The safety of drugs for OTC use: what evidence is required for an NSAID switch?

Real-world Data and Evidence to support a switch in status from Prescription drug to Over the Counter drug as applied by the EMA, the US FDA, the MHRA, and the BfArM

PURPOSE

We studied under which circumstances and to what extent Real-World Data (RWD) and Real-World Evidence (RWE) were used in regulatory decisions when switching products from Prescription-only (Rx) to Over-the-Counter (OTC) status with the aim of extracting learnings that could be applied in future switches.

METHODS

Sanofi commissioned Clarivate Analytics to identify switches from Rx to OTC in the European Union (centrally by the European Medicines Agency [EMA] and in Germany by the Bundesinstitut für Arzneimittel und Medizinprodukte [BfArM]), in the United States by the Food and Drug Administration (FDA), and in the United Kingdom by the Medicines and Healthcare products Regulatory Agency (MHRA) as far back as data were available in the public domain, mainly Health Authority webpages. They covered the period from and including 2022 and went as far back as they could find data in their proprietary database or in the public domain; for the EMA back to 2008, the US FDA back to 2001, the UK MHRA back to 1991, and the German BfArM for the period 2013-2022. We also asked Clarivate to investigate the nature of acceptance of RWD and RWE, and to what extent they are accepted by the different regulators in their decision-making and approval processes.

FINDINGS

We found that the number of drugs available in the OTC segment is higher in regulatory jurisdictions where OTC policies are clear and supplemented by guidelines and transparent decision-making processes at the regulator level. A wide range of different data sources, many of which can be regarded as RWD/RWE in their broadest definitions, have been used to support switches. The data required by regulators to support a switch from Rx-only to OTC availability primarily centers on drug safety-both the drug's intrinsic safety and the safety associated with consumer usage.

IMPLICATIONS

Clear and transparent regulatory switch frameworks are conducive to growing the number of medicines available to consumers willing to self-manage their conditions. Transparent disclosure of the RWD and RWE data sets that regulators have found acceptable in historic switch applications is desirable because it would help sponsors to facilitate and increase prospective switches, thereby benefiting patients and society.

Flavonoids in Ecuadorian Oreocallis grandiflora (Lam.) R. Br.: Perspectives of Use of This Species as a Food Supplement

Oreocallis grandiflora (Lam.) R. Br. is an Ecuadorian species belonging to the Proteaceae family, commonly known as cucharillo (Loja and Zamora provinces), cucharilla (Sierra region), gañal (Bolívar province), and algil (Chimborazo province). Its leaves and flowers, collected during blooming, are traditionally used for oral administration to treat liver diseases, vaginal bleeding, and ovary/uterus inflammation and as digestive, diuretic, and hypoglycemic remedy. Related literature does not report any scientific evidences regarding the chemical composition of the used parts of this species (leaves and flowers), while few indications are reported about the healthy properties of their preparations. Based on these premises, the present research was performed with the objectives to fill the gaps of the chemical and biological knowledge about this species, enriching the knowledge related to the plant biodiversity of Amazonian Ecuador and to the ethnobotanical tradition of Andean communities. Chemical and biological investigation (in vitro antioxidant and anti-inflammatory activity) of flower and leaf hydroalcoholic extracts shed a light on the functional metabolites putatively involved in healthy properties of the O. grandiflora traditional preparations. The chemical fingerprinting achieved by HPTLC and ¹HNMR analyses showed the presence of flavonoids, subsequently quantitatively estimated by AlCl₃ complexation assay and HPLC-DAD. Silica gel chromatography allowed the isolation of the main compounds of the flower extract: quercetin 3-O-β-glucuronide and myricetin 3-O-β-glucuronide. RP-HPLC-DAD-MS analyses showed the presence of quercetin 3-O-rutinoside and isorhamnetin 3-O-rutinoside, in addition to the above-mentioned molecules, in the leaf extract. Regarding the antioxidant (DPPH test, a radical scavenging assay) and anti-inflammatory (WST-1 assay, an oxidative burst test) activities, leaf extract showed the most promising results when compared to the positive controls. The same extract, however, exhibited a higher cytotoxicity compared to the flower extract, indicating the latter preparation as the most interesting anti-inflammatory crude drug.

Non-steroidal anti-inflammatory drugs and risk of first hospital admission for heart failure in the general population

OBJECTIVES

To estimate the risk of a first hospital admission for heart failure (HF) associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs).

METHODS

Cohort study with a nested case-control analysis based on the UK General Practice Research Database. Overall, 1396 cases of first hospital admission for non-fatal HF were identified (January 1997 to December 2000) and compared with a random sample of 5000 controls.

