, Pirmohamed M. Clinical coding of prospectively identified paediatric adverse drug reactions--a retrospective review of patient records. BMC Pharmacol Toxicol 2014; 15:72. [PMID: 25519049 PMCID: PMC4290086 DOI: 10.1186/2050-6511-15-72] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 12/12/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND National Health Service (NHS) hospitals in the UK use a system of coding for patient episodes. The coding system used is the International Classification of Disease (ICD-10). There are ICD-10 codes which may be associated with adverse drug reactions (ADRs) and there is a possibility of using these codes for ADR surveillance. This study aimed to determine whether ADRs prospectively identified in children admitted to a paediatric hospital were coded appropriately using ICD-10. METHODS The electronic admission abstract for each patient with at least one ADR was reviewed. A record was made of whether the ADR(s) had been coded using ICD-10. RESULTS Of 241 ADRs, 76 (31.5%) were coded using at least one ICD-10 ADR code. Of the oncology ADRs, 70/115 (61%) were coded using an ICD-10 ADR code compared with 6/126 (4.8%) non-oncology ADRs (difference in proportions 56%, 95% CI 46.2% to 65.8%; p < 0.001). CONCLUSIONS The majority of ADRs detected in a prospective study at a paediatric centre would not have been identified if the study had relied on ICD-10 codes as a single means of detection. Data derived from administrative healthcare databases are not reliable for identifying ADRs by themselves, but may complement other methods of detection.
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Affiliation(s)
- Jennifer R Bellis
- />Research & Development, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Jamie J Kirkham
- />Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Anthony J Nunn
- />Department of Women’s & Child Health, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- />Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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QT Interval Prolongation Associated with Intramuscular Ziprasidone in Chinese Patients: A Case Report and a Comprehensive Literature Review with Meta-Analysis. Case Rep Psychiatry 2014; 2014:489493. [PMID: 25530900 PMCID: PMC4235192 DOI: 10.1155/2014/489493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 08/02/2014] [Accepted: 08/27/2014] [Indexed: 11/17/2022] Open
Abstract
Intramuscular (IM) ziprasidone has been associated with QTc interval prolongations in patients with preexisting risk factors. A 23-year-old male Chinese schizophrenia patient experienced an increase of QTc interval of 83 milliseconds (ms) after receiving 20 mg IM ziprasidone (baseline and increased QT/QTc were, respectively, 384/418 and 450/501). This was rated as a probable adverse drug reaction (ADR) by the Liverpool ADR causality assessment tool. A systematic review including all types of trials reporting the effect of IM ziprasidone on the QTc interval prolongation identified 19 trials with a total of 1428 patients. Mean QTc change from baseline to end of each study was −3.7 to 12.8 ms after IM ziprasidone. Four randomized trials (3 of 4 published in Chinese) were used to calculate a meta-analysis of QTc interval prolongation which showed no significant differences between IM ziprasidone and IM haloperidol groups (risk ratio 0.49 to 4.31, 95% confidence interval 0.09 to 19.68, P = 0.06 to 0.41). However, our review included two cases of patients who experienced symptoms probably related to QTc prolongation after IM ziprasidone. Thus, careful screening and close monitoring, including baseline ECG, should be considered in patients receiving IM ziprasidone for the first time.
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Bellis JR, Kirkham JJ, Nunn AJ, Pirmohamed M. Adverse drug reactions and off-label and unlicensed medicines in children: a prospective cohort study of unplanned admissions to a paediatric hospital. Br J Clin Pharmacol 2014; 77:545-53. [PMID: 23919928 DOI: 10.1111/bcp.12222] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/14/2013] [Indexed: 11/30/2022] Open
Abstract
AIMS To examine the impact of off-label and unlicensed (OLUL) prescribing on adverse drug reactions (ADRs) causing unplanned admissions to a paediatric hospital. METHODS Prescription data from a 12 month prospective cohort study of ADRs detected in children admitted to a paediatric hospital were scrutinized. The relative risk for off-label and unlicensed medicines being implicated in an ADR was calculated. Logistic regression analyses were carried out with exposure to off-label and unlicensed medicines and number of off-label and unlicensed medicines administered as predictor variables. RESULTS Off-label and unlicensed medicines were more likely to be implicated in an ADR than authorized medicines (relative risk 1.67, 95% CI 1.38, 2.02, P < 0.001). There was a 25% increase in ADR risk (95% CI 1.16, 1.35, P < 0.001) with each additional authorized medicine and 23% (95% CI 1.10, 1.36, P < 0.001) with each additional off-label or unlicensed medicine. Logistic regression analysis focusing on non-oncology patients demonstrated that the number of authorized medicines (odds ratio 1.33, 95% CI 1.23, 1.44, P < 0.001), but not the number of off-label and unlicensed medicine courses, was a predictor of ADR risk. CONCLUSIONS In a heterogeneous population of children admitted to a secondary/tertiary hospital, off-label and unlicensed medicines are more likely to be implicated in an ADR than authorized medicines. This was largely driven by ADRs related to drugs used in oncological practice, where the usage of off-label or unlicensed medicines was associated with a higher ADR risk than in non-oncological areas.
