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Pérez-Ingidua C, Rivas-Paterna AB, González-Perrino C, Aleo-Luján E, Ascaso-Del-Rio A, Laredo-Velasco L, Portolés-Pérez A, Vargas-Castrillón E. Adverse drug reactions in paediatric surgery: prospective study on frequency and risk related factors. BMC Pediatr 2024; 24:344. [PMID: 38760745 PMCID: PMC11102197 DOI: 10.1186/s12887-024-04803-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 05/02/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Paediatric patients are especially prone to experiencing adverse drug reactions (ADRs), and the surgical environment gathers many conditions for such reactions to occur. Additionally, little information exists in the literature on ADRs in the paediatric surgical population. We aimed to quantify the ADR frequency in this population, and to investigate the characteristics and risk factors associated with ADR development. METHODS A prospective observational study was conducted in a cohort of 311 paediatric patients, aged 1-16 years, admitted for surgery at a tertiary referral hospital in Spain (2019-2021). Incidence rates were used to assess ADR frequency. Odds ratios (ORs) were calculated to evaluate the influence of potential risk factors on ADR development. RESULTS Distinct ADRs (103) were detected in 80 patients (25.7%). The most frequent being hypotension (N = 32; 35%), nausea (N = 16; 15.5%), and emergence delirium (N = 16; 15.5%). Most ADRs occurred because of drug-drug interactions. The combination of sevoflurane and fentanyl was responsible for most of these events (N = 32; 31.1%). The variable most robustly associated to ADR development, was the number of off-label drugs prescribed per patient (OR = 2.99; 95% CI 1.73 to 5.16), followed by the number of drugs prescribed per patient (OR = 1.26, 95% CI 1.13 to 1.41), and older age (OR = 1.26, 95% CI 1.07 to 1.49). The severity of ADRs was assessed according to the criteria of Venulet and the Spanish Pharmacovigilance System. According to both methods, only four ADRs (3.9%) were considered serious. CONCLUSIONS ADRs have a high incidence rate in the paediatric surgical population. The off-label use of drugs is a key risk factor for ADRs development.
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Affiliation(s)
- C Pérez-Ingidua
- Clinical Pharmacology Department, Hospital Clínico San Carlos, Madrid, Spain
- Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - A B Rivas-Paterna
- Clinical Pharmacology Department, Hospital Clínico San Carlos, Madrid, Spain
- Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - C González-Perrino
- Anaesthesiology and Resuscitation Department, Hospital Clínico San Carlos, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - E Aleo-Luján
- Paediatric Intensive Care Unit and Postanaesthesia Recovery Unit, Hospital Clínico San Carlos, Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - A Ascaso-Del-Rio
- Clinical Pharmacology Department, Hospital Clínico San Carlos, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - L Laredo-Velasco
- Clinical Pharmacology Department, Hospital Clínico San Carlos, Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - A Portolés-Pérez
- Clinical Pharmacology Department, Hospital Clínico San Carlos, Madrid, Spain.
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
| | - E Vargas-Castrillón
- Clinical Pharmacology Department, Hospital Clínico San Carlos, Madrid, Spain
- Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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Sandes V, Figueras A, Lima EC. Pharmacovigilance Strategies to Address Resistance to Antibiotics and Inappropriate Use-A Narrative Review. Antibiotics (Basel) 2024; 13:457. [PMID: 38786184 PMCID: PMC11117530 DOI: 10.3390/antibiotics13050457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/11/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
The spread of antimicrobial resistance (AMR) is a global challenge. Close and continuous surveillance for quick detection of AMR can be difficult, especially in remote places. This narrative review focuses on the contributions of pharmacovigilance (PV) as an auxiliary tool for identifying and monitoring the ineffectiveness, resistance, and inappropriate use of antibiotics (ABs). The terms "drug ineffective", "therapeutic failure", "drug resistance", "pathogen resistance", and "multidrug resistance" were found in PV databases and dictionaries, denoting ineffectiveness. These terms cover a range of problems that should be better investigated because they are useful in warning about possible causes of AMR. "Medication errors", especially those related to dose and indication, and "Off-label use" are highlighted in the literature, suggesting inappropriate use of ABs. Hence, the included studies show that the terms of interest related to AMR and use are not only present but frequent in PV surveillance programs. This review illustrates the feasibility of using PV as a complementary tool for antimicrobial stewardship activities, especially in scenarios where other resources are scarce.
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Affiliation(s)
- Valcieny Sandes
- Postgraduate Program in Pharmaceutical Sciences, School of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho-373, Rio de Janeiro 21941-170, RJ, Brazil;
- National Cancer Institute, Pr. da Cruz Vermelha-23, Rio de Janeiro 20230-130, RJ, Brazil
| | | | - Elisangela Costa Lima
- Postgraduate Program in Pharmaceutical Sciences, School of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho-373, Rio de Janeiro 21941-170, RJ, Brazil;
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Leporini C, De Sarro C, Palleria C, Caccavo I, Piro B, Citraro R, De Sarro G. Pediatric Drug Safety Surveillance: A 10-Year Analysis of Adverse Drug Reaction Reporting Data in Calabria, Southern Italy. Drug Saf 2022; 45:1381-1402. [PMID: 36112324 PMCID: PMC9483327 DOI: 10.1007/s40264-022-01232-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2022] [Indexed: 01/09/2023]
Abstract
Introduction The paucity of pediatric clinical trials has led to many medicines frequently prescribed to children without a license for use in pediatrics, resulting in an increased risk of adverse drug reactions. Pharmacovigilance databases remain, among others, a valuable tool for evaluating pediatric drug safety in the real-life setting. Objective We aimed to characterize pediatric adverse drug reactions reported in the Italian Pharmacovigilance database coming from the Calabria region (Southern Italy) over 10 years. Methods All Individual Case Safety Reports (ICSRs) concerning individuals aged under 18 years were extracted from 2010 to 2019. Duplicate and vaccine ICSRs were excluded. The remaining ICSRs were analyzed with respect to patients’ demographic data, suspected drugs, and category of adverse drug reactions across different age groups. Results Among 6529 selected ICSRs, 395 pediatric ICSRs corresponding to 556 adverse drug reactions were analyzed. From 2010 to 2015, an increasing number of ICSRs were observed, but the reporting rate decreased after 2015. The highest proportion of ICSRs concerned children and adolescents. Around 52% of ICSRs involved boys: a trend observed in all age groups excluding newborns. Sixty ICSRs were serious and among them, 75% required hospitalization mainly in children and adolescents. Most of the ICSRs were issued by physicians (64.1%), followed by other healthcare professionals (22.5%) and pharmacists (9.9%). Anti-infective agents for systemic use and skin disorders were, respectively, the most frequently reported drug group and adverse drug reaction category. Conclusions This study provides an overview of adverse drug reactions reported in the pediatric population of the Calabria region and emphasizes the need for strengthening the surveillance in specific age subgroups and on given drugs in relation to their pattern of use. Supplementary Information The online version contains supplementary material available at 10.1007/s40264-022-01232-w.
