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Callaway Kim K, Rothenberger SD, Tadrous M, Hernandez I, Gellad WF, Devine JW, Hershey TB, Maillart LM, Suda KJ. Drug Shortages Prior to and During the COVID-19 Pandemic. JAMA Netw Open 2024; 7:e244246. [PMID: 38578641 PMCID: PMC10998160 DOI: 10.1001/jamanetworkopen.2024.4246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/29/2024] [Indexed: 04/06/2024] Open
Abstract
Importance Drug shortages are a chronic and worsening issue that compromises patient safety. Despite the destabilizing impact of the COVID-19 pandemic on pharmaceutical production, it remains unclear whether issues affecting the drug supply chain were more likely to result in meaningful shortages during the pandemic. Objective To estimate the proportion of supply chain issue reports associated with drug shortages overall and with the COVID-19 pandemic. Design, Setting, and Participants This longitudinal cross-sectional study used data from the IQVIA Multinational Integrated Data Analysis database, comprising more than 85% of drug purchases by US pharmacies from wholesalers and manufacturers, from 2017 to 2021. Data were analyzed from January to May 2023. Exposure Presence of a supply chain issue report to the US Food and Drug Administration or the American Society of Health-Systems Pharmacists (ASHP). Main Outcomes and Measures The main outcome was drug shortage, defined as at least 33% decrease in units purchased within 6 months of a supply chain issue report. Random-effects logistic regression models compared the marginal odds of shortages for drugs with vs without reports. Interaction terms assessed heterogeneity prior to vs during the COVID-19 pandemic and by drug characteristics (formulation, age, essential medicine status, clinician- vs self-administered, sales volume, and number of manufacturers). Results A total of 571 drugs exposed to 731 supply chain issue reports were matched to 7296 comparison medications with no reports. After adjusting for drug characteristics, 13.7% (95% CI, 10.4%-17.8%) of supply chain issue reports were associated with subsequent drug shortages vs 4.1% (95% CI, 3.6%-4.8%) of comparators (marginal odds ratio [mOR], 3.7 [95% CI, 2.6-5.1]). Shortages increased among both drugs with and without reports in February to April 2020 (34.2% of drugs with supply chain issue reports and 9.5% of comparison drugs; mOR, 4.9 [95% CI, 2.1-11.6]), and then decreased after May 2020 (9.8% of drugs with reports and 3.6% of comparison drugs; mOR, 2.9 [95% CI, 1.6-5.3]). Significant associations were identified by formulation (parenteral mOR, 1.9 [95% CI, 1.1-3.2] vs oral mOR, 5.4 [95% CI, 3.3-8.8]; P for interaction = .008), WHO essential medicine status (essential mOR, 2.2 [95% CI, 1.3-5.2] vs nonessential mOR, 4.6 [95% CI, 3.2-6.7]; P = .02), and for brand-name vs generic status (brand-name mOR, 8.1 [95% CI, 4.0-16.0] vs generic mOR, 2.4 [95% CI, 1.7-3.6]; P = .002). Conclusions and Relevance In this national cross-sectional study, supply chain issues associated with drug shortages increased at the beginning of the COVID-19 pandemic. Ongoing policy work is needed to protect US drug supplies from future shocks and to prioritize clinically valuable drugs at greatest shortage risk.
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Affiliation(s)
- Katherine Callaway Kim
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Scott D. Rothenberger
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Women’s College Research Institute, Toronto, Ontario, Canada
| | - Inmaculada Hernandez
- School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla
| | - Walid F. Gellad
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center of Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Joshua W. Devine
- Des Moines University, Department of Public Health, Des Moines, Iowa
| | - Tina B. Hershey
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Lisa M. Maillart
- Department of Industrial Engineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, Pennsylvania
| | - Katie J. Suda
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center of Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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2
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Stocker KJ, Tiemann A, Brunk KM, Agegnehu B, Buhlinger K, Amerine L, Roberts MC, McLaughlin JE, Clark SM, Rose R, Mekonnen B, Bhakta N, Fentie AM, Alexander TB, Ozawa S, Chargualaf M, Muluneh B. Processes and perceptions of chemotherapy supply chain in Ethiopia: A mixed-method study. J Oncol Pharm Pract 2023; 29:1555-1564. [PMID: 36303425 DOI: 10.1177/10781552221134254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
BACKGROUND The impact and downstream effects of the chemotherapy supply chain in Ethiopia are not well understood. The purpose of this study was to identify perceived gaps in supply chain and characterize their impact on patient care. METHODS A concurrent mixed-method study was conducted at a large academic cancer center in Ethiopia. In-depth interviews (IDIs) and surveys were completed in collaboration with external stakeholders with knowledge about chemotherapy supply chain in Ethiopia. Thematic coding was used for qualitative analysis of IDI and descriptive statistics were used to summarize quantitative survey data. RESULTS Six stakeholders participated in the IDIs and seven completed surveys. IDIs revealed that most chemotherapeutic agents are purchased by the Ethiopian Pharmaceutical Supply Agency (EPSA) and are distributed to cancer treatment centers. A free-market purchasing option also exists, but for chemotherapy obtained outside of government-subsidized channels, the potential for substandard or falsified chemotherapy was a concern. Participants expressed confidence that the correct treatment was administered to patients, but viewpoints on reliability and consistency of medication supply were variable. Quantitative data from the survey showed that participants were not confident that medications are prepared safely and correctly. Improper storage and manipulation of high-risk medications remain a significant risk to staff. CONCLUSIONS This study provides insight from a healthcare staff perspective on how gaps in the chemotherapy supply chain process impact patient care in a low-income country. Inventory management, disruptions in supply chain, and product integrity were perceived as the largest gaps in the current chemotherapy supply chain structure.