RESULTS

The incidence rate was 2.7/1000 person years. Prior clinical diagnosis of HF was the main independent risk factor triggering a first HF hospitalisation (relative risk 7.3, 95% confidence interval (CI) 6.1 to 8.8). The risk of a first hospital admission for HF associated with current use of NSAIDs was 1.3 (95% CI 1.1 to 1.6) after controlling for major confounding factors. No effects of dose and duration were found. The relative risk in current users of NSAIDs with prior HF was 8.6 (95% CI 5.3 to 13.8) compared with patients who did not use NSAIDs and without prior clinical diagnosis of HF.

CONCLUSION

Use of NSAIDs was associated with a small increase in risk of a first hospitalisation for HF. In patients with prior clinical diagnosis of HF, the use of NSAIDs may lead to worsening of pre-existing HF that triggers their hospital admission. This increased risk, although small, may result in considerable public health impact, particularly among the elderly.

Inhibition of respiratory burst in human neutrophils and lipoxygenase enzyme by compounds fromHaloxylon griffithii

Secondary metabolites, ferulic acid (1), 2,6-dimethoxy-4-hydroxy acetophenone (2), herniarin (3), p-hydroxy acetophenone (4), methyl 3,4-dihydroxycinnamate (5), and methyl 4-hydroxy-3-methoxycinnamate (6) were isolated from Haloxylon griffithii, a member of the family Chenopodiaceae. The structures of compounds 1-6 were identified with the help of spectroscopic techniques. These compounds were isolated for the first time from this plant. The lipoxygenase and respiratory burst inhibitory activities were determined. Compound 5 was found to be the most potent inhibitory activity against respiratory burst in human neutrophils among all the compounds as well as exhibited moderate lipoxygenase inhibitory activity from this plant.

Nonsteroidal anti-inflammatory drugs and risk of ARF in the general population

BACKGROUND

Most epidemiological studies evaluating the association between nonsteroidal anti-inflammatory drugs (NSAIDs) and acute renal failure (ARF) found an increased risk for developing ARF while taking NSAIDs. Despite these studies, little is known about the effect of dose and duration of therapy, risk of individual NSAIDs, comorbidity, or concomitant use of other nephrotoxic drugs.

METHODS

This is a nested case-control study using the General Practice Research Database from the United Kingdom. Participants were 386,916 patients aged 50 to 84 years on January 1, 1997, and free of known cancer, renal disorder, cirrhosis, or systemic connective tissue disease. After validation of cases identified from this cohort, 103 patients were confirmed as idiopathic cases of ARF and compared with 5,000 controls frequency matched by age and sex.

RESULTS

Current users of NSAIDs had a relative risk (RR) for ARF of 3.2 (95% confidence interval [CI], 1.8 to 5.8), and the risk declined after treatment was discontinued. Increased risk was present with both short- and long-term therapy and was slightly greater among users of high doses. History of heart failure (HF), hypertension, diabetes, and hospitalizations and consultant visits in the previous year were all associated with a greater risk for ARF. There was a suggestion of a modification of the effect of NSAIDs in patients with hypertension and those with HF. Use of selected cardiovascular drugs was associated with a 5-fold increase in risk for ARF. Diuretics presented the greatest risk. Risk increased with concomitant use of NSAIDs and diuretics (RR, 11.6; 95% CI, 4.2 to 32.2) and NSAIDs and calcium channel blockers (RR, 7.8; 95% CI, 3.0 to 20.5).

CONCLUSION

NSAID users had a 3-fold greater risk for developing a first-ever diagnosis of clinical ARF compared with non-NSAID users in the general population. NSAIDs should be used with special caution in patients with hypertension and/or HF.

Selecting nonprescription analgesics

Worldwide, there has been an emerging patient demand for access to efficient drugs without consulting a doctor and obtaining a prescription. As a result, there has been an expanding movement of prescription-only drugs to over-the-counter (OTC) status. An increasing number of drugs are becoming available OTC, empowering patients to treat themselves. Where the principle of empowering individuals to treat themselves can fail is when consumers lack the knowledge to do so safely. This potentially applies to the self-selection of analgesic drugs by consumers. When used inappropriately, these drugs pose significant risks. The nonsteroidal antiinflammatory drugs (NSAIDs) are associated with many adverse reactions, interactions, and contraindications in a number of patient groups, even at OTC doses. In particular, in the elderly, the high incidence of cardiovascular and gastrointestinal disease, coupled with age-related decline in renal function and multiple medication use, all warrant extra caution with the use of NSAIDs and make paracetamol the simple analgesic drug of first choice. Despite the possibility of hepatotoxicity in overdose, paracetamol represents a better all-round option for most patients requiring OTC analgesic therapy.