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4
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Dubrall D, Leitzen S, Toni I, Stingl J, Schulz M, Schmid M, Neubert A, Sachs B. Descriptive analysis of adverse drug reaction reports in children and adolescents from Germany: frequently reported reactions and suspected drugs. BMC Pharmacol Toxicol 2021; 22:56. [PMID: 34620231 PMCID: PMC8499510 DOI: 10.1186/s40360-021-00520-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 09/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adverse drug reactions (ADRs) in the pediatric population may differ in types and frequencies compared to other populations. Respective studies analyzing ADR reports referring to children have already been performed for certain countries. However, differences in drug prescriptions, among others, complicate the transferability of the results from other countries to Germany or were rarely considered. Hence, the first aim of our study was to analyze the drugs and ADRs reported most frequently in ADR reports from Germany referring to children contained in the European ADR database (EudraVigilance). The second aim was to set the number of ADR reports in relation to the number of drug prescriptions. These were provided by the Research Institute for Ambulatory Health Care in Germany. METHODS For patients aged 0-17 years 20,854 spontaneous ADR reports were received between 01/01/2000-28/2/2019. The drugs and ADRs reported most frequently were identified. Stratified analyses with regard to age, sex and drugs used "off-label" were performed. Reporting rates (number of ADR reports/number of drug prescriptions) were calculated. RESULTS Methylphenidate (5.5%), ibuprofen (2.3%), and palivizumab (2.0%) were most frequently reported as suspected. If related to the number of drug prescriptions, the ranking changed (palivizumab, methylphenidate, ibuprofen). Irrespective of the applied drugs, vomiting (5.4%), urticaria (4.6%) and dyspnea (4.2%) were the ADRs reported most frequently. For children aged 0-1 year, drugs for the treatment of nervous system disorders and foetal exposure during pregnancy were most commonly reported. In contrast, methylphenidate ranked first in children older than 6 years and referred 3.5 times more often to males compared to females. If age- and sex-specific exposure was considered, more ADR reports for methylphenidate referred to children 4-6 years and females 13-17 years. Drugs for the treatment of nervous system disorders ranked first among "off-label" ADR reports. CONCLUSIONS Our analysis underlines the importance of putting the number of ADR reports of a drug in context with its prescriptions. Additionally, differences in age- and sex-stratified analysis were observed which may be associated with age- and sex-specific diseases and, thus, drug exposure. The drugs most frequently included in "off-label" ADR reports differed from those most often used according to literature.
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Affiliation(s)
- Diana Dubrall
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany. .,Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany.
| | - Sarah Leitzen
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany.,Department of Physics, Chemistry and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Irmgard Toni
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Julia Stingl
- Institute of Clinical Pharmacology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - M Schulz
- Central Research Institute of Ambulatory Health Care in Germany, Berlin, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Antje Neubert
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Bernhardt Sachs
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany.,Department for Dermatology and Allergy, University Hospital Aachen, Aachen, Germany
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Suk JW, Soltis-Vaughan B, Mahato K, Hwang S. Practical and Ethical Issues in Pediatric Psychopharmacology: Introductory Considerations. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20210913-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lagler FB, Hirschfeld S, Kindblom JM. Challenges in clinical trials for children and young people. Arch Dis Child 2021; 106:321-325. [PMID: 33077422 DOI: 10.1136/archdischild-2019-318676] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 07/07/2020] [Accepted: 09/12/2020] [Indexed: 01/21/2023]
Abstract
There is a well-known knowledge gap regarding the efficacy and safety of medicines in children of all ages and children are often treated with medicines off-label. Children are thus deprived of treatment based on the same quality of information that guides treatment in adults. The knowledge gap regarding efficacy and safety of medicines in children has been acknowledged by authorities and is reflected in legislation both in North America and in the European Union. Recent reports on the effects of legislation indicates that paediatric clinical trials remain a challenge.Paediatric clinical trials are needed in the entire developmental age spectrum and are especially needed in certain therapy areas. Paediatric clinical trials have special features compared with trials in adults, and these need to be taken into account. These special features include scientific issues related to small samples and heterogeneity, the consent/assent procedure, the need for age-appropriate study information, specific outcomes and safety issues related to development and maturation. Competence in paediatric clinical trials is required in both designing, planning, co-ordinating and organising paediatric clinical trials, as well as research infrastructure and networks to increase power and disseminate information and expert advice. Strengthening of paediatric clinical research is essential to facilitate generating the data that will let children enjoy new medical advances in a similar manner as adults.
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Affiliation(s)
- Florian B Lagler
- Institute for Inherited Metabolic Diseases and Department of Pediatrics, Paracelsus Medical University, Clinical Research Center Salzburg GmBH, Strubergasse 21, Salzburg, Austria.,European Society of Developmental, Perinatal and Pediatric Pharmacology (ESDPPP) council, Leuven, Belgium
| | - Steven Hirschfeld
- Uniformed Services University of the Health Sciences, 4201 Jones Bridge Road, Bethesda, Maryland, 20814 USA
| | - Jenny M Kindblom
- European Society of Developmental, Perinatal and Pediatric Pharmacology (ESDPPP) council, Leuven, Belgium .,Pediatric Clinical Research Center, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Goteborg, Sweden
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Leitzen S, Dubrall D, Toni I, Stingl J, Schulz M, Schmid M, Neubert A, Sachs B. Analysis of the reporting of adverse drug reactions in children and adolescents in Germany in the time period from 2000 to 2019. PLoS One 2021; 16:e0247446. [PMID: 33657139 PMCID: PMC7928460 DOI: 10.1371/journal.pone.0247446] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 02/07/2021] [Indexed: 11/18/2022] Open
Abstract
The objective of this study was to analyse reports on adverse drug reactions (ADRs) from Germany in the particularly vulnerable patient group of children and adolescents. Reporting characteristics, demographic parameters and off-label use were examined among others. The ratio of ADR reports per number of German inhabitants and the ratio of ADR reports per number of German inhabitants exposed to drugs were calculated and compared. These parameters were examined to derive trends in reporting of ADRs. 20,854 spontaneous ADR reports for the age group 0-17 years were identified in the European ADR database EudraVigilance for the time period 01.01.2000-28.02.2019 and analysed with regard to the aforementioned criteria. 86.5% (18,036/20,854) of the ADR reports originated from Healthcare Professionals and 12.2% (2,546/20,854) from non-Healthcare Professionals. 74.4% (15,522/20,854) of the ADR reports were classified as serious. The proportion of ADR reports per age group was 11.8% (0-1 month), 11.0% (2 months-1 year), 7.4% (2-3 years), 9.3% (4-6 years), 25.8% (7-12 years), and 34.8% (13-17 years) years, respectively. Male sex slightly dominated (51.2% vs. 44.8% females). Only 3.5% of the ADR reports reported off-label use. The annual number of ADR reports increased since 2000, even if set in context with the number of inhabitants and assumed drug-exposed inhabitants. The pediatric population declined in the study period which argues against its prominent role for the increase in the total number of ADR reports. Instead, among others, changes in reporting obligations may apply. The high proportion of serious ADR reports underlines the importance of pediatric drug safety.