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Affiliation(s)
- Kurtis J Stocker
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Andrew Tiemann
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Kelly M Brunk
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Bemnat Agegnehu
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Kaitlyn Buhlinger
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Lindsey Amerine
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Megan C Roberts
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | | | - Stephen M Clark
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Robert Rose
- Department of pharmacy, University of Kentucky HealthCare, Lexington, KY, USA
| | | | | | - Atalay Mulu Fentie
- Addis Ababa University, College of Health Sciences, School of Pharmacy, Addis Ababa, Ethiopia
- Addis Ababa University, College of Health Sciences, Tikur Anbesa Specialized Hospital, Oncology Unit, Addis Ababa, Ethiopia
| | - Thomas B Alexander
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sachiko Ozawa
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Michael Chargualaf
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Benyam Muluneh
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
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3
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Shukar S, Shahid MH, Zhang J, Din SM, Khan FU, Fang Y, Yang C. Pharmacists' approach to oncology medicine shortages: results of a cross-sectional survey in Pakistan. BMJ Open 2023; 13:e070634. [PMID: 37723107 PMCID: PMC10510916 DOI: 10.1136/bmjopen-2022-070634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 08/30/2023] [Indexed: 09/20/2023] Open
Abstract
OBJECTIVES The study estimated the shortages of oncology medicines in Pakistan, their causes, impacts, mitigation strategies, and possible interventions. DESIGN Cross-sectional survey. SETTING Oncology pharmacists working at 43 oncology settings (out of 80) from five regions of Pakistan (four provinces (Punjab, Sindh, Khyber Pakhtunkhwa and Baluchistan) and one federal territory (Islamabad)) were approached. PARTICIPANTS Oncology pharmacists with more than 1 year of experience were selected using stratified random sampling, and data were collected using a questionnaire from September 2021 to January 2022. PRIMARY AND SECONDARY OUTCOME MEASURES To estimate the prevalence of oncology medicine shortages in Pakistan and establish recommendations to overcome them. RESULTS Of 167 responded pharmacists, 87% experienced shortages in their practice. Most respondents (50%) experienced both oncology and support agent shortages. It was a current problem in hospitals (58%) and increased with time, but the situation varied across regions (p=0.007). Mainly shortages occur half-yearly (p=0.001) and last for <3 months. Injectable (56.8%) and branded drugs (44.9%) were short. The most frequently mentioned drugs affected by shortages were etoposide, paclitaxel, dacarbazine, bleomycin and carboplatin. Usually, distributors (51.5%) notify the pharmacists about the shortages, and federal agencies (36%) are responsible for these shortages. Distributors (53.4%) were the main source of supply, and shortages were encountered by them as well. The impacts included delayed care (25%) and suboptimal outcomes (23%) on patients, extra time (32%) for staff, prioritisation issues (31%) for pharmacists, delayed clinical trials (60.5%) and increased drugs prices (52.1%). Some hospitals have reporting systems (39.5%) and recording (29.3%) drug shortages. The shortages were managed using available alternative options (21%) and redistributing (21%) the currently available stock. CONCLUSION Pakistan's healthcare system is affected by oncology medicine shortages. The government should establish a cancer registry and drug shortage platform, revise drug prescribing/pricing policies and practice penalties for breaching regulations. Oncology medicines must be widely available to avoid the grey market.
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Affiliation(s)
- Sundus Shukar
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | | | - Jinwei Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Shayan Muhammad Din
- Department of Hospital Pharmacy, National Hospital and Medical Center, Lahore, Pakistan
| | - Faiz Ullah Khan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Xi'an, Shaanxi, China
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4
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Ostrenga AR, Thackray J, McLearan HMH, Mulieri KM, Bisaccia E, Militano O, Dupuis LL, Bernhardt MB. Children's Oncology Group's 2023 blueprint for research: Pharmacy. Pediatr Blood Cancer 2023; 70 Suppl 6:e30581. [PMID: 37460409 PMCID: PMC10529855 DOI: 10.1002/pbc.30581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/22/2023]
Abstract
Children's Oncology Group (COG) pharmacists and pharmacy technicians from more than 200 COG-member institutions comprise the COG Pharmacy Discipline. Discipline members serve an essential role in the design and execution of COG clinical trials. Core activities include study drug management, study drug access, clinical trial operations, protocol harmonization, and direct patient care. Discipline members are also actively involved in continuing education, membership engagement, and research across other COG committees/domains. Future areas of committed growth for the discipline include pharmacogenomics, pharmacokinetics, pharmacoeconomics, pharmaceutics, and implementation science.
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Affiliation(s)
- Andrew R Ostrenga
- Department of Pharmacy, University of Mississippi Medical Center, Children's of Mississippi, Jackson, Mississippi, USA
| | - Jennifer Thackray
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ha-Mill H McLearan
- Department of Pharmacy, University of California Davis Medical Center and Children's Hospital, Sacramento, California, USA
| | - Kevin M Mulieri
- Department of Pharmacy, Penn State Children's Hospital, Hershey, Pennsylvania, USA
| | - Elizabeth Bisaccia
- Department of Pharmacy, Advocate Children's Hospital-Park Ridge, Park Ridge, Illinois, USA
| | - Olga Militano
- Study Development Office, Children's Oncology Group, Monrovia, California, USA
| | - L Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - M Brooke Bernhardt
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, Texas, USA
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5
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Bai L, Zhan Y, Zhou Y, Zhang Y, Shi L, Gupta S, Denburg A, Guan X. Evidence of clinical benefit of WHO essential anticancer medicines for children, 2011-2021. EClinicalMedicine 2023; 59:101966. [PMID: 37125406 PMCID: PMC10130597 DOI: 10.1016/j.eclinm.2023.101966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 05/02/2023] Open
Abstract
Background Access to essential cancer medicines is a key determinant of childhood cancer survival. WHO published the Model List of Essential Medicine for Children (EMLc) and updated it every two years since 2007 to promote better access to medicines for children. This study aimed to assess whether the inclusion of essential anticancer medicines for respective indications for children was based on evidence of significant clinical benefit between 2011 and 2021. Methods We identified all anticancer medicine indications added to the WHO EMLc Section 8 since 2011 and extracted evidence of benefit documented in the corresponding technical reports. Evidence in children was defined as evidence that included participants under 12, and graded into five levels, according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence. We analyzed whether each anticancer medicine indication was listed with documented OS benefit or improvements in surrogate measures based on the highest level of documented evidence in children. Findings A total of 115 anticancer medicine indications were added to the EMLc from 2011 to 2021, of which 101 (87.8%) had some clinical evidence in children and 4 (3.5%) were added without any clinical evidence. Among the 101 medicine indications, none were added with level-1 evidence in children, and 43 (42.6%), 11 (10.9%), 41 (40.6%), and 6 (5.9%) were listed with level-2, level-3, level-4, and level-5 evidence in children, respectively. Only eight (7.9%) medicine indications were reported to have OS benefit, another 12 (11.9%) were reported to have improvements on surrogate measures, and 81 (80.2%) were listed in the EMLc without documented improvements in either OS or surrogate measures. Interpretation Most anticancer medicine indications of the WHO EMLc were added based on limited evidence of statistically significant clinical benefit in children. Our results suggest that WHO should refine requirements for clinical benefit criteria and permissible forms, quality, and reporting of evidence of essential anticancer medicines for children, specify whether anticancer medicine indications have required evidence of clinical benefit in children, and provide further details in its technical reports that summarise the available evidence. Funding Not applicable.
