The utilization and challenges of Japan's MID‐NET ® medical information database network in postmarketing drug safety assessments: A summary of pilot pharmacoepidemiological studies

Risk of neutropenia in psoriasis patients prescribed anti-IL-23 antibody in comparison with anti-IL-17 antibody or adalimumab based on real-world data from the MID-NET® in Japan

BACKGROUND

To evaluate the risk of neutropenia during treatment with anti-IL-23 antibodies in patients with psoriasis.

METHOD

We conducted an observational study with cohort design using MID-NET® in Japan. We identified patients with psoriasis who were newly prescribed anti-IL-23 antibodies, anti-IL-17-antibodies, adalimumab, or apremilast between January 1, 2009, and March 31, 2021. We estimated the adjusted hazard ratio (aHR) of anti-IL-23 antibodies compared to that of anti-IL-17 antibodies, adalimumab, or apremilast, for the risk of grade 2 (neutrophil count < 1,500/μL) or grade 3 (neutrophil count < 1,000/μL) neutropenia.

RESULTS

Overall, 287 patients on anti-IL-23 antibodies, 189 patients on anti-IL-17 antibodies, 293 patients on adalimumab, and 540 patients on apremilast were included. Compared with anti-IL-17 antibodies, the aHR (95% confidence interval (CI)) of anti-IL-23 antibodies was 0.83 (0.27-2.51) for grade 2 and 0.40 (0.02-7.60) for grade 3 neutropenia; that when compared with adalimumab was 0.76 (0.28-2.06) for grade 2 but was not calculated for grade 3 as no cases were found; and that compared with apremilast was 3.88 (0.62-24.48) for grade 2 and 0.43 (0.02-11.63) for grade 3 neutropenia.

CONCLUSION

No clear increase in the risk of neutropenia with anti-IL-23 antibodies was observed.

Increased risk of hypocalcemia with decreased kidney function in patients prescribed bisphosphonates based on real-world data from the MID-NET® in Japan: a new-user cohort study

BACKGROUND

In the post-marketing stage, cases of hypocalcemia associated with bisphosphonate preparations (BPs) have been reported in patients with decreased kidney function, despite warning against use of BPs in such patients in the package insert (PI) of Japan. The purpose of this study was to investigate the safety of BPs in patients with decreased kidney function.

METHODS

The cohort study was conducted in patients with osteoporosis and newly prescribed bisphosphonate utilizing real-world data from MID-NET® in Japan. The adjusted hazard ratios (aHRs) for hypocalcemia (a corrected serum Ca level < 8.00 mg/dL) relative to the normal group were calculated in each decreased kidney function group (mild, moderate or severe group).

RESULTS

A total of 14,551 patients were included in the analysis, comprising 2,601 (17.88%) with normal (eGFR ≥ 90 mL/min/1.73m2), 7,613 (52.32%) with mild (60 ≤ eGFR < 90 mL/min/1.73m2), 3,919 (26.93%) with moderate (30 ≤ eGFR < 60 mL/min/1.73m2), and 418 (2.87%) with severe kidney function (eGFR < 30 mL/min/1.73m2). The aHRs (95% confidence interval) for hypocalcemia were 1.85 (0.75-4.57), 2.30 (0.86-6.21), and 22.74 (8.37-61.78) in the mild, moderate, and severe groups, respectively. The increased risk of hypocalcemia depending on kidney function was also observed even when calculating the aHR for each specific BP such as alendronate sodium hydrate, minodronic acid hydrate, and sodium risedronate hydrate. Furthermore, similar results were obtained in the sensitivity analysis by altering the outcome definition to a 20% or more reduction in corrected serum Ca level from the baseline, as well as when focusing on patients with more than one laboratory test result per 30 days during the follow-up period.

CONCLUSIONS

These findings suggest that the risk of hypocalcemia during BP prescription is higher in patients with decreased kidney function, particularly those with severely decreased kidney function. The quantitative real-world evidence on the safety risk of BPs obtained in this study has led to the PI revision describing a relationship between hypocalcemia risk and decreased kidney function as a regulatory action in Japan and will contribute to promoting the proper use of BPs with appropriate risk management in clinical practice.

A new electronic medical record database linked to claims data and discharge abstract data (the RWD database) in Japan: Study design and profile

Background

This article aims to introduce the Real World Database-a new clinical database in Japan.