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Affiliation(s)
- Sarah Leitzen
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany
- Department of Physics, Chemistry and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Diana Dubrall
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Irmgard Toni
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Julia Stingl
- Institute of Clinical Pharmacology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Maike Schulz
- Central Research Institute of Ambulatory Health Care in Germany, Berlin, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Antje Neubert
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Bernhardt Sachs
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany
- Department for Dermatology and Allergy, University Hospital Aachen, Aachen, Germany
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Mascolo A, Scavone C, Bertini M, Brusco S, Punzo F, Pota E, Di Martino M, Di Pinto D, Rossi F. Safety of Anticancer Agents Used in Children: A Focus on Their Off-Label Use Through Data From the Spontaneous Reporting System. Front Pharmacol 2020; 11:621. [PMID: 32457620 PMCID: PMC7221123 DOI: 10.3389/fphar.2020.00621] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 04/20/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Among factors influencing the higher risk of developing unknown or rare adverse drug reactions (ADRs) among children and adolescents, there is the frequent off-label use of drugs that seems to be very common in pediatric oncological patients. Our study aim to collect and evaluate data on the safety profile of antineoplastic drugs and their off-label use in the pediatrics population using real life data. METHODS We retrieved Individual Case Safety Reports (ICSRs) with an anticancer agent as suspected drug among those reported through the Campania spontaneous reporting system from 1 January 2013 to 30 September 2019. We classified ICSRs into four off-label categories: "age," "route of administration," "weight," and "therapeutic indication." We defined an ICSR as an off-label case if it met at least one of the aforementioned categories for at least one of the reported suspected antineoplastic drugs. RESULTS A total of 18 ICSRs (7.6%) out of 236 were classified as off-label cases. The median age of patients was 13 years (interquartile range, IQR: 6-16), with 94.4% of cases occurring in male patients. In the classification of the off-label category, 16 ICSRs were categorized according to the "therapeutic indication" and two for the "age." No case was categorized for the off-label categories "route of administration" and "weight." The two off-label cases categorized as "age" were both related to the use of brentuximab vedotin for Hodgkin's lymphoma in patients aged 16 years. Twenty-nine ADRs (1.6 suspected adverse drug reactions per ICSR) were identified among off-label cases. Among ADRs, those reported more than one were diarrhea (N = 3), neutropenia (N = 3), nausea (N = 2), pyrexia (N = 2), and vomit (N = 2). CONCLUSIONS Our findings showed a low number of ICSRs classified as off-label. The majority of off-label ICSRs were categorized for the "therapeutic indication." This low number of off-label ICSRs might be largely due to the underreporting phenomenon, which is a major limit in pharmacovigilance. Therefore, we believe that spreading pharmacovigilance knowledge and awareness might improve this aspect.
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Affiliation(s)
- Annamaria Mascolo
- Department of Experimental Medicine–Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Cristina Scavone
- Department of Experimental Medicine–Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Michele Bertini
- Department of Experimental Medicine–Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Simona Brusco
- Department of Experimental Medicine–Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Francesca Punzo
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Elvira Pota
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Martina Di Martino
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Daniela Di Pinto
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Francesca Rossi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy
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Oshikoya KA, Abayomi Ogunyinka I, Godman B. Off-label use of pentazocine and the associated adverse events among pediatric surgical patients in a tertiary hospital in Northern Nigeria: a retrospective chart review. Curr Med Res Opin 2019; 35:1505-1512. [PMID: 30836774 DOI: 10.1080/03007995.2019.1591109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background and aims: Pentazocine remains a widely used opioid pre-anesthetic medication and post-operative analgesic in low- and middle-income countries despite concerns. We assessed the adverse events (AEs) associated with off-label use of pentazocine in pediatric surgical patients and determined the possible risk factors associated with slow respiratory AEs.Method: Children ≤18 years old were administered pentazocine IM/IV as a pre-anesthetic medication or post-operative analgesic. Pertinent data including total daily dose and duration of use of pentazocine and its associated AEs were obtained from patients' case files. Risk factors associated with slow respiratory AEs were determined using logistic regression analyses.Results: One hundred and fifty-nine patients were included with a median age of 2 years; they were mainly males (52.8%). Pentazocine was administered off-label to all patients for post-operative pain management (96.2%) or pre-anesthetic medication (3.8%). All patients experienced at least one AE with most experiencing 2-7 AEs. Rapid breathing (120; 18.7%), followed by fast pulse (101; 15.7%) and sleepiness/sedation/drowsiness (81; 12.6%) were the most common AEs. None of the demographics and clinical variables significantly predicted the risk of slow respiratory AEs.Conclusion: Off-label use of pentazocine is common and associated with multiple AEs. Care is needed as no predictors of slow respiratory AEs were observed.
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Affiliation(s)
- Kazeem A Oshikoya
- Department of Pharmacology, Therapeutics and Toxicology, Lagos State University College of Medicine, Lagos, Nigeria
| | | | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Division of Clinical Pharmacology, Karolinska Institutet, Solna, Sweden
- Health Economics Centre, Liverpool University Management School, Liverpool, UK
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Oshikoya KA, Wharton GT, Avant D, Van Driest SL, Fenn NE, Lardieri A, Doe E, Sood BG, Taketomo C, Lieu P, Yen L, McMahon AW. Serious Adverse Events Associated with Off-Label Use of Azithromycin or Fentanyl in Children in Intensive Care Units: A Retrospective Chart Review. Paediatr Drugs 2019; 21:47-58. [PMID: 30484072 PMCID: PMC6387682 DOI: 10.1007/s40272-018-0318-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Half of prescription drugs commonly given to children lack product labeling on pediatric safety, efficacy, and dosing. Two drugs most widely used off-label in pediatrics are azithromycin and fentanyl. We sought to determine the risk of serious adverse events (SAEs) when oral azithromycin or intravenous/intramuscular fentanyl are used off-label compared to on-label in pediatric intensive care units (ICUs). STUDY DESIGN Six pediatric hospitals participated in a retrospective chart review of patients administered oral azithromycin (n = 241) or intravenous/intramuscular fentanyl (n = 367) between January 5, 2013 and December 26, 2014. Outcomes were SAEs by drug and labeling status: off-label compared to on-label by Food and Drug Administration (FDA)-approved age and/or indication. Statistical analysis was performed using logistic regression to estimate odds ratios (ORs) and Cox regression to estimate hazard ratios (HRs). RESULTS Twenty-one (9%) children receiving azithromycin experienced SAEs. Off-label use of azithromycin was not associated with a higher risk of SAE (OR 0.87, 95% CI 0.27-2.71, p = 0.81). Ninety-five (26%) children receiving fentanyl experienced SAEs. Fentanyl off-label use by both age and indication was not associated with a higher risk of overall SAEs compared to on-label use (OR 1.99, 95% CI 0.94-4.19, p = 0.07). However, the risk of the SAE respiratory depression was significantly greater when fentanyl was used off-label by both age and indication (OR 5.05, 95% CI 1.08-23.56, p = 0.044). Results based on HRs were similar. CONCLUSIONS Azithromycin off-label use in pediatric ICUs does not appear to be associated with an increased risk of SAEs. Off-label use of fentanyl appears to be more frequently associated with respiratory depression when used off-label by both age and indication in pediatric ICUs. Prospective studies should be undertaken to assess the safety and efficacy of fentanyl in the pediatric population so that data can be added to the FDA labeling.