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Affiliation(s)
- Jennifer R Bellis
- Research and Development, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Reynolds HE, Chrdle A, Egan D, Chaponda M, Else L, Chiong J, Back DJ, Khoo SH. Effect of intermittent rifampicin on the pharmacokinetics and safety of raltegravir. J Antimicrob Chemother 2014; 70:550-4. [PMID: 25261424 DOI: 10.1093/jac/dku376] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES Previous studies of raltegravir and rifampicin have not studied the interaction when rifampicin is dosed intermittently. This study aimed to assess the pharmacokinetics of twice daily raltegravir and intermittently dosed rifampicin. METHODS This was a prospective, open, single-arm, three-part, controlled study in healthy volunteers. Over a period of 38 days subjects received 5 days of standard-dose raltegravir (400 mg twice daily) followed by 28 days of standard-dose raltegravir plus rifampicin three times a week followed by 5 days of high-dose (800 mg twice daily) raltegravir plus rifampicin three times a week. Pharmacokinetic sampling was performed on days 5, 33 and 38. Raltegravir pharmacokinetic parameters were determined by non-compartmental analysis and reported as geometric means and 90% CIs. ClinicalTrials.gov: NCT01424826. RESULTS Sixteen subjects (12 females) completed the study. Raltegravir trough plasma concentration (C12) was significantly lower in the presence of rifampicin when dosed at 400 mg twice daily (40%), which was not observed with 800 mg twice daily dosing. Raltegravir Cmax and AUC0-12 were both significantly higher in the presence of rifampicin when dosed at 800 mg twice daily (76% and 84%, respectively), but this dose was well tolerated. CONCLUSIONS This study suggests that rifampicin induction of raltegravir is comparable between daily and intermittent rifampicin. In the absence of definitive clinical efficacy data to suggest otherwise, doses of 800 mg of raltegravir twice daily with rifampicin thrice weekly are well tolerated and yield higher AUCs and comparable C12 when compared with raltegravir alone.
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Affiliation(s)
- Helen E Reynolds
- Royal Liverpool & Broadgreen University Hospitals NHS Trust, Prescot Street, Liverpool, UK
| | - Ales Chrdle
- Royal Liverpool & Broadgreen University Hospitals NHS Trust, Prescot Street, Liverpool, UK
| | - Deirdre Egan
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Mas Chaponda
- Royal Liverpool & Broadgreen University Hospitals NHS Trust, Prescot Street, Liverpool, UK
| | - Laura Else
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Justin Chiong
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - David J Back
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Saye H Khoo
- Royal Liverpool & Broadgreen University Hospitals NHS Trust, Prescot Street, Liverpool, UK Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Hawcutt DB, O’Connor O, Turner MA. Adverse drug reactions in neonates: could we be documenting more? Expert Rev Clin Pharmacol 2014; 7:807-20. [DOI: 10.1586/17512433.2014.956090] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Heap GA, Weedon MN, Bewshea CM, Singh A, Chen M, Satchwell JB, Vivian JP, So K, Dubois PC, Andrews JM, Annese V, Bampton P, Barnardo M, Bell S, Cole A, Connor SJ, Creed T, Cummings FR, D'Amato M, Daneshmend TK, Fedorak RN, Florin TH, Gaya DR, Greig E, Halfvarson J, Hart A, Irving PM, Jones G, Karban A, Lawrance IC, Lee JC, Lees C, Lev-Tzion R, Lindsay JO, Mansfield J, Mawdsley J, Mazhar Z, Parkes M, Parnell K, Orchard TR, Radford-Smith G, Russell RK, Reffitt D, Satsangi J, Silverberg MS, Sturniolo GC, Tremelling M, Tsianos EV, van Heel DA, Walsh A, Watermeyer G, Weersma RK, Zeissig S, Rossjohn J, Holden AL, Ahmad T. HLA-DQA1-HLA-DRB1 variants confer susceptibility to pancreatitis induced by thiopurine immunosuppressants. Nat Genet 2014; 46:1131-4. [PMID: 25217962 DOI: 10.1038/ng.3093] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 08/22/2014] [Indexed: 12/16/2022]
Abstract
Pancreatitis occurs in approximately 4% of patients treated with the thiopurines azathioprine or mercaptopurine. Its development is unpredictable and almost always leads to drug withdrawal. We identified patients with inflammatory bowel disease (IBD) who had developed pancreatitis within 3 months of starting these drugs from 168 sites around the world. After detailed case adjudication, we performed a genome-wide association study on 172 cases and 2,035 controls with IBD. We identified strong evidence of association within the class II HLA region, with the most significant association identified at rs2647087 (odds ratio 2.59, 95% confidence interval 2.07-3.26, P = 2 × 10(-16)). We replicated these findings in an independent set of 78 cases and 472 controls with IBD matched for drug exposure. Fine mapping of the HLA region identified association with the HLA-DQA1*02:01-HLA-DRB1*07:01 haplotype. Patients heterozygous at rs2647087 have a 9% risk of developing pancreatitis after administration of a thiopurine, whereas homozygotes have a 17% risk.