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Affiliation(s)
- Lin Bai
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Yuqi Zhan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Yue Zhou
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
- Department of Pharmacy, Peking University People's Hospital, Beijing, 100044, China
| | - Yichen Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
- International Research Center for Medicinal Administration, Peking University, Beijing, 100191, China
| | - Sumit Gupta
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Avram Denburg
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
- International Research Center for Medicinal Administration, Peking University, Beijing, 100191, China
- Corresponding author. Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China.
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6
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Benedetti DJ, Marron JM, Thomas SM, Brown AEC, Pyke-Grimm KA, Johnson LM, Unguru Y, Kodish E. The role of ethicists in pediatric hematology/oncology: Current status and future needs. Pediatr Blood Cancer 2023; 70:e30132. [PMID: 36495529 DOI: 10.1002/pbc.30132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/09/2022] [Accepted: 11/12/2022] [Indexed: 12/14/2022]
Abstract
As pediatric hematology/oncology (PHO) becomes more complex and sub-subspecialized, dedicated PHO ethicists have emerged as sub-subspecialists focused on addressing ethical issues encountered in clinical and research practices. PHO physicians and other clinicians with advanced training in bioethics contribute to the field through ethics research, education, and ethics consultation services. Furthermore, there exists a newer generation of PHO trainees interested in bioethics. This review details the experiences of current PHO ethicists, providing a blueprint for future educational, research and service activities to strengthen the trajectory of the burgeoning sub-subspecialty of PHO ethics. Creating an American Society of Pediatric Hematology/Oncology (ASPHO) ethics Special Interest Group, enhancing clinical ethics education for pediatric hematologists/oncologists (PHOs), developing multi-institutional research collaborations, and increasing attention to ethical issues germane to nonmalignant hematology will serve the interests of the entire field of PHO, enhancing the care of PHO patients and careers of PHOs.
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Affiliation(s)
- Daniel J Benedetti
- Division of Pediatric Hematology/Oncology, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan M Marron
- Division of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, and Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
| | - Stefanie M Thomas
- Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Amy E Caruso Brown
- Division of Pediatric Hematology/Oncology, and Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Kimberly A Pyke-Grimm
- Department of Nursing Research and Evidence-Based Practice, Stanford Children's Health and Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Liza-Marie Johnson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Yoram Unguru
- Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, Maryland, USA.,Johns Hopkins University Berman Institute of Bioethics, Baltimore, Maryland, USA
| | - Eric Kodish
- Departments of Pediatrics, Oncology, and Bioethics, Cleveland Clinic Children's and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio, USA
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7
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Unguru Y, Bernhardt MB, Berg SL, Marie-Johnson L, Grimm KP, Woodman C, Fernandez CV. Essential medicines for childhood cancer in Europe. Lancet Oncol 2023; 24:e67. [PMID: 36725147 DOI: 10.1016/s1470-2045(23)00009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/06/2023] [Accepted: 01/06/2023] [Indexed: 02/01/2023]
Affiliation(s)
- Yoram Unguru
- Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, MD 21215-5271, USA; Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA.
| | | | - Stacey L Berg
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | | | - Kim Pyke Grimm
- Department of Nursing Research and Evidence-Based Practice, Stanford Medicine Children's Health, Stanford, CA, USA; Division of Pediatric Hematology/Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Conrad V Fernandez
- Pediatric Hematology-Oncology, IWK Health Centre, Dalhousie University, Halifax, NS, Canada
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8
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Shukar S, Zahoor F, Omer S, Awan SE, Yang C, Fang Y. Experience of Pharmacists with Anti-Cancer Medicine Shortages in Pakistan: Results of a Qualitative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16373. [PMID: 36498446 PMCID: PMC9740989 DOI: 10.3390/ijerph192316373] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 06/17/2023]
Abstract
This study aimed to examine the current situation of anti-cancer drug shortages in Pakistan, namely its determinants, impacts, adopted mitigation strategies, and proposed solutions. Qualitative semi-structured, in-depth interviews were conducted with 25 pharmacists in oncology hospitals in Pakistan from August to October 2021. Data were collected in person and online, recorded, and subjected to inductive thematic analysis after being transcribed verbatim. Most participants experienced anti-cancer drug shortages that increased during the pandemic. Etoposide, paclitaxel, vincristine, dacarbazine, and methotrexate were frequently short. Important causes included the compromised role of regulatory authorities, lack of local production, and inventory mismanagement. The impacts were delayed/suboptimal treatment and out-of-pocket costs for patients, patients' prioritization, increased workload, negative work environment, and patients' trust issues for pharmacists. The participants proposed that a cautious regulator's role is needed to revise policies for all stakeholders and support all stakeholders financially at their level to increase access to these medicines. Based on the outcomes, it is clear that anti-cancer medicine shortages are a current issue in Pakistan. Governmental authorities need to play a role in revising policies for all levels of the drug supply chain and promoting local production of these drugs. Stakeholders should also collaborate and manage inventory.