Methods

The Health, Clinic, and Education Information Evaluation Institute and Real World Data Co., Ltd. began developing the Real World Database in 2015. This is an electronic medical record database linked to claims data and discharge abstract data from medical institutions in Japan. The institutions agreed to collect data from 218 medical institutions as of June 2021.

Results

In 2019, 82 medical institutions provided data, which showed that 2,184,666 patients received treatment at medical institutions. There were also 334,437 inpatients with at least one hospital stay and 2,011,628 outpatients with at least one visit. More than 200 laboratory test results were available.

Discussion

This database is a potential data source for producing descriptive studies, comparative effectiveness studies, studies of adverse effects, and prediction studies.

Conclusions

The Real World Database provides an opportunity and strategy to produce real-world evidence for Japan.

Real-world prescription of anti-COVID-19 drugs in hospitalized patients with COVID-19 in Japan

OBJECTIVE

Prescription trends and patterns of anti-COVID-19 drugs in hospitalized patients were examined based on real world data to understand the use of anti-COVID-19 drugs in clinical practice in Japan.

DESIGN

The longitudinal and cross-sectional study was conducted utilizing data from January 1, 2019 to December 31, 2021 of the MID-NET® medical information database, which stored the electronic medical records, administrative claim data, and diagnosis procedure combination data of patients in Japan.

PARTICIPANTS

Hospitalized patients with a COVID-19-related diagnosis who received at least one anti-COVID-19 drug between April 1, 2020 and December 31, 2021.

EXPOSURES

The following 14 drugs were included in this study: remdesivir, baricitinib, combination product of casirivimab and imdevimab, favipiravir, dexamethasone, ivermectin, azithromycin, nafamostat mesylate, camostat mesylate, ciclesonide, tocilizumab, sarilumab, combination product of lopinavir and ritonavir, and hydroxychloroquine.

RESULTS

We identified 5,717 patients hospitalized with COVID-19 and prescribed at least one anti-COVID-19 drug. The entire cohort generally included patients over 41-50 years and more males. The most common prescription pattern was dexamethasone monotherapy (22.9%), followed by the concomitant use of remdesivir and dexamethasone (15.0%), azithromycin monotherapy (15.0%), remdesivir monotherapy (10.2%), and nafamostat mesylate monotherapy (8.5%). However, an often prescribed anti-COVID-19 drug differed depending on the period.

CONCLUSIONS AND RELEVANCE

This study revealed the real-world situation of anti-COVID-19 drug prescriptions in hospitalized COVID-19 patients in Japan. A prescribed drug would depend on the latest scientific evidence, such as efficacy, safety, and approval status, at the time of prescription. Understanding the prescription of anti-COVID-19 drugs will be important for providing the most up-to-date treatments to patients and evaluating the benefit and/or risk of anti-COVID-19 drugs based on the utilization of an electronic medical record database.

Prescription trend and lactic acidosis in patients prescribed metformin before and after the revision of package insert for allowing metformin administration to patients with moderately decreased kidney function based on real-world data from MID-NET® in Japan

Introduction

This study was conducted to understand the impact of package insert (PI) revision in Japan on 18 June 2019 to allow metformin use for patients with moderately decreased kidney function (30 ≤ estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2).

Methods

A new user cohort design was employed to examine the prescription trend and the occurrence of lactic acidosis in patients prescribed metformin before and after PI revision using the Medical Information Database Network (MID-NET®).

Results

From 12 May 2016 to 31 March 2020, 5,874 patients (before, n = 4,702; after, n = 1,172) were identified as new metformin users, including 1,145 patients (before, n = 914; after, n = 231) with moderately decreased kidney function. Although no marked changes in metformin prescription were observed before and after PI revision, the daily metformin dose at the first prescription decreased after PI revision. For both before and after PI revision, less than 10 cases of lactic acidosis occurred in all patients prescribed metformin, and no lactic acidosis was observed in patients with moderately decreased kidney function.

Conclusion

The results of this study are useful for understanding the safety of metformin use in patients with decreased kidney function and suggest no worse impacts of PI revision in Japan, indicating no further safety concerns on metformin use in patients with moderately decreased kidney function under the situation with careful use and safety monitoring of metformin.