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Affiliation(s)
- Graham A Heap
- 1] IBD Pharmacogenetics, Royal Devon and Exeter Hospital, Exeter, UK. [2] Precision Medicine Exeter, University of Exeter, Exeter, UK. [3]
| | - Michael N Weedon
- 1] Precision Medicine Exeter, University of Exeter, Exeter, UK. [2]
| | - Claire M Bewshea
- 1] IBD Pharmacogenetics, Royal Devon and Exeter Hospital, Exeter, UK. [2] Precision Medicine Exeter, University of Exeter, Exeter, UK
| | - Abhey Singh
- IBD Pharmacogenetics, Royal Devon and Exeter Hospital, Exeter, UK
| | - Mian Chen
- Oxford Transplant Centre, Oxford University Hospital National Health Service (NHS) Trust, Oxford, UK
| | - Jack B Satchwell
- Oxford Transplant Centre, Oxford University Hospital National Health Service (NHS) Trust, Oxford, UK
| | - Julian P Vivian
- Department of Biochemistry and Molecular Biology, School of Biomedical Sciences, Monash University, Clayton, Victoria, Australia
| | - Kenji So
- IBD Pharmacogenetics, Royal Devon and Exeter Hospital, Exeter, UK
| | - Patrick C Dubois
- Department of Gastroenterology, King's College Hospital, London, UK
| | - Jane M Andrews
- IBD Service, Department of Gastroenterology and University of Adelaide at Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vito Annese
- Division of Gastroenterology, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Peter Bampton
- Flinders Medical Centre, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Martin Barnardo
- Oxford Transplant Centre, Oxford University Hospital National Health Service (NHS) Trust, Oxford, UK
| | - Sally Bell
- Department of Gastroenterology, St. Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Andy Cole
- Gastroenterology and Hepatology, Royal Derby Hospital, Derby, UK
| | - Susan J Connor
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Tom Creed
- Joint Clinical Research Unit, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Fraser R Cummings
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mauro D'Amato
- Department of Biosciences and Nutrition, Karolinska Institute, Stockholm, Sweden
| | | | - Richard N Fedorak
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Timothy H Florin
- The University of Queensland School of Medicine, South Brisbane, Queensland, Australia
| | - Daniel R Gaya
- Gastroenterology Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Emma Greig
- Department of Gastroenterology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Jonas Halfvarson
- Division of Gastroenterology, Örebro University Hospital and School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Alisa Hart
- Department of Medicine, St. Mark's Hospital and Academic Institute, North West London Hospitals NHS Trust, London, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Gareth Jones
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
| | - Amir Karban
- Department of Gastroenterology, Rambam Medical Center, Haifa, Israel
| | - Ian C Lawrance
- Centre for Inflammatory Bowel Diseases, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - James C Lee
- Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Charlie Lees
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
| | - Raffi Lev-Tzion
- Paediatric Gastroenterology and Nutrition Unit, Shaare Zedek Medical Centre, Jerusalem, Israel
| | - James O Lindsay
- Department of Gastroenterology, Barts and The London NHS Trust, London, UK
| | - John Mansfield
- Department of Gastroenterology, Newcastle University Hospitals NHS Trust, Newcastle, UK
| | - Joel Mawdsley
- Department of Gastroenterology, West Middlesex University Hospital NHS Trust, Isleworth, UK
| | - Zia Mazhar
- Department of Gastroenterology, Basildon and Thurrock Hospital NHS Trust, Basildon, UK
| | - Miles Parkes
- Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | | | | | - Graham Radford-Smith
- 1] Department of Gastroenterology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia. [2] IBD Group, Queensland Institute of Medical Research and University of Queensland School of Medicine, Herston Campus, Brisbane, Queensland, Australia
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Yorkhill Hospital, Glasgow, UK
| | - David Reffitt
- Department of Gastroenterology, Lewisham and Greenwich NHS Trust, London, UK
| | - Jack Satsangi
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
| | - Mark S Silverberg
- Inflammatory Bowel Disease Group, Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Mark Tremelling
- Department of Gastroenterology, Norfolk and Norwich Hospital NHS Trust, Norwich, UK
| | - Epameinondas V Tsianos
- 1st Division of Internal Medicine and Division of Gastroenterology, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - David A van Heel
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alissa Walsh
- Department of Gastroenterology, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Gill Watermeyer
- Gastrointestinal Clinic, Groote Schuur Hospital, Cape Town, South Africa
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University Medical Center Groningen and the University of Groningen, Groningen, the Netherlands
| | - Sebastian Zeissig
- Department of Internal Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Jamie Rossjohn
- Department of Biochemistry and Molecular Biology, School of Biomedical Sciences, Monash University, Clayton, Victoria, Australia
| | - Arthur L Holden
- The International Serious Adverse Events Consortium, Chicago, Illinois, USA
| | | | | | - Tariq Ahmad