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Affiliation(s)
- Sundus Shukar
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China
| | - Fatima Zahoor
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Bandar Sunway 47500, Malaysia
| | - Sumaira Omer
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China
| | - Sundas Ejaz Awan
- Faculty of Pharmacy, Gadjah Mada University, Yogyakarta 55281, Indonesia
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China
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9
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Otth M, Brack E, Kearns PR, Kozhaeva O, Ocokoljic M, Schoot RA, Vassal G, Balduzzi A, Beck Popovic M, Beishuizen A, Bergamaschi L, Biondi A, Bourdeaut F, Braicu E, Brok J, Brugières L, Burke A, Calaminus G, Casanova M, Choucair ML, Cleirec M, Corbaciouglu S, Correa Llano MG, De Rojas T, Domínguez Pinilla N, Elmaraghi C, Ferrari A, Fossa A, Gaspar N, Herold N, Karapiperi K, Karu M, Kjærsgaar M, Knörr F, Koenig C, Kranjcec I, Krawczyk M, Lehmberg K, Lehrnbecher T, Lunesink M, Massano D, Matijasic N, Merks H, Metzler M, Michalski A, Minkov M, Morland B, Niktoreh N, Oltenau E, Orbach D, Owens C, Papachristidou S, Pasqualini C, Pavlovic M, Perez Albert P, Poyer F, Radulovic I, Reinhardt D, Rebelo J, Roser E, Russo I, Scheinemann K, Schindera C, Schrappe M, Sehested A, Sehouli J, Spreafico F, Strauss SJ, Stutterheim J, Svojgr K, Tzotzola V, Van Ewijk R, Verschuur A, Vora A, Woessmann W, Zajac-Spychala O, Zwaan M. Essential medicines for childhood cancer in Europe: a pan-European, systematic analysis by SIOPE. Lancet Oncol 2022; 23:1537-1546. [PMID: 36332647 DOI: 10.1016/s1470-2045(22)00623-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Shortages and unequal access to anticancer medicines for children and adolescents are a reality in Europe. The aim of the European Society for Paediatric Oncology (SIOPE) Essential Anticancer Medicines Project was to provide a list of anticancer medicines that are considered essential in the treatment of paediatric cancers to help ensure their continuous access to all children and adolescents with cancer across Europe. METHODS This pan-European project, done between Jan 20, 2020, and Feb 18, 2022, was designed to be a systematic collection and review of treatment protocols and strategies that are used to treat childhood cancer in Europe. We formed 16 working groups on the basis of paediatric cancer types, and which were based on the existing SIOPE Clinical Trial Groups. Workings groups consisted of representatives from the SIOPE Clinical Trial Groups, Young SIOPE members, and senior paediatric oncology experts. Each group collected existing treatment protocols that are used to treat the respective cancer types in Europe. Medicines from the standard group of each protocol were extracted. For medicines not on the WHO Essential Medicines List for children (EMLc) 2017, working groups did a literature search to determine whether the medicines should be defined as essential, promising, or neither essential nor promising. Each group provided an individual summary, and all medicines that were considered essential by at least one group were combined in a joint list. FINDINGS The working groups identified 73 treatment protocols used in Europe and defined 66 medicines as essential. For several newer medicines, such as kinase inhibitors or tisagenlecleucel, the supporting evidence was insufficient to consider them essential, so these medicines were defined as promising. 25 medicines were considered promising by at least one working group. 22 (33%) of the 66 essential and none of the promising medicines were included in the WHO EMLc 2017. The WHO EMLc 2021 included two new medicines (everolimus and vinorelbine) following applications we made as a result of this project. INTERPRETATION Medicines that were defined as essential within this project should be available for the treatment of childhood and adolescent cancer continuously and across Europe. This list can be used to support and guide stakeholders and policy makers in negotiations on a national and European level regarding shortages, accessibility, and affordability of these medicines. FUNDING None.
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Affiliation(s)
- Maria Otth
- Division of Oncology-Hematology, Department of Pediatrics, Kantonsspital Aarau, Aarau, Switzerland; Department of Oncology, Haematology, Immunology, Stem Cell Transplantation and Somatic Gene Therapy, University Children's Hospital Zurich, Zurich, Switzerland.
| | - Eva Brack
- Division of Pediatric Hematology and Oncology, University Children's Hospital Bern, Bern, Switzerland
| | - Pamela R Kearns
- Cancer Research UK Clinical Trials Unit, National Institute for Health Research Birmingham Biomedical Research Centre, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Olga Kozhaeva
- Policy Department, European Society for Paediatric Oncology, SIOP Europe, Brussels, Belgium
| | - Marko Ocokoljic
- Policy Department, European Society for Paediatric Oncology, SIOP Europe, Brussels, Belgium
| | - Reineke A Schoot
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Gilles Vassal
- Department of Children and Adolescent Oncology, Gustave Roussy Comprehensive Cancer Center, Villejuif, France
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10
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Shukar S, Yang C, Khan SA, Bhutta OA. Anti-cancer medicine shortages in an oncology tertiary hospital of Pakistan: A five-year retrospective study. J Oncol Pharm Pract 2022:10781552221114278. [PMID: 35837718 DOI: 10.1177/10781552221114278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Anti-cancer medicine shortages are advancing challenges for patients and hospitals. This study aims to evaluate anti-cancer and supportive medicine shortages in a tertiary hospital in Pakistan and propose solutions. METHOD A retrospective observational research was performed in a tertiary care hospital in Pakistan from 2016 to 2020. Data was retrieved from the hospital database using a questionnaire regarding short medicines' generic name, brand, dosage, source, total source, frequency, causes, impact, management, and analyzed by Microsoft Excel 2013. RESULTS Between January 2016 and December 2020, 43 individual medicine shortages were observed, with an average of 8.6 shortages per year. There were shortages of 22 medicines, including 8 anti-cancer (36.4%) and 14 supportive agents (63.6%). Total shortage days were 27,100, with an average of 1232 days (SD 757) per medicine. Supportive medicines' shortages were frequent, but oncology agents' shortages were constant. The most affected dosage form was injection. Cardiovascular drugs and alkylating agents were the most affected class in supportive and anti-cancer medicines, respectively. The use of "alternative medicine" and "patient needs based importation" were the most common mitigation strategies. CONCLUSION Shortages of oncology medicines are challenging in Pakistan. The most prominent causes are the lack of updated governmental regulations, registration, and import issues. The tertiary care hospital has very few sources of supply, so it imports these drugs on a need basis to manage the shortages. But it is still concerning because of the huge financial burden on patients and institutions due to expensive import, and therapy become delayed as the import process takes time. Moreover, the most affected drug class was alkylating agents, and dosage was both injectable and oral medicines.