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Affiliation(s)
| | - Gerold T. Wharton
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration, 10903 New Hampshire Avenue, Building 32, Room 5158, Silver Spring, MD 20993, USA
| | - Debbie Avant
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration, 10903 New Hampshire Avenue, Building 32, Room 5158, Silver Spring, MD 20993, USA
| | | | | | | | - Edwin Doe
- INOVA Children’s Hospital, Falls Church, VA, USA
| | | | | | - Phuong Lieu
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Lilly Yen
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Ann W. McMahon
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration, 10903 New Hampshire Avenue, Building 32, Room 5158, Silver Spring, MD 20993, USA
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11
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Risk analysis in pediatric inpatients. Arch Pediatr 2018; 25:405-410. [DOI: 10.1016/j.arcped.2018.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 06/28/2018] [Accepted: 08/15/2018] [Indexed: 11/20/2022]
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12
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Moulis F, Durrieu G, Lapeyre-Mestre M. Off-label and unlicensed drug use in children population. Therapie 2018; 73:135-149. [PMID: 29580614 DOI: 10.1016/j.therap.2018.02.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 11/15/2017] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Off-label (OL) and unlicensed (UL) drug use is widely developed in the pediatric population according to previous reviews published in the early 2010s. The present study is a narrative review of the literature of OL-UL drug use from 2013. METHODS We performed a literature search of research articles assessing OL-UL drug use in children (<18 years-old) published in Medline® from January 2013 until May 2017. RESULTS Twenty-seven studies were included. OL drug use was defined by inappropriate age, indication, dosage or way of administration according to the summary of product characteristics in >80% of studies. UL drug used was defined by the use of drugs not licensed in the country or modifications of licensed drugs in >70% of studies. Among in- and out-patients, the frequency of patients exposed to at least one OL-UL drug ranged from 36.3 to 97.0% and from 18.6 to 40.2%, respectively. Drug use was categorized as OL mostly due to inappropriate age, dosage or indication. OL-UL drug use was the most prevalent in newborns (mainly preterms) and pre-school children (aged 2-5years). Various drugs were involved, depending on patients' age. Polypharmacy and long hospital stays were risk factors for OL-UL drug use. Whether OL-UL drug use leads to a higher incidence of adverse drug reactions is a controversial finding. CONCLUSIONS OL-UL drug use is frequent in children. A standardized definition of OL-UL drug use is needed to better assess its frequency, risk factors and impact.
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Affiliation(s)
- Florence Moulis
- Department of medical and clinical pharmacology, Toulouse university hospital, faculty of medicine, 37, allées Jules-Guesde, 31000 Toulouse, France
| | - Geneviève Durrieu
- Department of medical and clinical pharmacology, Toulouse university hospital, faculty of medicine, 37, allées Jules-Guesde, 31000 Toulouse, France.
| | - Maryse Lapeyre-Mestre
- Department of medical and clinical pharmacology, Toulouse university hospital, faculty of medicine, 37, allées Jules-Guesde, 31000 Toulouse, France
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Oshikoya KA, Oreagba IA, Godman B, Fadare J, Orubu S, Massele A, Senbanjo IO. Off-label prescribing for children with chronic diseases in Nigeria; findings and implications. Expert Opin Drug Saf 2017. [PMID: 28627939 DOI: 10.1080/14740338.2017.1344639] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Prescribing medicines in an off-label manner for children with chronic conditions is sparsely documented, even more so among developing countries. This needs addressing. The objective of this research was to investigate the extent of off-label prescribing among children with epilepsy, asthma, and sickle cell anaemia in Nigeria. METHODS Prescriptions for children ≤16 years documented in their case files that attended paediatric clinics in Lagos, Nigeria, for these three conditions between January and October 2015, were reviewed retrospectively to extract data on the medicines prescribed. British National Formulary for children and American Hospital Formulary Service Drug information were used as references. RESULTS 477 patients received 1746 prescriptions. Off-label prescriptions were seen in 7.7% of prescriptions, related to dose (93; 68.9%), indication (22; 16.3%), and age (20; 14.8%). Nervous system (525; 30.1%) and anti-infective (441; 25.2%) medicines were the most prescribed but only 9.5% and 8.2% of the respective prescriptions were off-label. Children with epilepsy received the most number (94; 69.6%) of off-label prescriptions. The three chronic conditions did not associate significantly with the category of off-label medicine prescribed (p = 0.925). CONCLUSION Off-label prescribing for children with epilepsy, asthma and sickle cell anaemia occurs. Encouragingly, the overall rate appears low in Nigeria.
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Affiliation(s)
- Kazeem Adeola Oshikoya
- a Pharmacology Department , Lagos State University College of Medicine , Lagos , Nigeria
| | - Ibrahim Adekunle Oreagba
- b Pharmacology, Therapeutic and Toxicology Department , College of Medicine, University of Lagos , Lagos , Nigeria
| | - Brian Godman
- c Division of Clinical Pharmacology , Karolinska Institute , Stockholm , Sweden.,d Strathclyde Institute of Pharmacy and Biomedical Sciences , University of Strathclyde , Glasgow , UK.,e Health Economics Centre , Liverpool University Management School, Liverpool University , Liverpool , UK
| | - Joseph Fadare
- f Department of Pharmacology , Ekiti State University , Ado-Ekiti , Nigeria
| | - Samuel Orubu
- g Faculty of Pharmacy , Niger Delta University , Amassoma , Nigeria
| | - Amos Massele
- h Department of Clinical Pharmacology , School of Medicine, University of Botswana , Gaborone , Botswana
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Berthod C, Kassaï B, Boussageon R, Adelaide L, Jacquet-Lagrèze M, Lajoinie A. [Justification of off-label antibiotics uses in hospitalized children]. Therapie 2017. [PMID: 28647107 DOI: 10.1016/j.therap.2017.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Unlicensed and off-label (UL/OL) drugs are commonly used in pediatrics wards, especially the antibiotics. It remains unclear if this strategy is justified by randomized controlled trials of good quality? OBJECTIVE The aim of this study was to compare the level of evidence of UL/OL antibiotics prescription in hospitalized children. The initial hypothesis was that the UL/OL antibiotics prescriptions had a lower level of evidence than licensed antibiotics. METHOD This observational study assessed the antibiotics prescription in the children mother and women hospital of Lyon. Each antibiotic medicine courses was classified depending on: (i) they were licensed, UL or OL, (ii) their level of evidence for efficiency (sufficient evidence, insufficient evidence, no evidence) and (iii) the existence or not of randomized controlled trials (RCT) or not. The antibiotics medicine courses in atypical cases were excluded (rare disease, lack of diagnosis, comorbidities modifying antibiotic use). Data were collected with computerized patient file data. The data were compared using Fisher exact test and χ2. RESULTS One hundred and eight medicine courses were identified, corresponding to 72 mono, bi or tri-antibiotic therapies administered to 62 patients; 34% were OL and 66% were licensed. No prescriptions were UL. Thirty-two prescriptions were excluded from the evidence assessment. No proof of efficiency was found for any of the 76 analyzed medicine courses. RCTs were found for 36 of the analyzed medicine courses (47%); licensed medicine courses were significantly more justified by RCTs than UL/OL medicine courses (63% vs. 16%, P<0.001). DISCUSSION This study has shown the absence of RCTs of good quality to justify the prescriptions of antibiotics in pediatrics, regardless their license status. Nevertheless, the licensed prescriptions have shown more data of efficiency than OL prescriptions. Still, even when data were found, no antibiotics prescriptions reach the threshold of good quality studies. New clinical trials should respond to the patient needs.