- 1] IBD Pharmacogenetics, Royal Devon and Exeter Hospital, Exeter, UK. [2] Precision Medicine Exeter, University of Exeter, Exeter, UK
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Smyth RL, Peak M, Turner MA, Nunn AJ, Williamson PR, Young B, Arnott J, Bellis JR, Bird KA, Bracken LE, Conroy EJ, Cresswell L, Duncan JC, Gallagher RM, Gargon E, Hesselgreaves H, Kirkham JJ, Mannix H, Smyth RMD, Thiesen S, Pirmohamed M. ADRIC: Adverse Drug Reactions In Children – a programme of research using mixed methods. PROGRAMME GRANTS FOR APPLIED RESEARCH 2014. [DOI: 10.3310/pgfar02030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AimsTo comprehensively investigate the incidence, nature and risk factors of adverse drug reactions (ADRs) in a hospital-based population of children, with rigorous assessment of causality, severity and avoidability, and to assess the consequent impact on children and families. We aimed to improve the assessment of ADRs by development of new tools to assess causality and avoidability, and to minimise the impact on families by developing better strategies for communication.Review methodsTwo prospective observational studies, each over 1 year, were conducted to assess ADRs in children associated with admission to hospital, and those occurring in children who were in hospital for longer than 48 hours. We conducted a comprehensive systematic review of ADRs in children. We used the findings from these studies to develop and validate tools to assess causality and avoidability of ADRs, and conducted interviews with parents and children who had experienced ADRs, using these findings to develop a leaflet for parents to inform a communication strategy about ADRs.ResultsThe estimated incidence of ADRs detected in children on admission to hospital was 2.9% [95% confidence interval (CI) 2.5% to 3.3%]. Of the reactions, 22.1% (95% CI 17% to 28%) were either definitely or possibly avoidable. Prescriptions originating in the community accounted for 44 out of 249 (17.7%) of ADRs, the remainder originating from hospital. A total of 120 out of 249 (48.2%) reactions resulted from treatment for malignancies. Off-label and/or unlicensed (OLUL) medicines were more likely to be implicated in an ADR than authorised medicines [relative risk (RR) 1.67, 95% CI 1.38 to 2.02;p < 0.001]. When medicines used for the treatment of oncology patients were excluded, OLUL medicines were not more likely to be implicated in an ADR than authorised medicines (RR 1.03, 95% CI 0.72 to 1.48;p = 0.830). For children who had been in hospital for > 48 hours, the overall incidence of definite and probable ADRs based on all admissions was 15.9% (95% CI 15.0 to 16.8). Opiate analgesic drugs and drugs used in general anaesthesia (GA) accounted for > 50% of all drugs implicated in ADRs. The odds ratio of an OLUL drug being implicated in an ADR compared with an authorised drug was 2.25 (95% CI 1.95 to 2.59;p < 0.001). Risk factors identified were exposure to a GA, age, oncology treatment and number of medicines. The systematic review estimated that the incidence rates for ADRs causing hospital admission ranged from 0.4% to 10.3% of all children [pooled estimate of 2.9% (95% CI 2.6% to 3.1%)] and from 0.6% to 16.8% of all children exposed to a drug during hospital stay. New tools to assess causality and avoidability of ADRs have been developed and validated. Many parents described being dissatisfied with clinician communication about ADRs, whereas parents of children with cancer emphasised confidence in clinician management of ADRs and the way clinicians communicated about medicines. The accounts of children and young people largely reflected parents’ accounts. Clinicians described using all of the features of communication that parents wanted to see, but made active decisions about when and what to communicate to families about suspected ADRs, which meant that communication may not always match families’ needs and expectations. We developed a leaflet to assist clinicians in communicating ADRs to parents.ConclusionThe Adverse Drug Reactions In Children (ADRIC) programme has provided the most comprehensive assessment, to date, of the size and nature of ADRs in children presenting to, and cared for in, hospital, and the outputs that have resulted will improve the management and understanding of ADRs in children and adults within the NHS. Recommendations for future research: assess the values that parents and children place on the use of different medicines and the risks that they will find acceptable within these contexts; focusing on high-risk drugs identified in ADRIC, determine the optimum drug dose for children through the development of a gold standard practice for the extrapolation of adult drug doses, alongside targeted pharmacokinetic/pharmacodynamic studies; assess the research and clinical applications of the Liverpool Causality Assessment Tool and the Liverpool Avoidability Assessment Tool; evaluate, in more detail, morbidities associated with anaesthesia and surgery in children, including follow-up in the community and in the home setting and an assessment of the most appropriate treatment regimens to prevent pain, vomiting and other postoperative complications; further evaluate strategies for communication with families, children and young people about ADRs; and quantify ADRs in other settings, for example critical care and neonatology.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Rosalind L Smyth
- Institute of Child Health, University of Liverpool, Liverpool, UK
- Institute of Child Health, University College London, London, UK
| | - Matthew Peak