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Affiliation(s)
- Sundus Shukar
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy Xi'an Jiaotong University, Xi'an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi'an, China
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy Xi'an Jiaotong University, Xi'an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi'an, China
| | - Shahbaz Ahmad Khan
- Department of Pharmacy, Shaukat Khanum Memorial Hospital & Research Center, Lahore, Pakistan
| | - Omar Akhlaq Bhutta
- Department of Pharmacy, Shaukat Khanum Memorial Hospital & Research Center, Lahore, Pakistan
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11
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Lee BM, Jecker NS, Marron JM, Rosenberg AR. Striving for equity: Patient prioritization during a critical cancer drug shortage. Pediatr Blood Cancer 2021; 68:e29280. [PMID: 34357696 DOI: 10.1002/pbc.29280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Brittany M Lee
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA.,Department of Pediatrics, Division of Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA.,Palliative Care and Resilience Lab, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Nancy S Jecker
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA.,Fulbright U.S. Scholar Program, University of Johannesburg, Johannesburg, Gauteng, South Africa
| | - Jonathan M Marron
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA.,Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
| | - Abby R Rosenberg
- Department of Pediatrics, Division of Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA.,Palliative Care and Resilience Lab, Seattle Children's Research Institute, Seattle, Washington, USA
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12
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Abu-Arja MH, Rojas Del Río N, Morales La Madrid A, Lassaletta A, Coven SL, Moreno R, Valero M, Perez V, Espinoza F, Fernandez E, Santander J, Tordecilla J, Oyarce V, Kopp K, Bartels U, Qaddoumi I, Finlay JL, Cáceres A, Reyes M, Espinoza X, Osorio DS. Evaluation of the Pediatric Neuro-Oncology Resources Available in Chile. JCO Glob Oncol 2021; 7:425-434. [PMID: 33788596 PMCID: PMC8081533 DOI: 10.1200/go.20.00430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Pediatric neuro-oncology resources are mostly unknown in Chile. We report the human and material resources available in Chilean hospitals providing pediatric neuro-oncology services. METHODS A cross-sectional survey was distributed to 17 hospitals providing pediatric neuro-oncology services (Programa Infantil Nacional de Drogas Antineoplásicas [PINDA] hospitals, 11; private, 6). RESULTS Response rate was 71% (PINDA, 8; private, 4). Pediatric neuro-oncology services were mainly provided within general hospitals (67%). Registries for pediatric CNS tumors and chemotherapy-related toxicities were available in 100% and 67% of hospitals, respectively. CNS tumors were treated by pediatric oncologists in 92% of hospitals; none were formally trained in neuro-oncology. The most used treatment protocols were the national PINDA protocols. All WHO essential medicines for childhood cancer were available in more than 80% of the hospitals except for gemcitabine, oxaliplatin, paclitaxel, and procarbazine. The median number of pediatric neurosurgeons per hospital was two (range, 2-6). General neuroradiologists were available in 83% of the centers. Pathology specimens were sent to neuropathologists (58%), adult pathologists (25%), and pediatric pathologists (17%). Intensity-modulated radiotherapy, conformal radiotherapy, and cobalt radiotherapy were used by 67%, 58%, and 42% of hospitals, respectively. Only one private hospital performed autologous hematopoietic cell transplant for children with CNS tumors. CONCLUSION A wide range of up-to-date treatment modalities are available for children with CNS tumors. Our survey highlights future directions to improve the pediatric neuro-oncology services available in Chile such as the expansion of multidisciplinary clinics, palliative care services, long-term cancer survivorship programs, dedicated clinical research support teams, establishing standardized mechanism for sending pathologic specimen for second opinion to international specialized centers, and establishing specialized neuro-oncology training program.
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Affiliation(s)
- Mohammad H Abu-Arja
- Department of Pediatrics, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | - Nicolás Rojas Del Río
- Department of Pediatrics, Division of Hematology Oncology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Alvaro Lassaletta
- The Pediatric Oncology, Hematology and Stem Cell Transplant Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Scott L Coven
- Division of Pediatric Hematology-Oncology, Riley Hospital for Children and Indiana University School of Medicine, Indianapolis, IN
| | - Rosa Moreno
- Department of Pediatrics, Pediatría Hospital Dr. Sótero del Río, Puente Alto, Chile
| | - Miguel Valero
- Department of Pediatrics, Hospital Carlos van Buren, Valparaíso, Chile
| | - Veronica Perez
- Department of Pediatrics, Hospital San Juan de Dios, Santiago, Chile
| | - Felipe Espinoza
- Department of Pediatrics, San Borja Arriaran Clinic Hospital, Santiago, Chile.,Department of Pediatrics, Clínica Bicentenario, Santiago, Chile
| | - Eduardo Fernandez
- Department of Pediatrics, Hospital Clínico Regional Dr. Guillermo Grant Benavente de Concepción, Concepción, Chile
| | - José Santander
- Department of Pediatrics, Clinica Davila, Recoleta, Chile
| | - Juan Tordecilla
- Department of Pediatrics, Clinica Santa Maria, Providencia, Chile
| | - Veronica Oyarce
- Department of Pediatrics, Dr. Exequiel González Cortés Hospital, San Miguel, Chile
| | - Katherine Kopp
- Department of Pediatrics, Dr. Luis Calvo Mackenna Hospital, Santiago, Chile
| | - Ute Bartels
- Department of Hematology Oncology, Hospital for Sick Children, Toronto, Canada
| | - Ibrahim Qaddoumi
- Global Pediatric Medicine Department, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Jonathan L Finlay
- Division of Hematology, Oncology, Blood and Marrow Transplant, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Adrián Cáceres
- Neurosurgery Unit, Hospital Nacional de Niños Carlos Sáenz Herrera, San José, Costa Rica
| | - Mauricio Reyes
- Department of Radiation Oncology, Instituto Nacional del Cáncer, Santiago, Chile
| | - Ximena Espinoza
- Department of Pediatrics, The Hematology Oncology Unit, Hospital de Niños Dr. Roberto del Río, Santiago, Chile
| | - Diana S Osorio
- Division of Hematology, Oncology, Blood and Marrow Transplant, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
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13
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Shukar S, Zahoor F, Hayat K, Saeed A, Gillani AH, Omer S, Hu S, Babar ZUD, Fang Y, Yang C. Drug Shortage: Causes, Impact, and Mitigation Strategies. Front Pharmacol 2021; 12:693426. [PMID: 34305603 PMCID: PMC8299364 DOI: 10.3389/fphar.2021.693426] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/29/2021] [Indexed: 11/13/2022] Open
Abstract
Drug shortage is a global issue affecting low, middle, and high-income countries. Many countries have developed various strategies to overcome the problem, while the problem is accelerating, affecting the whole world. All types of drugs, such as essential life-saving drugs, oncology medicines, antimicrobial drugs, analgesics, opioids, cardiovascular drugs, radiopharmaceutical, and parenteral products, are liable to the shortage. Among all pharmaceutical dosage forms, sterile injectable products have a higher risk of shortage than other forms. The causes of shortage are multifactorial, including supply issues, demand issues, and regulatory issues. Supply issues consist of manufacturing problems, unavailability of raw materials, logistic problems, and business problems. In contrast, demand issues include just-in-time inventory, higher demand for a product, seasonal demand, and unpredictable demand. For regulatory issues, one important factor is the lack of a unified definition of drug shortage. Drug shortage affects all stakeholders from economic, clinical, and humanistic aspects. WHO established global mitigation strategies from four levels to overcome drug shortages globally. It includes a workaround to tackle the current shortage, operational improvements to reduce the shortage risk and achieve early warning, changes in governmental policies, and education and training of all health professionals about managing shortages.