Lower Risks of Gastrointestinal Perforation and Intestinal Obstruction in Patients with Atypical Antipsychotics in Comparison with Typical Antipsychotics Based on Real-World Data from the MID-NET® in Japan

Intestinal perforation and obstruction are known to be one of the adverse events caused by antipsychotics; however, warning information on package inserts varies among antipsychotics. To investigate the risks of gastrointestinal perforation and intestinal obstruction in patients prescribed atypical antipsychotics compared with those in patients prescribed typical antipsychotics, a nested case-control study was conducted utilizing real-world data from the MID-NET® medical information database in Japan. The study period spanned from January 1, 2009, to December 31, 2018. We found that the risks of gastrointestinal perforation and intestinal obstruction in patients prescribed atypical antipsychotics were significantly lower than those in patients prescribed typical antipsychotics (adjusted odds ratio, 0.48; 95% confidence interval, 0.29-0.80). This finding was supported with prolonged periods for the exposure definition in the sensitivity analyses. In addition, no major differences in the risks of atypical antipsychotics, such as risperidone, quetiapine, olanzapine, and aripiprazole, were identified in this study. The safety profile regarding the lower risks of gastrointestinal perforation and intestinal obstruction in patients prescribed atypical antipsychotics should be considered when choosing antipsychotics in clinical practice in terms of the proper use of such drugs.

Dealing with missing data in laboratory test results used as a baseline covariate: results of multi-hospital cohort studies utilizing a database system contributing to MID-NET® in Japan

BACKGROUND

To evaluate missing data methods applied to laboratory test results used for confounding adjustment, utilizing data from 10 MID-NET®-collaborative hospitals.

METHODS

Using two scenarios, five methods dealing with missing laboratory test results were applied, including three missing data methods (single regression imputation (SRI), multiple imputation (MI), and inverse probability weighted (IPW) method). We compared the point estimates of adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) between the five methods. Hospital variability in missing data was considered using the hospital-specific approach and overall approach. Confounding adjustment methods were propensity score (PS) weighting, PS matching, and regression adjustment.

RESULTS

In Scenario 1, the risk of diabetes due to second-generation antipsychotics was compared with that due to first-generation antipsychotics. The aHR adjusted by PS weighting using SRI, MI, and IPW by the hospital-specific-approach was 0.61 [95%CI, 0.39-0.96], 0.63 [95%CI, 0.42-0.93], and 0.76 [95%CI, 0.46-1.25], respectively. In Scenario 2, the risk of liver injuries due to rosuvastatin was compared with that due to atorvastatin. Although PS matching largely contributed to differences in aHRs between methods, PS weighting provided no substantial difference in point estimates of aHRs between SRI and MI, similar to Scenario 1. The results of SRI and MI in both scenarios showed no considerable changes, even upon changing the approaches considering hospital variations.

CONCLUSIONS

SRI and MI provide similar point estimates of aHR. Two approaches considering hospital variations did not markedly affect the results. Adjustment by PS matching should be used carefully.

Characterizing Granulocytopenia Associated with Thiamazole in Patients with Hyperthyroidism Based on Real-World Data from the MID-NET in Japan

Despite the requirement of routine blood tests during thiamazole treatment in Japan, granulocytopenia among patients treated with thiamazole has been occasionally reported to the Pharmaceuticals and Medical Devices Agency (PMDA). To characterize granulocytopenia in patients with thiamazole in Japan, the effects of routine blood tests were examined in a cohort of new users of thiamazole or propylthiouracil utilizing the MID-NET. The occurrence of granulocytopenia (neutrophil count ≤ 1,500/μL) in a given period was compared between patients with and without blood test results prior to the period. The trend in neutrophil count during thiamazole treatment was also compared between patients with and without granulocytopenia. A nested case-control study based on the cohort was conducted to identify potential risk factors for granulocytopenia during thiamazole treatment. In the new user cohort including 4,371 patients treated with thiamazole, the occurrence of granulocytopenia in patients who had undergone blood tests at all previous periods was similar or higher than that among those who had not undergone blood test in all previous periods (e.g., adjusted odds ratio in period 2 was 1.63). The neutrophil count was relatively lower in the group of patients with granulocytopenia even before the occurrence of granulocytopenia. In a nested case-control study, an upward tendency of the risk was observed when a patient was co-prescribed anti-arrhythmic drugs or antiulcer drugs with thiamazole. The characteristics of granulocytopenia during thiamazole treatment elucidated in this study should be recognized in clinical practice for the proper use of thiamazole.