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | - Mark A Turner
- Institute of Translational Medicine, Liverpool Women’s National Health Service Foundation Trust and University of Liverpool, Liverpool, UK
| | - Anthony J Nunn
- National Institute for Health Research Medicines for Children Research Network, University of Liverpool, Liverpool, UK
| | | | - Bridget Young
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Janine Arnott
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jennifer R Bellis
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | - Kim A Bird
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | - Louise E Bracken
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | | | - Lynne Cresswell
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Jennifer C Duncan
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | | | - Elizabeth Gargon
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Hannah Hesselgreaves
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jamie J Kirkham
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Helena Mannix
- Alder Hey Children’s National Health Service Foundation Trust, Liverpool, UK
| | - Rebecca MD Smyth
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Signe Thiesen
- Institute of Child Health, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Langerová P, Vrtal J, Urbánek K. Adverse drug reactions causing hospital admissions in childhood: a prospective, observational, single-centre study. Basic Clin Pharmacol Toxicol 2014; 115:560-4. [PMID: 24810357 DOI: 10.1111/bcpt.12264] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/22/2014] [Indexed: 01/04/2023]
Abstract
Adverse drug reactions (ADRs) are common problems in both paediatric and adult medicine. The aim of this study was to prospectively identify the ADRs causing hospital admission of children and identification of the risk factors and involved drugs. The study was performed at the University Hospital in Olomouc, Czech Republic. All patients aged 19 years or under admitted to hospital were included in the study, and all admissions for ADRs were prospectively screened for a period of 9 months. Suspected ADRs were subsequently evaluated in detail, and causality assessment was undertaken to determine whether each suspected reaction was possible, probable or definite. The assessment of ADR causality was performed using the Naranjo algorithm, the Liverpool ADR Causality Assessment Tool and the Edwards and Aronson causality assessment method. During the study period, 2903 admissions were identified; of these, there were 143 admissions of patients with an oncological disease. Sixty-four admissions (2.2%) were caused by an ADR. Anticancer chemotherapy accounted for 35% of the cases, followed by antibiotics (18%), immunosuppressants and vaccines (9% each). The use of different scoring systems does not lead to the differences in the numbers of ADR-diagnosed patient but may result in differences in the determination of the level of certainty. ADRs cause a substantial proportion of children's hospital admissions. The majority of the ADR-diagnosed patient affected the hematopoietic and gastrointestinal systems; the drugs most frequently involved were cytotoxic agents and antibiotics. The most important risk factors identified were female sex and oncological disease.
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Affiliation(s)
- Petra Langerová
- Department of Pharmacology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic
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Ondansetron and the risk of cardiac arrhythmias: a systematic review and postmarketing analysis. Ann Emerg Med 2013; 64:19-25.e6. [PMID: 24314899 DOI: 10.1016/j.annemergmed.2013.10.026] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 10/02/2013] [Accepted: 10/24/2013] [Indexed: 01/23/2023]
Abstract
STUDY OBJECTIVE To explore the risk of cardiac arrhythmias associated with ondansetron administration in the context of recent recommendations for identification of high-risk individuals. METHODS We conducted a postmarketing analysis and systematically reviewed the published literature, grey literature, manufacturer's database, Food and Drug Administration Adverse Events Reporting System, and the World Health Organization Individual Safety Case Reports Database (VigiBase). Eligible cases described a documented (or perceived) arrhythmia within 24 hours of ondansetron administration. The primary outcome was arrhythmia occurrence temporally associated with the administration of a single, oral ondansetron dose. Secondary objectives included identifying all cases associating ondansetron administration (any dose, frequency, or route) to an arrhythmia. RESULTS Primary: No reports describing an arrhythmia associated with single oral ondansetron dose administration were identified. Secondary: Sixty unique reports were identified. Route of administration was predominantly intravenous (80%). A significant medical history (67%) or concomitant use of a QT-prolonging medication (67%) was identified in 83% of reports. Approximately one third occurred in patients receiving chemotherapeutic agents, many of which are known to prolong the QT interval. An additional third involved administration to prevent postoperative vomiting. CONCLUSION Current evidence does not support routine ECG and electrolyte screening before single oral ondansetron dose administration to individuals without known risk factors. Screening should be targeted to high-risk patients and those receiving ondansetron intravenously.