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Affiliation(s)
- Sundus Shukar
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Fatima Zahoor
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
- Yusra Institute of Pharmaceutical Sciences, Islamabad, Pakistan
| | - Khezar Hayat
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Amna Saeed
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Ali Hassan Gillani
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Sumaira Omer
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Shuchen Hu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Zaheer-Ud-Din Babar
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, United Kingdom
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xian Jiaotong University, Xi’an, China
- Shaanxi Centre for Health Reform and Development Research, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an, China
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14
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Vassal G, Kozhaeva O, Griskjane S, Arnold F, Nysom K, Basset L, Kameric L, Kienesberger A, Kamal S, Cherny N, Bricalli G, Latino N, Kearns P. Access to essential anticancer medicines for children and adolescents in Europe. Ann Oncol 2021; 32:560-568. [PMID: 33388384 DOI: 10.1016/j.annonc.2020.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 12/16/2020] [Accepted: 12/20/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Essential anticancer medicines are an indispensable component of multidisciplinary treatment of paediatric malignancies. A European Society for Medical Oncology (ESMO) study reported inequalities in the availability of anticancer medicines for adult solid tumours and provided a model for the present survey. The aim of this survey was to assess the accessibility of essential medicines used in paediatric cancer patients aged 0 to 18 years across Europe from 2016 to 2018. METHODS A list of medicines was drawn with input from the European Society for Paediatric Oncology (SIOP Europe) Clinical Research Council referring to the World Health Organization Model List of Essential Medicines for Children (WHO EMLc) 2017. A survey was sent to nominated national clinician and pharmacist rapporteurs and parent associations in up to 37 countries; answers were obtained from 34 countries. RESULTS The full survey list contained 68 medicines, including 24 on the WHO EMLc 2017. Health professionals reported that 35% of all medicines were prescribed off-label in at least one country and that 44% were always available in >90% of countries. Only 63% of the EMLc 2017 medicines were reported as always available. The main determinant of unavailability was shortages, reported for 72% of medicines in at least one country. Out-of-pocket costs were reported in eight countries. Twenty-seven percent of orally administered medicines were never available in child-friendly formulations. Parents detailed individual efforts and challenges of facilitating ingestion of oral medicines as prescribed. Inequalities in access to pain control during procedures were reported by parents across Europe. CONCLUSIONS Children and adolescents with cancer in Europe experience lack of access to essential medicines. Urgent actions are needed to address shortages, financial accessibility, availability of safe age-appropriate oral formulations, and pain management across Europe.
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Affiliation(s)
- G Vassal
- Paediatric Oncology Department, Gustave Roussy, Villejuif, France; Paris-Sud University, Orsay, France; European Society for Paediatric Oncology (SIOP Europe), Brussels, Belgium.
| | - O Kozhaeva
- Policy Department, SIOP Europe, Brussels, Belgium
| | - S Griskjane
- Children's Clinical University Hospital, Riga, Latvia; European Society of Oncology Pharmacy (ESOP), Luxembourg
| | - F Arnold
- Childhood Cancer International - Europe (CCI-E), Montpellier, France
| | - K Nysom
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark; SIOP Europe, Brussels, Belgium
| | - L Basset
- CCI-E, Madrid, Spain; Universitat Politècnica de València, Valencia, Spain
| | - L Kameric
- CCI-E, Sarajevo, Bosnia and Herzegovina
| | | | - S Kamal
- Department of Pharmaceutical Services, Children's Cancer Hospital, Cairo, Egypt; ESOP, Luxembourg
| | - N Cherny
- Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel; European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - G Bricalli
- European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - N Latino
- European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - P Kearns
- Institute of Cancer and Genomic Sciences, NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK; SIOP Europe, Brussels, Belgium
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15
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Martei YM, Iwamoto K, Barr RD, Wiernkowski JT, Robertson J. Shortages and price variability of essential cytotoxic medicines for treating children with cancers. BMJ Glob Health 2020; 5:bmjgh-2020-003282. [PMID: 33173011 PMCID: PMC7656942 DOI: 10.1136/bmjgh-2020-003282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/14/2020] [Accepted: 08/28/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Low-income and middle-income countries (LMICs) face the largest burden of mortality from childhood cancers with limited access to curative therapies. Few comparative analyses across all income groups and world regions have examined the availability and acquisition costs of essential medicines for treating cancers in children. Methods A cross-sectional survey involved countries in five income groups—low-income (LIC), lower-middle-income (LMC), upper-middle-income (UMC), two high-income country groups (HIC1, HIC2). Physicians and pharmacists reported institutional use, availability, stock outs and prices (brand and generic products) of 34 essential medicines. Price comparisons used US$, applying foreign exchange rates (XR) and purchasing power parity (PPP) adjustments. Medicine costs for treating acute lymphoblastic leukaemia (ALL), Burkitt lymphoma (BL) and Wilms tumour (WT) were calculated (child 29 kg, body surface area 1 m2). Comparisons were conducted using non-parametric Kruskal-Wallis tests. Results Fifty-eight respondents (50 countries) provided information on medicine use, availability and stock outs, with usable price data from 42 facilities (37 countries). The extent of use of International Society of Paediatric Oncology core and ancillary medicines varied across income groups (p<0.0001 and p=0.0002 respectively). LMC and LIC facilities used fewer medicines than UMC and HIC facilities. UMC and LMC facilities were more likely to report medicines not available or stockouts. Medicine prices varied widely within and between income bands; generic products were not always cheaper than brand equivalents. PPP adjustment showed relatively higher prices in UMC and LMC facilities for some medicines. Medicine costs were highest in HICs for ALL (p=0.0075 XR; p=0.0178 PPP-adjusted analyses) and WT (p =<0.0001 XR; p=0.0007 PPP-adjusted). Medicine costs for BL were not significantly different. Conclusion Problems with the availability of essential medicines, dependable supply chains, confidential medicine prices and wide variability in treatment costs contribute to persistent challenges in the care of children with treatable cancers, especially in LMICs.