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Affiliation(s)
- Christelle Berthod
- Centre d'investigation clinique pédiatrique CIC 1407 Inserm-UMR 5558 CNRS Lyon, université et hospices civils de Lyon, 69003 Lyon, France.
| | - Behrouz Kassaï
- Centre d'investigation clinique pédiatrique CIC 1407 Inserm-UMR 5558 CNRS Lyon, université et hospices civils de Lyon, 69003 Lyon, France; Département de pharmacologie clinique et d'essais cliniques, UMR 5558, Lyon université, 69003 Lyon, France
| | - Remy Boussageon
- Département de médecine générale, université de Poitiers UFR de médecine et pharmacie, 86000 Poitiers, France
| | - Léopold Adelaide
- Service des maladies infectieuses et tropicales, hôpital Édouard-Herriot, hospices civils de Lyon, 69003 Lyon, France
| | - Matthias Jacquet-Lagrèze
- Service d'anesthésie réanimation, centre hospitalier Louis-Pradel, hospices civils de Lyon, 69500, Bron, France
| | - Audrey Lajoinie
- Centre d'investigation clinique pédiatrique CIC 1407 Inserm-UMR 5558 CNRS Lyon, université et hospices civils de Lyon, 69003 Lyon, France; Département de pharmacologie clinique et d'essais cliniques, UMR 5558, Lyon université, 69003 Lyon, France
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Kim B, Kim SZ, Lee J, Jung AH, Jung SH, Hahn HJ, Kang HR, Suh DI. Clinical profiles of adverse drug reactions spontaneously reported at a single Korean hospital dedicated to children with complex chronic conditions. PLoS One 2017; 12:e0172425. [PMID: 28199420 PMCID: PMC5310859 DOI: 10.1371/journal.pone.0172425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 02/03/2017] [Indexed: 12/02/2022] Open
Abstract
Children with complex chronic conditions (CCC) are presumed to be vulnerable to adverse drug reactions (ADRs). The clinical profiles of ADRs in CCC are not well known. Herein, we aim to describe the ADR profiles in CCC with regard to typical presentations and vulnerable groups. We accessed the ADR yearly reports at a tertiary children's hospital whose practice is mainly dedicated to CCC and descriptively analyzed their clinical profiles according to the presence of a complex chronic condition, ADR severity, and age groups. A total of 1841 cases were analyzed, among which 1258 (68.3%) were mild, 493 (26.8%) moderate, and 90 (4.9%) cases were severe. A total of 1581 (85.9%) cases of complex chronic condition were reported. The proportion of CCC in each severity group increased as the ADR becomes more severe. In CCC, ADRs were most frequently reported by nurses in the adolescent group and in cases where the symptoms involved the gastrointestinal system. The class of antineoplastic and immunomodulating drugs was the most commonly suspected of causing an ADR, followed by one of the antibiotics. When we focus on the trend across the age groups, the ratio of severe-to-total ADRs decreased with older age. Among severe cases, the ratio of off-label prescription-related cases was the highest in the infant/toddler group and decreased as the groups aged. In conclusion, ADRs of CCCs admitted to a tertiary children's hospital have a unique profile. These groups are vulnerable to ADRs and thus they should be monitored closely, especially when they are infants or toddlers, so that severe ADRs can be identified and treated immediately.
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Affiliation(s)
- Bomi Kim
- Department of Pharmacy, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sunwha Zara Kim
- Student in training, Bachelor of Medicine and Bachelor of Surgery (MBBS), Shanghai Medical College of Fudan University, Shanghai, China
| | - Jin Lee
- Department of Pharmacy, Seoul National University Hospital, Seoul, Republic of Korea
- Regional Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ae Hee Jung
- Department of Pharmacy, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sun-Hoi Jung
- Department of Pharmacy, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyeon-Joo Hahn
- Department of Pharmacy, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye Ryun Kang
- Regional Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Republic of Korea
- Division of Allergy, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong In Suh
- Regional Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University Hospital, Seoul, Republic of Korea
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García-López I, Fuentes-Ríos JE, Manrique-Rodríguez S, M. Fernández-Llamazares C. Off-label and unlicensed drug use: Results from a pilot study in a paediatric intensive care unit. An Pediatr (Barc) 2017. [DOI: 10.1016/j.anpede.2016.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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García-López I, Fuentes-Ríos JE, Manrique-Rodríguez S, M. Fernández-Llamazares C. Utilización de medicamentos en condiciones off-label y unlicensed : resultados de un estudio piloto realizado en una unidad de cuidados intensivos pediátricos. An Pediatr (Barc) 2017; 86:28-36. [DOI: 10.1016/j.anpedi.2016.01.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 01/06/2016] [Accepted: 01/11/2016] [Indexed: 02/05/2023] Open
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Carnovale C, Gentili M, Matacena M, Dimov Di Giusti M, Krnic D, Dolinic B, Kolaric D, Margan Koletic Z, Macolic Sarinic V, Culjak M, Fortino I, Merlino L, Clementi E, Radice S. A retrospective review of paediatric adverse drug reactions reported in Lombardy and Croatia from 2005 to 2013. Expert Opin Drug Saf 2016; 15:35-43. [DOI: 10.1080/14740338.2016.1253678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, University Hospital ‘Luigi Sacco’, Università di Milano, Milan, Italy
| | - Marta Gentili
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, University Hospital ‘Luigi Sacco’, Università di Milano, Milan, Italy
| | - Marco Matacena
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, University Hospital ‘Luigi Sacco’, Università di Milano, Milan, Italy
| | - Marina Dimov Di Giusti
- Department for Pharmacovigilance and Rational Pharmacotherapy, Agency for Medical Products and Medical Devices of Croatia, Zagreb, Croatia
| | - Darko Krnic
- Department for Pharmacovigilance and Rational Pharmacotherapy, Agency for Medical Products and Medical Devices of Croatia, Zagreb, Croatia
| | - Barbara Dolinic
- Department for Pharmacovigilance and Rational Pharmacotherapy, Agency for Medical Products and Medical Devices of Croatia, Zagreb, Croatia
| | - Darija Kolaric
- Department for Pharmacovigilance and Rational Pharmacotherapy, Agency for Medical Products and Medical Devices of Croatia, Zagreb, Croatia
| | - Zeljana Margan Koletic
- Department for Pharmacovigilance and Rational Pharmacotherapy, Agency for Medical Products and Medical Devices of Croatia, Zagreb, Croatia
| | - Viola Macolic Sarinic
- Department for Pharmacovigilance and Rational Pharmacotherapy, Agency for Medical Products and Medical Devices of Croatia, Zagreb, Croatia
| | - Maja Culjak
- Department for Pharmacovigilance and Rational Pharmacotherapy, Agency for Medical Products and Medical Devices of Croatia, Zagreb, Croatia