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Bellis JR, Kirkham JJ, Thiesen S, Conroy EJ, Bracken LE, Mannix HL, Bird KA, Duncan JC, Peak M, Turner MA, Smyth RL, Nunn AJ, Pirmohamed M. Adverse drug reactions and off-label and unlicensed medicines in children: a nested case-control study of inpatients in a pediatric hospital. BMC Med 2013; 11:238. [PMID: 24229060 PMCID: PMC4231613 DOI: 10.1186/1741-7015-11-238] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/19/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Off-label and unlicensed (OLUL) prescribing has been prevalent in pediatric practice. Using data from a prospective cohort study of adverse drug reactions (ADRs) among pediatric inpatients, we aimed to test the hypothesis that OLUL status is a risk factor for ADRs. METHODS A nested case?control study was conducted within a prospective cohort study. Details of all medicines administered were recorded, including information about OLUL status. The odds ratio for OLUL medicines being implicated in a probable or definite ADR was calculated. A multivariate Cox proportional hazards regression model was fitted to the data to assess the influence that OLUL medicine use had on the hazard of an ADR occurring. RESULTS A total of 10,699 medicine courses were administered to 1,388 patients. The odds ratio (OR) of an OLUL medicine being implicated in an ADR compared with an authorized medicine was 2.25 (95% confidence interval (CI) 1.95 to 2.59). Medicines licensed in children but given to a child below the minimum age or weight had the greatest odds of being implicated in an ADR (19% of courses in this category were implicated, OR 3.54 (95% CI 2.82 to 4.44). Each additional OLUL medicine given significantly increased the hazard of an ADR (hazard ratio (HR) 1.3 95% CI 1.2 to 1.3, P <0.001). Each additional authorized medicine given also significantly increased the hazard (HR 1.2 95% CI 1.2 to 1.3, P <0.001). CONCLUSIONS OLUL medicines are more likely to be implicated in an ADR than authorized medicines. The number of medicines administered is a risk factor for ADRs highlighting the need to use the lowest number of medicines, at the lowest dose for the shortest period, with continual vigilance by prescribers, in order to reduce the risk of ADRs.
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Affiliation(s)
- Jennifer R Bellis
- Research and Development, Alder Hey Children?s NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK.
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Thiesen S, Conroy EJ, Bellis JR, Bracken LE, Mannix HL, Bird KA, Duncan JC, Cresswell L, Kirkham JJ, Peak M, Williamson PR, Nunn AJ, Turner MA, Pirmohamed M, Smyth RL. Incidence, characteristics and risk factors of adverse drug reactions in hospitalized children - a prospective observational cohort study of 6,601 admissions. BMC Med 2013; 11:237. [PMID: 24228998 PMCID: PMC4225679 DOI: 10.1186/1741-7015-11-237] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/19/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Adverse drug reactions (ADRs) are an important cause of harm in children. Current data are incomplete due to methodological differences between studies: only half of all studies provide drug data, incidence rates vary (0.6% to 16.8%) and very few studies provide data on causality, severity and risk factors of pediatric ADRs. We aimed to determine the incidence of ADRs in hospitalized children, to characterize these ADRs in terms of type, drug etiology, causality and severity and to identify risk factors. METHODS We undertook a year-long, prospective observational cohort study of admissions to a single UK pediatric medical and surgical secondary and tertiary referral center (Alder Hey, Liverpool, UK). Children between 0 and 16 years 11 months old and admitted for more than 48 hours were included. Observed outcomes were occurrence of ADR and time to first ADR for the risk factor analysis. RESULTS A total of 5,118 children (6,601 admissions) were included, 17.7% of whom experienced at least one ADR. Opiate analgesics and drugs used in general anesthesia (GA) accounted for more than 50% of all drugs implicated in ADRs. Of these ADRs, 0.9% caused permanent harm or required admission to a higher level of care. Children who underwent GA were at more than six times the risk of developing an ADR than children without a GA (hazard ratio (HR) 6.40; 95% confidence interval (CI) 5.30 to 7.70). Other factors increasing the risk of an ADR were increasing age (HR 1.06 for each year; 95% CI 1.04 to 1.07), increasing number of drugs (HR 1.25 for each additional drug; 95% CI 1.22 to 1.28) and oncological treatment (HR 1.90; 95% CI 1.40 to 2.60). CONCLUSIONS ADRs are common in hospitalized children and children who had undergone a GA had more than six times the risk of developing an ADR. GA agents and opiate analgesics are a significant cause of ADRs and have been underrepresented in previous studies. This is a concern in view of the increasing number of pediatric short-stay surgeries.