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Affiliation(s)
- Yehoda M Martei
- Hematology - Oncology Division, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kotoji Iwamoto
- Health Technology and Pharmaceuticals Programme, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Ronald D Barr
- Pediatric Haematology/Oncology, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - John T Wiernkowski
- Pediatric Haematology/Oncology, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Jane Robertson
- Health Technology and Pharmaceuticals Programme, World Health Organization Regional Office for Europe, Copenhagen, Denmark.,Clinical Pharmacology, University of Newcastle, Waratah, New South Wales, Australia
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16
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Sinow C, Burgart A, Char DS. How Anesthesiologists Experience and Negotiate Ethical Challenges from Drug Shortages. AJOB Empir Bioeth 2020; 12:84-91. [PMID: 33124970 DOI: 10.1080/23294515.2020.1839596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND In the face of ongoing drug shortages, anesthesiologists have been described as having to become "Iron Chefs, challenged to create safe patient outcomes with missing ingredients. Unfortunately, developing responsive ethical guidance for how anesthesiologists should best handle ethical concerns with ongoing and mutable drug shortages is limited by the dearth of studies examining how bedside clinicians actually experience drug shortages and what ethical challenges they encounter. In order to better understand what ethical concerns individual anesthesiologists experience around drug shortages and how they negotiate them, we undertook this qualitative interview study. Methods: We conducted semi-structured interviews with anesthesiologists at three field sites: an academic tertiary care adult hospital that performs approximately 46,000 anesthetics annually comprising cases ranging across all surgical disciplines; the affiliated veteran's affairs hospital that performs 12,000 anesthetics annually; and, the affiliated children's hospital that performs 20,500 anesthetics annually. Results: 29 anesthesiologists were interviewed (17 adult and 12 pediatric anesthesiologists), representing a spectrum of practice areas in clinical anesthesia: general, pediatric, regional, pain, critical care, obstetrics, liver transplant, and palliative medicine. Three themes emerged: (1) uncertainty about responsibility for clinical decisions made in consequence to a shortage; (2) creativity, and its limits, in choosing anesthetic plans; and, (3) disclosure of concerns about shortages (to patients and colleagues). Conclusions: Our data suggests anesthesiologists have unmet needs for ethical guidance on how to approach drug shortages. First is managing responsibility for decisions stemming from a drug shortage. Second, interviewees struggled with disclosure of their concerns, both to patients and to surgical colleagues. A formal shared decision making approach may present the best solution, since the act of structuring a shared decision making conversation or creating a decision making tool will have to incorporate the views of all stakeholders around shortages and their potential clinical consequences.
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Affiliation(s)
- Carolyn Sinow
- Division of Obstetrics and Gynecology, Kaiser Permanente Santa Clara, Santa Clara, California, USA
| | - Alyssa Burgart
- Department of Anesthesiology, School of Medicine Division of Pediatric Anesthesia, Stanford University, Stanford, California, USA.,Center for Biomedical Ethics, School of Medicine, Stanford University, Stanford, California, USA
| | - Danton S Char
- Department of Anesthesiology, School of Medicine Division of Pediatric Cardiac Anesthesia, Stanford University, Stanford, California, USA.,Center for Biomedical Ethics, School of Medicine, Stanford University, Stanford, California, USA
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Sruamsiri R, Ferrario A, Ross-Degnan D, Denburg AE, Frazier AL, Gupta S, Ward ZJ, Yeh JM, Wagner AK. What are the volume and budget needs to provide chemotherapy to all children with acute lymphoblastic leukaemia in Thailand? Development and application of an estimation tool. BMJ Open 2020; 10:e041901. [PMID: 33109678 PMCID: PMC7592266 DOI: 10.1136/bmjopen-2020-041901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Insufficient access to anticancer medicines may contribute to the wide survival differences of children with cancers across the globe. We developed a tool to estimate the volume of medicines and budget requirements to provide chemotherapy to children with acute lymphoblastic leukaemia (ALL). DESIGN Development and application of an estimation tool. SETTING Paediatric oncology hospital departments in Thailand. PARTICIPANTS 318 children aged 0-14 years diagnosed with ALL and 215 children with undiagnosed ALL. INTERVENTIONS Estimates of volume and budget requirements for administering a full course of chemotherapy for ALL and a further course for children who relapse, according to National Treatment Guidelines. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome measures were the volume (mg) and cost (US$) of medicines needed to treat children with ALL. For medicines whose main indication is paediatric ALL (asparaginase and 6-mercaptopurine), we estimated the difference between volume needed and actual sales in 2017 (secondary outcome). RESULTS Ten anticancer medicines and four chemoprotective agents are needed for the treatment of paediatric ALL according to the Thai treatment guidelines. Of these 14 medicines, 13 are included in the WHO essential medicines list for children. All are available as generics. We estimated that essential chemotherapy and chemoprotective agents to treat all children diagnosed with ALL in Thailand in 2017 would cost US$ 814 952 (US$ 1 365 422 for diagnosed and undiagnosed children), which corresponds to 0.005% (0.008%) of the country's total health expenditure. The volumes of asparaginase and 6-mercaptopurine available on the Thai market in 2017 were more than sufficient (2.3 and 1.5 times the amounts needed, respectively) to treat all children diagnosed with ALL. CONCLUSIONS Procuring sufficient quantities of essential medicines to treat children with ALL requires relatively modest resources. Medicine cost should not be a major barrier to ALL treatment in similar settings.
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Affiliation(s)
- Rosarin Sruamsiri
- Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Tha Pho, Phitsanulok, Thailand
| | - Alessandra Ferrario
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Dennis Ross-Degnan
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Avram E Denburg
- Unit for Policy and Economic Research in Childhood Cancer, Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - A Lindsay Frazier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Sumit Gupta
- Unit for Policy and Economic Research in Childhood Cancer, Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Zachary J Ward
- Center for Health Decision Science, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Jennifer M Yeh
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Anita Katharina Wagner
- Department of Population Medicine, Division of Health Policy and Insurance Research, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
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Mangum R, Bernhardt MB, Cheng WS, Schafer ES, Berg SL, Foster JH. Do intravenous fluid substitutions influence methotrexate clearance? An unanticipated impact of an intravenous sodium bicarbonate drug shortage. Pediatr Blood Cancer 2020; 67:e28334. [PMID: 32608575 DOI: 10.1002/pbc.28334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND National drug shortages of essential medications for childhood cancer have increasingly posed a challenge in the treatment of patients. The efficacy of standardized supportive care practices to avoid treatment-related toxicities may be limited during these drug shortages. High-dose methotrexate (HDMTX) plays a critical role in modern treatment protocols for acute lymphoblastic leukemia and requires stringent supportive care measures to mitigate toxicity. As the result of a national intravenous (IV) sodium bicarbonate shortage, institutional standard HDMTX supportive care guidelines had to be modified. We describe the unanticipated consequences on HDMTX clearance. METHODS We performed a retrospective chart review assessing the impact of alternative compositions of IV fluids on the mean 24-h methotrexate levels (Cpss ) of 25 patients receiving 76 total HDMTX infusions at Texas Children's Hospital Cancer Center from March to October 2017. During the sodium bicarbonate drug shortage, all patients received IV hydration consisting of either dextrose 5%, 0.45% normal saline (D5 ½ NS-Group A) or dextrose 5%, 0.2% normal saline (D5 ¼ NS-Group B). RESULTS Patients receiving a higher total sodium dose demonstrated significantly lower Cpss (25.36 ± 16.6 μMol) compared to patients receiving less sodium (53.9 ± 37.9 μMol; P < .001). CONCLUSIONS Our report shows that in the setting of IV sodium bicarbonate shortage, the composition of hydration IV fluids may affect methotrexate clearance. Patient who received a higher sodium load had a lower 24-h methotrexate level. This demonstrates the potential for unanticipated outcomes resulting from national drug shortages.