Use of National Database of Health Insurance Claims and Specific Health Checkups for examining practical utilization and safety signal of a drug to support regulatory assessment on postmarketing drug safety in Japan

The Pharmaceuticals and Medical Devices Agency (PMDA) has conducted many pharmacoepidemiological studies for postmarketing drug safety assessments based on real-world data from medical information databases. One of these databases is the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), containing health insurance claims of almost all Japanese individuals (over 100 million) since April 2009. This article describes the PMDA's regulatory experiences in utilizing the NDB for postmarketing drug safety assessment, especially focusing on the recent cases of use of the NDB to examine the practical utilization and safety signal of a drug. The studies helped support regulatory decision-making for postmarketing drug safety, such as considering a revision of prescribing information of a drug, confirming the appropriateness of safety measures, and checking safety signals in real-world situations. Different characteristics between the NDB and the MID-NET^® (another database in Japan) were also discussed for appropriate selection of data source for drug safety assessment. Accumulated experiences of pharmacoepidemiological studies based on real-world data for postmarketing drug safety assessment will contribute to evolving regulatory decision-making based on real-world data in Japan.

Assessing the Risk of Decrease in Kidney Function in Patients Prescribed Direct-Acting Antivirals for Hepatitis C Utilizing the MID-NET® Medical Information Database Network in Japan

An association between kidney disease and direct-acting antivirals against hepatitis C (DAAs) has been suggested, however the warning on the package insert (PI) of the drug varies among DAAs. In this study, the risk of decreased kidney function associated with DAAs marketed in Japan was investigated to determine whether the risk of kidney disease is a common adverse event and class effect of DAAs. Data for patients who were new users of DAAs marketed in Japan, with eGFR ≥ 45 mL/min/1.73 m² and without specific risk factors, were extracted from the MID-NET^® medical information database network in Japan. Changes from the baseline on estimated glomerular filtration rate (eGFR) categories (eGFR ≥ 90, 90 > eGFR ≥ 60, 60 > eGFR ≥ 45, 45 > eGFR ≥ 30, 30 > eGFR ≥ 15, 15 > eGFR; unit: mL/min/1.73 m²) were used for evaluating the risk of decreased kidney function. Exposure groups for DAAs and relevant concomitant drugs were categorized into 10 patterns based on the PI. Among the 10 patterns, a significant increase in the incidence rate ratio (P < 0.01) was observed in the prescription patterns of concomitant use of telaprevir with peginterferon alpha and ribavirin, concomitant use of daclatasvir hydrochloride with asunaprevir, and ombitasvir hydrate combined with paritaprevir hydrate and ritonavir, which were concomitantly used with ribavirin; such an increase was not observed in the other prescription patterns. The effects of DAAs on kidney function may differ among drugs, suggesting the possibility that the risk of kidney disease is not a class effect of DAAs and should be evaluated individually for each DAA.

MIHARI project, a preceding study of MID-NET, adverse event detection database of Ministry Health of Japan-Validation study of the signal detection of adverse events of drugs using export data from EMR and medical claim data

We studied the effectiveness of the direct data collection from electronic medical records (EMR) when it is used for monitoring adverse drug events and also detection of already known adverse events. In this study, medical claim data and SS-MIX2 standardized storage data were used to identify four diseases (diabetes, dyslipidemia, hyperthyroidism, and acute renal failure) and the validity of the outcome definitions was evaluated by calculating positive predictive values (PPV). The maximum positive predictive value (PPV) for diabetes based on medical claim data was 40.7% and that based on prescription data from SS-MIX2 Standardized Storage was 44.7%. The PPV for dyslipidemia was 50% or higher under either of the conditions. The PPV for hyperthyroidism based on disease name data alone was 20–30%, but exceeded 60% when prescription data was included in the evaluation. Acute renal failure was evaluated using information from medical records in addition to the data. The PPV for acute renal failure based on the data of disease names and laboratory examination results was slightly higher at 53.7% and increased to 80–90% when patients who previously had a high serum creatinine (Cre) level were excluded. When defining a disease, it is important to include the condition specific to the disease; furthermore, it is very useful if laboratory examination results are also included. Therefore, the inclusion of laboratory examination results in the definitions, as in the present study, was considered very useful for the analysis of multi-center SS-MIX2 standardized storage data.