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Affiliation(s)
- Signe Thiesen
- Department of Women?s and Children?s Health, Institute of Translational Medicine (Child Health), University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool L12 2AP, UK.
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Zakaria R, Ellenbogen J, Graham C, Pizer B, Mallucci C, Kumar R. A decision analysis tool for the assessment of posterior fossa tumour surgery outcomes in children--the "Liverpool Neurosurgical Complication Causality Assessment Tool". Childs Nerv Syst 2013; 29:1277-83. [PMID: 23494657 DOI: 10.1007/s00381-013-2065-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 02/26/2013] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Complications may occur following posterior fossa tumour surgery in children. Such complications are subjectively and inconsistently reported even though they may have significant long-term behavioural and cognitive consequences for the child. This makes comparison of surgeons, programmes and treatments problematic. MATERIALS AND METHODS We have devised a causality tool for assessing if an adverse event after surgery can be classified as a surgical complication using a series of simple questions, based on a tool used in assessing adverse drug reactions. This tool, which we have called the "Liverpool Neurosurgical Complication Causality Assessment Tool", was developed by reviewing a series of ten posterior fossa tumour cases with a panel of neurosurgery, neurology, oncology and neuropsychology specialists working in a multidisciplinary paediatric tumour treatment programme. DISCUSSION AND CONCLUSION We have demonstrated its use and hope that it may improve reliability between different assessors both in evaluating the outcomes of existing programmes and treatments as well as aiding in trials which may directly compare the effects of surgical and medical treatments.
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Affiliation(s)
- Rasheed Zakaria
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Lower Lane, Fazakerley, Liverpool L9 7LJ, UK.
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Tocilizumab-Induced Acute Liver Injury in Adult Onset Still's Disease. Case Reports Hepatol 2013; 2013:964828. [PMID: 25374723 PMCID: PMC4208420 DOI: 10.1155/2013/964828] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 06/06/2013] [Indexed: 02/08/2023] Open
Abstract
Background. Tocilizumab, a monoclonal humanized anti-IL-6 receptor antibody, is used in treatment of refractory adult onset Still's disease (AOSD). Mild to moderate liver enzyme elevation is a well-known side effect, but severe liver injury has only been reported in 3 cases in the literature. Case. A young female suffering from corticoid and methotrexate refractory AOSD was treated by tocilizumab. After 19 months of consecutive treatment, she developed acute severe liver injury. Liver biopsy showed extensive hepatocellular necrosis with ballooned hepatocytes, highly suggestive of drug-induced liver injury. No other relevant drug exposure beside tocilizumab was recorded. She recovered totally after treatment discontinuation and an initial 3-day course of intravenous N-acetylcysteine with normalization of liver function tests after 6 weeks. Conclusion. Acute severe hepatitis can be associated with tocilizumab as documented in this case. Careful monitoring of liver function tests is warranted during tocilizumab treatment.
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Comparison of Three Methods (An Updated Logistic Probabilistic Method, the Naranjo and Liverpool Algorithms) for the Evaluation of Routine Pharmacovigilance Case Reports Using Consensual Expert Judgement as Reference. Drug Saf 2013; 36:1033-44. [DOI: 10.1007/s40264-013-0083-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Alfreijat M, Habibi M, Bhatia P, Bhatia A. Severe hepatitis associated with tocilizumab in a patient with rheumatoid arthritis. Rheumatology (Oxford) 2013; 52:1340-1. [DOI: 10.1093/rheumatology/kes397] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Gallagher RM, Mason JR, Bird KA, Kirkham JJ, Peak M, Williamson PR, Nunn AJ, Turner MA, Pirmohamed M, Smyth RL. Adverse drug reactions causing admission to a paediatric hospital. PLoS One 2012; 7:e50127. [PMID: 23226510 PMCID: PMC3514275 DOI: 10.1371/journal.pone.0050127] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Accepted: 10/15/2012] [Indexed: 12/31/2022] Open
Abstract
Objective(s) To obtain reliable information about the incidence of adverse drug reactions, and identify potential areas where intervention may reduce the burden of ill-health. Design Prospective observational study. Setting A large tertiary children’s hospital providing general and specialty care in the UK. Participants All acute paediatric admissions over a one year period. Main Exposure Any medication taken in the two weeks prior to admission. Outcome Measures Occurrence of adverse drug reaction. Results 240/8345 admissions in 178/6821 patients admitted acutely to a paediatric hospital were thought to be related to an adverse drug reaction, giving an estimated incidence of 2.9% (95% CI 2.5, 3.3), with the reaction directly causing, or contributing to the cause, of admission in 97.1% of cases. No deaths were attributable to an adverse drug reaction. 22.1% (95% CI 17%, 28%) of the reactions were either definitely or possibly avoidable. Prescriptions originating in the community accounted for 44/249 (17.7%) of adverse drug reactions, the remainder originating from hospital. 120/249 (48.2%) reactions resulted from treatment for malignancies. The drugs most commonly implicated in causing admissions were cytotoxic agents, corticosteroids, non-steroidal anti-inflammatory drugs, vaccines and immunosuppressants. The most common reactions were neutropenia, immunosuppression and thrombocytopenia. Conclusions Adverse drug reactions in children are an important public health problem. Most of those serious enough to require hospital admission are due to hospital-based prescribing, of which just over a fifth may be avoidable. Strategies to reduce the burden of ill-health from adverse drug reactions causing admission are needed.