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Affiliation(s)
- Ross Mangum
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - M Brooke Bernhardt
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - W Susan Cheng
- Department of Public Heath, Benedictine University, Lisle, Illinois
| | - Eric S Schafer
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Stacey L Berg
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Jennifer H Foster
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
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Shuman AG, Fox E, Unguru Y. Preparing for COVID-19-related Drug Shortages. Ann Am Thorac Soc 2020; 17:928-931. [PMID: 32492353 PMCID: PMC7393783 DOI: 10.1513/annalsats.202004-362vp] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/26/2020] [Indexed: 01/15/2023] Open
Affiliation(s)
- Andrew G. Shuman
- Center for Bioethics and Social Sciences in Medicine, and
- Michigan Institute for Clinical and Health Research, University of Michigan Medical School, Ann Arbor, Michigan
| | - Erin Fox
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah
| | - Yoram Unguru
- Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children’s Hospital at Sinai, Baltimore, Maryland; and
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland
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20
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Biltaji E, Enioutina EY, Yellepeddi V, Rower JE, Sherwin CMT, Ward RM, Lemons RS, Constance JE. Supportive care medications coinciding with chemotherapy among children with hematologic malignancy. Leuk Lymphoma 2020; 61:1920-1931. [PMID: 32264729 PMCID: PMC7725403 DOI: 10.1080/10428194.2020.1749604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pharmacokinetic (PK) conflicts can arise between supportive care medications (SCM) and chemotherapy in children with hematologic malignancy (HM). In this retrospective study, medical records for children (28 days-18 years) diagnosed with HM and receiving an SCM antimicrobial were collected from a hospital network between 1 May 2000 and 31 December 2014. PK drug-gene associations were obtained from a curated pharmacogenomics database. Among 730 patients (median age of 7.5 (IQR 3.7-13.9) years), primarily diagnosed with lymphoid leukemia (52%), lymphoma (28%), or acute myeloid leukemia (16%), chemotherapy was administered in 2846 hospitalizations. SCM accounted for 90.5% (n = 448) of distinct drugs with 93% (n = 679) of children, receiving ≥5 different SCM/hospitalization. Same-day SCM/chemotherapeutic PK gene overlap occurred in 48.3% of hospitalizations and was associated with age (p = 0.026), number of SCM, HM subtype, surgery, and hematopoietic stem cell transplant (p < 0.0001). A high and variable SCM burden among children with HM receiving chemotherapy poses a risk for unanticipated PK conflicts.
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Affiliation(s)
- Eman Biltaji
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Elena Y Enioutina
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Venkata Yellepeddi
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Joseph E Rower
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, OH, USA
| | - Robert M Ward
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Richard S Lemons
- Division of Hematology and Oncology, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jonathan E Constance
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
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Shuman A, Unguru Y. Drug Shortages: The View Across an Ocean. Oncologist 2020; 25:274-276. [PMID: 32027068 DOI: 10.1634/theoncologist.2019-1010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 01/10/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Andrew Shuman
- Center for Bioethics and Social Sciences in Medicine (CBSSM), University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Yoram Unguru
- Division of Pediatric Hematology/Oncology, The Herman and Walter Samuelson Children's Hospital at Sinai, Baltimore, Maryland, USA
- Johns Hopkins University, Berman Institute of Bioethics, Baltimore, Maryland, USA
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23
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Dyer O. US paediatric oncologists are forced to prioritise patients for vincristine treatment as supplies run short. BMJ 2019; 367:l6086. [PMID: 31624062 DOI: 10.1136/bmj.l6086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Brusamento S, Kyaw BM, Whiting P, Li L, Tudor Car L. Digital Health Professions Education in the Field of Pediatrics: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. J Med Internet Res 2019; 21:e14231. [PMID: 31573906 PMCID: PMC6785725 DOI: 10.2196/14231] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/17/2019] [Accepted: 08/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Reducing childhood morbidity and mortality is challenging, particularly in countries with a shortage of qualified health care workers. Lack of trainers makes it difficult to provide the necessary continuing education in pediatrics for postregistration health professionals. Digital education, teaching and learning by means of digital technologies, has the potential to deliver medical education to a large audience while limiting the number of trainers needed. OBJECTIVE The goal of the research was to evaluate whether digital education can replace traditional learning to improve postregistration health professionals' knowledge, skills, attitudes, and satisfaction and foster behavior change in the field of pediatrics. METHODS We completed a systematic review of the literature by following the Cochrane methodology. We searched 7 major electronic databases for articles published from January 1990 to August 2017. No language restrictions were applied. We independently selected studies, extracted data, and assessed risk of bias, and pairs of authors compared information. We contacted authors of studies for additional information if necessary. All pooled analyses were based on random effects models. We included individually or cluster randomized controlled trials that compared digital education with traditional learning, no intervention, or other forms of digital education. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. RESULTS Twenty studies (1382 participants) were included. Participants included pediatricians, physicians, nurses, and midwives. Digital education technologies were assessed including high-fidelity mannequins (6 studies), computer-based education (12 studies), mobile learning (1 study), and virtual reality (1 study). Most studies reported that digital education was either as effective as or more effective than the control intervention for outcomes including skill, knowledge, attitude, and satisfaction. High-fidelity mannequins were associated with higher postintervention skill scores compared with low-fidelity mannequins (standardized mean difference 0.62; 95% CI 0.17-1.06; moderate effect size, low-quality evidence). One study reported physician change in practicing behavior and found similar effects between offline plus online digital education and no intervention. The only study that assessed impact on patient outcome found no difference between intervention and control groups. None of the included studies reported adverse or untoward effects or economic outcomes of the digital education interventions. The risk of bias was mainly unclear or high. The quality of evidence was low due to study inconsistencies, limitations, or imprecision across the studies. CONCLUSIONS Digital education for postregistration health professions education in pediatrics is at least as effective as traditional learning and more effective than no learning. High-fidelity mannequins were found to be more effective at improving skills than traditional learning with low-fidelity mannequins. Computer-based offline/online digital education was better than no intervention for knowledge and skill outcomes and as good as traditional face-to-face learning. This review highlights evidence gaps calling for more methodologically rigorous randomized controlled trials on the topic. TRIAL REGISTRATION PROSPERO CRD42017057793; https://tinyurl.com/y5q9q5o6.
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Affiliation(s)
- Serena Brusamento
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Bhone Myint Kyaw
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Penny Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Li Li
- Office of Medical Education, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Lorainne Tudor Car
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom.,Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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