| | | | | | - Emilio Clementi
- Scientific Institute, IRCCS E. Medea, Lecco, Italy
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, Consiglio Nazionale delle Ricerche Institute of Neuroscience, University Hospital ‘Luigi Sacco’, Milan, Italy
| | - Sonia Radice
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, University Hospital ‘Luigi Sacco’, Università di Milano, Milan, Italy
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Kaguelidou F, Beau-Salinas F, Jonville-Bera AP, Jacqz-Aigrain E. Neonatal adverse drug reactions: an analysis of reports to the French pharmacovigilance database. Br J Clin Pharmacol 2016; 82:1058-68. [PMID: 27276109 DOI: 10.1111/bcp.13034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 05/23/2016] [Accepted: 06/06/2016] [Indexed: 11/30/2022] Open
Abstract
AIM Term and preterm neonates are at high risk for serious adverse drug reactions (ADRs). METHODS A descriptive study of reports registered in the French pharmacovigilance database from 1986 to 2012 were obtained. All reports concerning neonates (≤1 month of life) with direct drug exposure were retrieved. Characteristics of the reports, including reported ADR(s), drug(s) and the causality assessment using the French causality assessment method, were described. RESULTS A total of 1688 reports were analyzed and more than half of them were classified as serious (n = 995). Median age at ADR occurrence was 9 days. Overall, 3127 ADRs were described in these reports in relation to 2238 suspect/interacting drugs. The most commonly reported system organ classes (SOCs) were injury, poisoning and procedural complications (16%), general disorders and administration site conditions (12.5%) and blood and lymphatic system disorders (12%). In the majority of ADRs reported (73%), infants fully recovered and less than 4% of neonates deceased as a consequence of the reported ADR. One out of five ADRs was associated with drug administration errors. Therapeutic classes commonly incriminated were anti-infectives, nervous system and alimentary tract drugs. Substances most frequently related to serious ADRs were zidovudine, ibuprofen and nevirapine. Among the 10 most frequently encountered drug-ADR pairs, two substances were mainly implicated, zidovudine in haematological adverse reactions and phytomenadione in maladministrations. CONCLUSIONS Anti-infective drugs, mainly antiretroviral therapy, account for the majority of ADRs reported in neonates. The specific issue of drug maladministration and medication errors remains to be addressed in neonates.
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Affiliation(s)
- Florentia Kaguelidou
- EA 08, University of Paris Diderot, Sorbonne Paris Cité, F-75010, Paris. .,Inserm, CIC 1426, F-75019, Paris. .,Department of Pediatric Pharmacology and Pharmacogenetics, AP-HP, Hôpital Robert Debré, F-75019, Paris.
| | - Frédérique Beau-Salinas
- CHRU of Tours, Department of Clinical Pharmacology, Regional Centre of Pharmacovigilance, F-37 044, Tours, France
| | - Annie Pierre Jonville-Bera
- CHRU of Tours, Department of Clinical Pharmacology, Regional Centre of Pharmacovigilance, F-37 044, Tours, France
| | - Evelyne Jacqz-Aigrain
- EA 08, University of Paris Diderot, Sorbonne Paris Cité, F-75010, Paris.,Inserm, CIC 1426, F-75019, Paris.,Department of Pediatric Pharmacology and Pharmacogenetics, AP-HP, Hôpital Robert Debré, F-75019, Paris
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20
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Off-label use and pharmacovigilance among infants: analysis of the Thai Health Product Vigilance National Database. DRUGS & THERAPY PERSPECTIVES 2016. [DOI: 10.1007/s40267-016-0300-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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21
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Attitudes et expériences des médecins face à la prescription hors autorisation de mise sur le marché dans un hôpital pédiatrique français. ANNALES PHARMACEUTIQUES FRANÇAISES 2016; 74:222-31. [DOI: 10.1016/j.pharma.2015.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 08/14/2015] [Accepted: 08/16/2015] [Indexed: 11/18/2022]
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Magalhães J, Rodrigues AT, Roque F, Figueiras A, Falcão A, Herdeiro MT. Use of off-label and unlicenced drugs in hospitalised paediatric patients: a systematic review. Eur J Clin Pharmacol 2014; 71:1-13. [DOI: 10.1007/s00228-014-1768-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 10/06/2014] [Indexed: 11/29/2022]
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Schmiedl S, Fischer R, Ibáñez L, Fortuny J, Klungel OH, Reynolds R, Gerlach R, Tauscher M, Thürmann P, Hasford J, Rottenkolber M. Utilisation and off-label prescriptions of respiratory drugs in children. PLoS One 2014; 9:e105110. [PMID: 25180704 PMCID: PMC4152124 DOI: 10.1371/journal.pone.0105110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 07/21/2014] [Indexed: 12/05/2022] Open
Abstract
Respiratory drugs are widely used in children to treat labeled and non-labeled indications but only some data are available quantifying comprehensively off-label usage. Thus, we aim to analyse drug utilisation and off-label prescribing of respiratory drugs focusing on age- and indication-related off-label use. Patients aged ≤18 years documented in the Bavarian Association of Statutory Health Insurance Physicians database (approx. 2 million children) between 2004 and 2008 were included in our study. Annual period prevalence rates (PPRs) per 10,000 children and the proportion of age- and indication-related off-label prescriptions were calculated and stratified by age and gender. Within the study period, highest PPRs were found for the fixed combination of clenbuterol/ambroxol (between 374–575 per 10,000 children) and the inhaled short acting beta-2-agonist salbutamol (between 378–527 per 10,000 children). Highest relative PPR increase was found for oral salbutamol (approx. 39-fold) whereas the most distinct decrease was found for oral long-acting beta-2-agonist clenbuterol (−97%). Compound classes most frequently involved in off-label prescribing were inhaled bronchodilative compounds (91,402; 37.3%) and oral beta-2-agonists (26,850; 22.5%). The highest absolute number of off-label prescriptions were found for inhaled salbutamol (n = 67,084; 42.0%) and oral clenbuterol/ambroxol (fixed combination, n = 18,897; 20.7%). Off-label prescribing due to indication was of much greater relevance than age-related off-label use. Most frequently, bronchodilative compounds were used off-label to treat respiratory tract infections. Highest off-label prescription rates were found in the youngest patients without relevant gender-related differences. Off-label prescribing of respiratory drugs is common especially in young children. Bronchodilative drugs were most frequently used off-label for treating acute bronchitis or upper respiratory tract infections underlining the essential need for a more rational prescribing in this area.