Factors Influencing Classifications of Safety Specifications in a Risk Management Plan for Antineoplastic Agents Approved in Japan: A Review and Descriptive Analysis

A risk management plan (RMP) has an important role in assuring the optimal benefit-risk balance of a drug throughout its life cycle. However, no clear standards have been established for differentiating risk classification between "important identified risks" and "important potential risks". This study was a review and descriptive analysis for Japanese RMPs with a focus on antineoplastic agents to identify effective factors to discriminate an important identified risk from an important potential risk. Analysis based on 51 RMPs, reporting 310 important identified risks and 72 important potential risks, revealed significant associations between selection of the risk classification and several factors, including severe cases, actual cases in the Japanese population, availability of confirmatory trial data, and incidence of adverse events. Trend of the association was also found for discontinuation cases and immune-oncology agents [IO (drug type)]. These results suggest that consideration of these factors may be useful for coherent risk classification in creating a RMP.

Development of an application concerning fast healthcare interoperability resources based on standardized structured medical information exchange version 2 data

BACKGROUND AND OBJECTIVE

A mobile application for personal health records (PHR) would allow patients to access their clinical data easily. When PHR connects with multiple electronic health records (EHRs), doctors and patients can exchange large quantities of patient data from the EHR (e.g., medication list, diagnoses, allergies, and laboratory data). Furthermore, personal daily records can also be retrieved from PHR (e.g., blood pressure, pulse, dietary habits, and exercise). However, no standard interoperability between EHRs and PHR has been established. This study aims to convert clinical data in EHRs into the Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) data format while developing a PHR application to present the FHIR data.

METHODS

In Japan, Standardized Structured Medical Information eXchange version 2 (SS-MIX2) is typically utilized as a health information exchange to preserve and elicit clinical data from EHRs. We converted clinical data in the SS-MIX2 storage at Tohoku University Hospital into the FHIR repository server using the R4 standard. Additionally, we used the Swift programming language to build a PHR application.

RESULTS

We converted patients' basic information, disease names, diagnostic reports, prescriptions, and injection data from the SS-MIX2 to the FHIR server. Besides, we launched a PHR application that could retrieve data from the FHIR server to display patients' clinical information.

CONCLUSIONS

Our work demonstrated the conversion of SS-MIX2 data into the FHIR and presented them with our PHR application. This mechanism may be useful to accelerate the sharing of clinical information among doctors and patients.

Identification and Validation of Hemophilia-Related Outcomes on Japanese Electronic Medical Record Database (Hemophilia-REAL V Study)

Purpose

Routinely collected data are useful for epidemiological study in hemophilia, but few studies validated the algorithm accuracy. We aimed to develop and validate algorithms to identify patients with hemophilia A and hemophilia A-related events.

Patients and Methods

This validation study compared data from medical chart reviews to a database of routinely collected health data, including claims data and discharge abstracts, and especially electronic medical records (EMR), at a single Japanese hospital (Kurashiki Central Hospital) using a stratified sampling method. Two physicians reviewed the charts for all patients at high risk for hemophilia A, and randomly sampled patients with moderate risk. Diagnostic accuracy was determined based on sensitivity, specificity, positive predictive value (PPV), and negative predictive value.

Results

There were 1,033,845 eligible patients, of whom 31 had a diagnosis of hemophilia A. ICD-10 diagnosis code D66 in the EMR identified hemophilia A with a sensitivity of 93.5% (95% confidence interval: 78.6-99) and PPV of 61.7% (95% confidence interval: 46.4-75.5). The administration of ≥10,000 units/month of factor VIII products, as documented in the EMR, identified 81.3% of patients with prophylactic factor replacement therapy. The ICD-10 diagnosis code for intracranial bleeding in the EMR identified 75.0% of patients with intracranial bleeding, but those of gastrointestinal bleeding and major joint bleeding identified only 11.1% and 1.7%, respectively.

Conclusion

We developed and validated algorithms to identify congenital hemophilia A and hemophilia A-related events. Hemophilia A could be identified with high sensitivity and PPV, but it was still challenging to identify hemophilia A-related events.

Characteristics of hospital differences in missing of clinical laboratory test results in a multi-hospital observational database contributing to MID-NET® in Japan

Background

In Japan, a multiple-hospital observational database system, the Medical Information Database Network (MID-NET®), was launched for post-marketing drug safety assessments. These assessments will be based on datasets with missing laboratory results. The characteristics of missing data considering hospital differences have not been evaluated. We assessed the missing proportion and the association between missingness and a factor through case studies using a database system, a part of MID-NET®.