A large simple clinical trial prototype for assessment of OTC drug effects using patient-reported data

PURPOSE

Innovative methods are needed to assess risks related to treatment for common medical conditions, where therapy is usually patient-directed or over-the-counter (OTC), and where tolerability, i.e. patient experienced events, may affect patterns of use. A large-scale, blinded, randomised trial was conducted to compare the tolerability of paracetamol (acetaminophen), aspirin and ibuprofen at OTC doses, with patient-reported adverse event (AE) data as the primary outcome.

METHODS

Patients with mild to moderate pain were randomised to either: paracetamol up to 3 g/d, aspirin up to 3 g/d or ibuprofen up to 1200 mg/d for 7 days. Patients recorded AE and severity in a diary as the primary data source. After inclusion, contact with patients by general practitioner (GP) investigators was by telephone after 24 hours and 7-9 days, and unscheduled visits, when GPs recorded AE. The study outcome was the frequency of significant adverse event (SGAE) (serious, severe, moderate or undefined intensity, or resulting in withdrawal or an investigator visit).

RESULTS

Of 8677 patients included, 44 patients were non-evaluable, leaving 8633 evaluable patients; 1347 patients reported SGAE (paracetamol: 14.5%, aspirin: 18.7%, ibuprofen: 13.7%). Completed diaries were returned by 98.5% of patients, and only 49 cases were lost to follow-up (0.6%). Almost all patients were contacted by telephone, 99.3% at the first call, and 98.5% at the second. Most SGAE were reported by patients; only 27 patients (2%) had a SGAE reported only by the GP. The tolerability rankings by treatment were consistent for all categories of SGAE: aspirin had the highest incidence of SGAE, and ibuprofen and paracetamol, lower, comparable incidences.

CONCLUSIONS

A large, simple, randomised trial with patient-generated data can provide a sensitive source of information on AE, particularly in comparative safety assessments of OTC medications and other short-term therapies. This suggests reconsideration of the view that investigators are the most valid source for identifying and reporting AE.

Over-the-counter analgesics in older adults: a call for improved labelling and consumer education

The use of analgesics increases with age and on any given day 20-30% of older adults take an analgesic medication. Over-the-counter (OTC) analgesics are generally well tolerated and effective when taken for brief periods of time and at recommended dosages. However, their long-term use, use at inappropriately high doses, or use by persons with contraindications may result in adverse effects, including gastrointestinal haemorrhage, cardiovascular toxicity, renal toxicity and hepatotoxicity. Many OTC drugs are also available through a prescription, for a broader range of indications and for longer durations of use and wider dose ranges, under the assumption that healthcare providers will help patients make safe choices about analgesics. Safe and effective use of medications is one of the greatest challenges faced by healthcare providers in medicine. More than 60% of people cannot identify the active ingredient in their brand of pain reliever. Additionally, about 40% of Americans believe that OTC drugs are too weak to cause any real harm. As a result of a recent US FDA policy, the conversion of prescription to OTC medications will result in a 50% increase of OTC medications. To reduce the risks of potential adverse effects from OTC drug therapy in older adults, we propose that the use of analgesics will be enhanced through the use of patient and healthcare provider education, as well as improved labelling of OTC analgesics. Improved labelling of OTC analgesics may help consumers distinguish common analgesic ingredients in a wide variety of preparations and facilitate informed decisions concerning the use of OTC drugs.

Anti-inflammatory isoflavonoids from the rhizomes of Iris germanica

The anti-inflammatory activity of nine isoflavonoids 5,7-dihydroxy-3-(3'-hydroxy-4',5'dimethoxy)-8-methoxy-4H-1-benzopyran-4-one 1, 5,7-dihydroxy-3-(3'-hydroxyl-4', 5'-dimethoxy)-6-methoxy-4H-1-benzopyran-4-one 2, 5, 7-dihydroxy-3-(4'-hydroxy)-6-methoxy-4H-1-benzopyrane-4-one 3, 5-hydroxy-3-(4'-hydroxy)-6,7-methylenedioxy-4H-1-benzopyran-4-one 4, 5-hydroxy-3-(4'-methoxy)-6,7-methylenedioxy-4H-1-benzopyran-4-one 5, 5-methoxy-3-(4'-hydroxy)-6,7-methyenedioxy-4H-1-benzopyran-4-one 6, 5,7-dihydroxy-3-(3'-hydroxy-4'-methoxy)-6-methoxy-4H-1-benzopyran-4-one 7, 5,7-dihydroxy-3-(3'-methoxy-4'-hydroxy)-6-methoxy-4H-1-benzopyran-4-one 8, and isopeonol 9 determined by a spectrophotometric assay using the activated human neutrophils. These isoflavonoids were isolated from an important folkloric medicinal plant Irsa (Iris germanica L.), a member of the family Iridaceae. Structures of these compounds were identified by spectral comparison with the reported data and active members of this group adds into the growing number of non-steroidal anti-inflammatory agents.