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Affiliation(s)
- Sven Schmiedl
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Wuppertal, Germany
- * E-mail:
| | | | - Luisa Ibáñez
- Fundació Institut Català de Farmacologia, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Departament de Farmacologia, Terapèutica i Toxicologia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Olaf H. Klungel
- Utrecht Institute for Pharmaceutical Sciences, Division Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - Robert Reynolds
- Epidemiology, Pfizer, New York, New York, United States of America
| | - Roman Gerlach
- National Association of Statutory Health Insurance Physicians of Bavaria, Munich, Germany
| | - Martin Tauscher
- National Association of Statutory Health Insurance Physicians of Bavaria, Munich, Germany
| | - Petra Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Wuppertal, Germany
| | - Joerg Hasford
- Institute for Medical Information Sciences, Biometry, and Epidemiology, Ludwig-Maximilians-Universitaet, Munich, Germany
| | - Marietta Rottenkolber
- Institute for Medical Information Sciences, Biometry, and Epidemiology, Ludwig-Maximilians-Universitaet, Munich, Germany
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Weidinger P, Nilsson JLG, Lindblad U. Medication prescribing for asthma and COPD: a register-based cross-sectional study in Swedish primary care. BMC FAMILY PRACTICE 2014; 15:54. [PMID: 24666507 PMCID: PMC3987171 DOI: 10.1186/1471-2296-15-54] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 03/20/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND There is a gap between prescribed asthma medication and diagnosed asthma in children and adolescents. However, few studies have explored this issue among adults, where asthma medication is also used for the treatment of chronic obstructive pulmonary disease (COPD). The aim of this study was to examine the relationship between prescribing of medications indicated for asthma and COPD and the recorded diagnosis for these conditions. METHOD In a register-based study, individuals prescribed a medication indicated for asthma and COPD during 2004-2005 (Group A; n = 14 101) and patients with diagnoses of asthma or COPD recorded during 2000-2005 (Group B; n = 12 328) were identified from primary health care centers in Skaraborg, Sweden. From a 5% random sample of the medication users (n = 670), the written medical records were accessed. PRIMARY OUTCOMES prevalence of medication and diagnoses, reasons for prescription. SECONDARY OUTCOMES type and number of prescribed drugs and performance of peak expiratory flow or spirometry. RESULTS Medications indicated for asthma and COPD was prescribed to 5.6% of the population in primary care (n = 14 101). Among them, an asthma diagnosis was recorded for 5876 individuals (42%), 1116 (8%) were diagnosed with COPD and 545 (4%) had both diagnoses. The remaining 6564 individuals (46%) were lacking a recorded diagnosis. The gap between diagnosis and medication was present in all age-groups. Medication was used as a diagnostic tool among 30% of the undiagnosed patients and prescribed off-label for 54%. Missed recording of ICD-codes for existing asthma or COPD accounted for 16%. CONCLUSION There was a large discrepancy between prescribing of medication and the prevalence of diagnosed asthma and COPD. Consequently, the prevalence of prescriptions of medications indicated for asthma and COPD should not be used to estimate the prevalence of these conditions. Medication was used both as a diagnostic tool and in an off-label manner. Therefore, the prescribing of medications for asthma and COPD does not adhere to national clinical guidelines. More efforts should be made to improve the prescribing of medication indicated for asthma and COPD so that they align with current guidelines.
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Affiliation(s)
- Paolina Weidinger
- Department of Public Health and Community Medicine/Primary Health Care, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Skaraborg Primary Care Research and Development Unit, Skövde, Sweden
| | - J Lars G Nilsson
- Skaraborg Primary Care Research and Development Unit, Skövde, Sweden
| | - Ulf Lindblad
- Department of Public Health and Community Medicine/Primary Health Care, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Skaraborg Institute, Skövde, Sweden
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Silva D, Ansotegui I, Morais-Almeida M. Off-label prescribing for allergic diseases in children. World Allergy Organ J 2014; 7:4. [PMID: 24528848 PMCID: PMC3928583 DOI: 10.1186/1939-4551-7-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 01/22/2014] [Indexed: 01/10/2023] Open
Abstract
The majority of drugs prescribed have not been tested in children and safety and efficacy of children's medicines are frequently supported by low quality of evidence. Therefore, a large percentage of prescriptions for children in the clinical daily practice are used off label. Despite the several recent legislation and regulatory efforts performed worldwide, they have not been successful in increasing availability of medicines adapted to children. Moreover, if we consider that 30% of the prescribed drugs for children are for the respiratory field and only 4% of new investigation projects for children research were proposed to access drugs for respiratory and allergy treatment, there is a clear imbalance of the children needs in this therapeutic area. This narrative review aimed to describe and discuss the off-label use of medicines in the treatment and control of respiratory and allergic diseases in children. It was recognized that a large percentage of prescriptions performed for allergy treatment in daily clinical practice are off label. The clinicians struggle on a daily basis with the responsibility to balance risk-benefits of an off-label prescription while involving the patients and their families in this decision. It is crucial to increase awareness of this reality not only for the clinician, but also to the global organizations and competent authorities. New measures for surveillance of off-label use should be established, namely through population databases implementation. There is a need for new proposal to correct the inconsistency between the priorities for pediatric drug research, frequently dependent on commercial motivations, in order to comply to the true needs of the children, especially on the respiratory and allergy fields.
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Affiliation(s)
- Diana Silva
- Immunoallergology Department, Centro Hospitalar de São João, Alameda Prof. Hernâni Monteiro, 4200-309 Porto, Portugal
- Immunoallergology Department, CUF Descobertas Hospital, R. Mário Botas, 1998-018 Lisboa, Portugal
| | - Ignacio Ansotegui
- Department of Allergy and Immunology, Hospital Quirón Bizkaia, Carretera de Leioa-Unbe, 33 Bis., 48950 Erandio, Spain
| | - Mário Morais-Almeida
- Immunoallergology Department, CUF Descobertas Hospital, R. Mário Botas, 1998-018 Lisboa, Portugal
- Center for Research in Health Technologies and Information Systems, University of Porto, Porto, Portugal
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Nicha V, Simonoska Crcarevska M, Glavas Dodov M, Slaveska Raichki R. Quality use of an unlicensed medicine and off label use of a medicine. MAKEDONSKO FARMACEVTSKI BILTEN 2014. [DOI: 10.33320/maced.pharm.bull.2014.60.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This paper gives an overview of the concept and process of quality use of unlicensed medicines and off label use of medicines, with special attention on the professional roles and responsibilities of prescribers and pharmacists. It also focuses on the policy requirements, sets of guidelines, recommendations, best practices, and other aspects addressed under this topic that represent the state of update knowledge. As a complex and specific issue, the use of an unlicensed medicine and off label prescribed medicine in different health care levels is of particular importance for the healthcare settings in the Republic of Macedonia since, the existing regulatory structure requires adoption and development of a comprehensive strategy relating to this topic in the near future with an aim of encouraging and supporting the development and maintenance of a sound health system with high standards of medication-use policies.