Methods

Seven scenarios using laboratory results before the prescription of the assessed drug as baseline covariates and data from 10 hospitals of Tokushukai Medical Group were used. The missing proportion and the association between missingness and patient background were investigated per hospital. The associations were assessed using the log of adjusted odds ratio (log-aOR). Additionally, an ad hoc survey was conducted to explore other factors affecting the missingness.

Results

For some laboratory tests, missing proportions varied among hospitals, such as 7.4–44.4% of alkaline phosphatase (ALP) and 8.1–31.2% of triglyceride (TG) among statin users. The association between missingness and affecting factors also differed among hospitals for some factors; example, the log-aOR of hospitalization associated with missingness of TG was − 0.41 (95% CI, − 1.06 to 0.24) in hospital 3 and 1.84 (95% CI, 1.34 to 2.34) in hospital 4. In the ad hoc survey focusing on ALP, hospital-dependent differences in the ordering system settings were observed.

Conclusions

Hospital differences in missing data appeared in some laboratory tests in our multi-hospital observational database, which could be attributed to the affecting factors, including the patient background.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01543-5.

Nested Case-Control Study Utilizing MID-NET® on Thrombocytopenia Associated With Pegfilgrastim in Patients Treated With Antineoplastic Agents

Although several spontaneous case reports on the occurrence of thrombocytopenia in patients treated with human granulocyte colony‐stimulating factor (G‐CSF) preparations have been accumulated, its actual causality is still unclear. To investigate the association between G‐CSF preparations (filgrastim, nartograstim, lenograstim, and pegfilgrastim) available in Japan and thrombocytopenia in patients treated with antineoplastic agents, a nested case‐control study was conducted using the Medical Information Database NETwork (MID‐NET®) with the cohort of the Japanese population taking antineoplastic agents between 2009 and 2018. A case of thrombocytopenia was defined as a patient who had decreased platelet counts (< 50,000/mm³). We identified a maximum of 10 controls for each case matched on the index date. Adjusted odds ratios (aORs) and their 95% confidence intervals (CIs) of thrombocytopenia for the use of G‐CSF preparations compared with nonuse were estimated using conditional logistic regression. From the cohort in which 33,124 patients were included, 733 cases and 5,592 controls were identified. Compared with the nonuse of G‐CSF preparations, the use of any G‐CSF preparations increased the risk of thrombocytopenia (aOR: 5.7, 95% CI: 4.3‐7.5). More detailed analysis showed that a distinctive increased risk was observed when pegfilgrastim was prescribed at 2–7 days before the index date (aOR: 7.4 95% CI: 2.0–28.1). Associations of the other G‐CSF preparations with thrombocytopenia were unclear due to the inconsistent results among different analyses. A significantly increased risk of thrombocytopenia associated with pegfilgrastim was identified, leading to a revision of precautions in the package inserts of pegfilgrastim as a regulatory safety action.

Effect of Hepatitis C Drugs on Blood Coagulability in Patients on Warfarin Using the Medical Information Database Network (MID-NET®) in Japan

Background

Previous studies suggested that direct-acting antivirals (DAAs) against hepatitis C increased the blood coagulability of patients on warfarin. This study aims to descriptively investigate the effects of DAAs on the blood coagulability and liver function of patients on warfarin in Japan.

Methods

The Medical Information Database Network (MID-NET^®) was used as data source. Fluctuations of blood coagulability and liver function were examined before and after DAA treatment in patients who were prescribed both DAAs and warfarin at least once during the study period from January 1, 2010, to December 31, 2017.

Results

For the 16 eligible patients, the mean values of both PT-INR and WSI (warfarin sensitivity index) defined as the value obtained by dividing the PT-INR by the warfarin daily dose slightly decreased at the date of completion of the DAA treatment in comparison with those at the date of initiation and subsequently increased at 12 weeks after treatment completion. In contrast, the warfarin daily dose increased at the date of completion of the DAA treatment, followed by a decrease at 12 weeks after its completion. Several laboratory tests related to the liver function also revealed a similar decrease at the end of the DAA treatment.

Conclusion

The analysis of MID-NET^® data provides useful information on drug safety assessment of real-world patients. The results of this study imply that fluctuation of the liver function test results may relate to the fluctuation of blood coagulability in patients on both DAA and warfarin. This study contributes to a deeper understanding of the usefulness and limitations of real-world data in MID-NET^® for regulatory purposes.