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Affiliation(s)
- Ruairi M Gallagher
- Department of Women's and Children's Health, University of Liverpool, Liverpool, United Kingdom.
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Arnott J, Hesselgreaves H, Nunn AJ, Peak M, Pirmohamed M, Smyth RL, Turner MA, Young B. Enhancing communication about paediatric medicines: lessons from a qualitative study of parents' experiences of their child's suspected adverse drug reaction. PLoS One 2012; 7:e46022. [PMID: 23071535 PMCID: PMC3468607 DOI: 10.1371/journal.pone.0046022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 08/27/2012] [Indexed: 11/23/2022] Open
Abstract
Background There is little research on parents' experiences of suspected adverse drug reactions in their children and hence little evidence to guide clinicians when communicating with families about problems associated with medicines. Objective To identify any unmet information and communication needs described by parents whose child had a suspected adverse drug reaction. Methods Semi-structured qualitative interviews with parents of 44 children who had a suspected adverse drug reaction identified on hospital admission, during in-patient treatment or reported by parents using the Yellow Card Scheme (the UK system for collecting spontaneous reports of adverse drug reactions). Interviews were conducted face-to-face or by telephone; most interviews were audiorecorded and transcribed. Analysis was informed by the principles of the constant comparative method. Results Many parents described being dissatisfied with how clinicians communicated about adverse drug reactions and unclear about the implications for their child's future use of medicines. A few parents felt that clinicians had abandoned their child and reported refusing the use of further medicines because they feared a repeated adverse drug reaction. The accounts of parents of children with cancer were different. They emphasised their confidence in clinicians' management of adverse drug reactions and described how clinicians prospectively explained the risks associated with medicines. Parents linked symptoms to medicines in ways that resembled the established reasoning that clinicians use to evaluate the possibility that a medicine has caused an adverse drug reaction. Conclusion Clinicians' communication about adverse drug reactions was poor from the perspective of parents, indicating that improvements are needed. The accounts of parents of children with cancer indicate that prospective explanation about adverse drug reactions at the time of prescription can be effective. Convergence between parents and clinicians in their reasoning for linking children's symptoms to medicines could be a starting point for improved communication.
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Affiliation(s)
- Janine Arnott
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, United Kingdom
| | - Hannah Hesselgreaves
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, United Kingdom
| | - Anthony J. Nunn
- Alder Hey Children's National Health Service Foundation Trust, Liverpool, United Kingdom
| | - Matthew Peak
- Alder Hey Children's National Health Service Foundation Trust, Liverpool, United Kingdom
| | - Munir Pirmohamed
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Rosalind L. Smyth
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Mark A. Turner
- Institute of Translational Medicine, Liverpool Women's National Health Service Foundation Trust and University of Liverpool, Liverpool, United Kingdom
| | - Bridget Young
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, United Kingdom
- * E-mail:
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Abstract
Adverse drug reactions (ADRs) complicate at least 5% of all courses of therapy for children. Dealing with an ADR requires a stepwise approach in appreciation of the possibility of an ADR, assessment of whether the adverse event in question is drug-related, assessment of causality, assistance in treating the symptoms of the ADR, and dealing with the aftermath of the event. Several new developments likely will improve the ability to assess, evaluate, treat, and prevent ADRs in children. These developments include tools to evaluate causality, laboratory tests to diagnose ADRs, pharmacogenomic approaches to prevent ADRs, and new insights into treating serious ADRs.
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Affiliation(s)
- Michael Rieder
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
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