Supplementary information

The online version of this article (10.1007/s43441-020-00247-8) contains supplementary material, which is available to authorized users.

The dawning of the digital era in the management of hypertension

Awareness, treatment, and control of hypertension are of the utmost importance in conquering stroke and cardiovascular disease. To reduce the global burden of hypertension, the Japanese Society of Hypertension (JSH) established the "JSH Future Plan" based on an increasing need to transform the strategy for combating hypertension. In addition to energizing conventional approaches in basic, translational, and clinical research, the application of rapidly evolving digital health technologies and artificial intelligence to hypertension healthcare and research (digital hypertension) holds promise for providing further insights into the pathophysiology and therapeutic targets and implementing predictive, personalized, and preemptive approaches in clinical practice. With great potential to revolutionize the landscape of hypertension, digital hypertension has some technical, legal, ethical, social, and financial issues to overcome. Given the multidisciplinary framework, digital hypertension requires comprehensive and strategic collaboration among industry, academia, and government to move forward toward the goal of "Future Medicine".

Characteristics on Drug Safety Measures in Japan Stratified by System Organ Classes and Therapeutic Categories in Relation to the Approval Date

Revisions of drug package inserts (PIs) may be made immediately after approval or after considerable clinical experience; however, it is unclear whether there is a relationship between the characteristics of these safety measures and the period since drug approval. Here, we analyzed 209 cases of safety measures (revisions of the PIs) taken in Japan over 5 years (FY2014 to FY2018). The median, minimum, and maximum period from approval date in Japan to PI revision date was 6.29 years (interquartile range 2.68-15.53 years), 0.16 years, and 59.69 years, respectively. The cases were classified into four groups depending on types of adverse reaction and therapeutic category in relation to the national approval date and international birth date, resulting in the grouping together of particular adverse reactions and therapeutic drugs. For example, "Hepatobiliary disorders", "Blood and lymphatic system disorders", "Respiratory, thoracic and mediastinal disorders", "Antineoplastics", "Chemotherapeutics", and "Other agents affecting metabolism" were associated with the group of safety measures taken early after approval of a drug soon after the international birth date, suggesting that careful attention at an earlier stage after approval is necessary for these adverse reactions and drugs. Understanding such features of PI revisions makes pharmacovigilance planning more appropriate, contributing to the implementation of rapid and proper safety measures after drug approval.

Evolving Vision of Regulatory Science in the Global Medical Community

"Regulatory science" (RS) has been defined in various ways, but, nevertheless, the definitions of RS in different parts of the world include many common elements. It seems to be a common view that RS is not basic or applied science but, rather, focuses on the estimation and prediction of safety and efficacy. Thus, we think RS overall should incorporate not only RS specifically for medical product assessment but also RS engineering to provide prediction and estimation tools for those purposes, including guideline/guidance development. It is important as well to consider the potential contribution of RS to rational medicine (i.e., to evidence-based medicine in a broader context), and especially to real-world evidence generation. We will look at how definitions of RS have evolved, and how we believe RS might develop in the future. Taking a patient-centric view, we re-emphasize RS is an ethical science contributing to society and human welfare.

Establishment of the MID-NET® medical information database network as a reliable and valuable database for drug safety assessments in Japan

Purpose

To establish a new medical information database network (designated MID‐NET^®) to provide real‐world data for drug safety assessments in Japan.

Methods

This network was designed and developed by the Ministry of Health, Labour and Welfare and the Pharmaceuticals and Medical Devices Agency in collaboration with 23 hospitals from 10 healthcare organizations across Japan. MID‐NET^® is a distributed and closed network system that connects all collaborative organizations through a central data center. A wide variety of data are available for analyses, including clinical and administrative information. Several coding standards are used to standardize the data stored in MID‐NET^® to allow the integration of information originating from different hospitals. A rigorous and consistent quality management system was implemented to ensure that MID‐NET^® data are of high quality and meet Japanese regulatory standards (good post‐marketing study practice and related guidelines).

Results

MID‐NET^® was successfully established as a reliable and valuable medical information database and was officially launched in April 2018. High data quality with almost 100% consistency was confirmed between original data in hospitals and the data stored in MID‐NET^®. A major advantage is that approximately 260 clinical laboratory test results are available for analysis.

Conclusions

MID‐NET^® is expected to be a major data source for drug safety assessments in Japan. Experiences and best practices established in MID‐NET^® may provide a model for the future development of similar database networks.