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Shamliyan TA, Kane RL, Ramakrishnan R, Taylor FR. Episodic migraines in children: limited evidence on preventive pharmacological treatments. J Child Neurol 2013; 28:1320-41. [PMID: 23752070 DOI: 10.1177/0883073813488659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The authors conducted a systematic literature review of preventive pharmacological treatments for episodic childhood migraines searching several databases through May 20, 2012. Episodic migraine prevention was examined in 24 publications of randomized controlled trials that enrolled 1578 children in 16 nonrandomized studies. Single randomized controlled trials provided low-strength evidence that propranolol would result in complete cessation of migraine attacks in 713 per 1000 children treated (95% confidence interval, 452-974); trazodone and nimodipine decreased migraine days, while topiramate, divalproex, and clonidine were no more effective than placebo in preventing migraines. Migraine prevention with multidisciplinary drug management was not sustained at 6 months. Divalproex resulted in treatment discontinuation due to adverse effects, and topiramate increased the risk of paresthesia, upper respiratory tract infection, and weight loss. Long-term preventive benefits and improvement in disability and quality of life are unknown. No studies examined quality of life or provided evidence for individualized treatment decisions.
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Affiliation(s)
- Tatyana A Shamliyan
- 1Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
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Yeh ML, Chang YJ, Yeh SJ, Huang LJ, Yen YT, Wang PY, Li YC, Hsu CY. Potential drug-drug interactions in pediatric outpatient prescriptions for newborns and infants. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2013; 113:15-22. [PMID: 24209715 DOI: 10.1016/j.cmpb.2013.07.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 07/20/2013] [Accepted: 07/21/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To surveyed the quantities, types, and related information of potential drug-drug interactions (DDIs) and estimate the off-label use percentage of pediatric outpatient prescriptions for newborns and infants from the National Health Insurance Research Database (NHIRD) of Taiwan. BACKGROUND Adverse drug reactions (ADR) may cause morbidity and mortality, potential drug-drug interactions (DDI) increase the probability of ADR. Research on ADR and DDI in infants is of particular urgency and importance but the related profiles in these individuals are not well known. METHODS All prescriptions written by physicians in 2000 were analyzed to identify potential DDIs among drugs appearing on the same prescription sheet. RESULTS Of a total of 150.6 million prescription sheets, with 669.5 million prescriptions registered in the NHIRD of Taiwan, six million (3.99%) prescription sheets were for 2.1 million infants with 19.4 million (2.85%) prescriptions. There were 672,020 potential DDIs in this category, accounting for 3.53% per prescription; an estimated one DDI in every three patients. The interactions between aspirin and aluminum/magnesium hydroxide were most common (4.42%). Of the most significant drug-drug interactions, the interaction of digoxin with furosemide ranked first (20.14%), followed by the interactions of cisapride with furosemide and erythromycin (6.02% and 4.85%, respectively). The interactions of acetaminophen and anti-cholinergic agents comprised most types of drug-drug interactions (6.62%). CONCLUSION Although the prevalence rates of DDIs are low, life-threatening interactions may develop. Physicians must be reminded of the potential DDIs when prescribing medications for newborns and infants.
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Affiliation(s)
- Min-Li Yeh
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Oriental Institute of Technology, New Taipei, Taiwan.
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Tansarli GS, Rafailidis PI, Kapaskelis A, Falagas ME. Frequency of the off-label use of antibiotics in clinical practice: a systematic review. Expert Rev Anti Infect Ther 2013; 10:1383-92. [PMID: 23253317 DOI: 10.1586/eri.12.137] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Antibiotics constitute a major class among drugs commonly prescribed either empirically or for microbiologically documented infections in clinical practice. In addition, due to medical necessity physicians are forced, at times, to prescribe medications for off-label indications. The authors sought to record the frequency of the off-label use of antibiotics among both adult and pediatric patients. PubMed and Scopus databases were searched to identify relevant studies. A total of 25 studies met the inclusion criteria (725,124,505 prescriptions); 16 were prospective and nine retrospective. Fifteen studies reported on the pediatric population, seven on adults who had received a specific antibiotic, two on adult critical-care patients, and one on the general outpatient population. In the pediatric population, the percentage of off-label prescriptions varied from 1 to 94%. Off-label prescriptions varied from 19 to 43% in adult critical-care patients. Last, one study reporting on general outpatient care showed that 23% of prescriptions were off-label. Antibiotics are frequently prescribed as off-label among patient populations. The wide variation observed in the off-label use of antibiotics among pediatric patients might be attributed to the heterogeneity among the study populations regarding the age of children. Although this unapproved manner of prescribing cannot always be avoided, clinicians should only use unapproved drugs in cases when there are no effective alternatives are available and based on scientific evidence regarding safety and effectiveness.
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Lee JH, Park KH, Moon HJ, Lee YW, Park JW, Hong CS. Spontaneous reporting of adverse drug reactions through electronic submission from regional society healthcare professionals in Korea. Yonsei Med J 2012; 53:1022-7. [PMID: 22869488 PMCID: PMC3423839 DOI: 10.3349/ymj.2012.53.5.1022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Pharmacovigilance Research Network built a spontaneous reporting system and collected adverse drug reactions (ADRs) by electronic submission (e-sub) in Korea. We analyzed ADRs spontaneously reported through e-sub from regional health professionals. MATERIALS AND METHODS Nine hundred and thirty three ADR cases were collected and analyzed from January to December in 2008. "A matter" was defined as one symptom matched to one culprit drug included in an ADR case. We collected and analyzed e-sub ADR cases and matters to determine common culprits and organ specified ADR matters. RESULTS There were 3,049 matters in 933 ADR cases for 1 year, and 3.3 matters per case were reported. In organ specific ADR classification, skin reactions which took the first place in 866 matters (28%) included urticaria and rash. The next cases were neurologic symptom (624 matters, 21%) and gastrointestinal symptom (581 matters, 19%). Doctor (53%) and pharmacist (31%) were the most important participants in e-sub spontaneous reporting system, and 3% of ADR cases were reported by patients or their guardians. WHO-Uppsala Monitoring Center causality assessment results showed certain 10.6%, probable 37.7%, possible 41.7% and below unlikely 10.0%. Culprit drugs were antibiotics (23.4%), neurologic agents (14.7%) and non-steroidal anti-inflammatory drugs (9.4%). CONCLUSION In our study, antibiotic was most common culprit drug, and skin manifestation was most common symptom in e-sub ADRs collected from regional healthcare practitioners in Korea.
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Affiliation(s)
- Jae-Hyun Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Pharmacovigilance Research Network, Seoul, Korea
| | - Kyung Hee Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Pharmacovigilance Research Network, Seoul, Korea
| | | | - Yong Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Pharmacovigilance Research Network, Seoul, Korea
| | - Jung-Won Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Pharmacovigilance Research Network, Seoul, Korea
| | - Chein-Soo Hong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Pharmacovigilance Research Network, Seoul, Korea
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Kimland E, Nydert P, Odlind V, Böttiger Y, Lindemalm S. Paediatric drug use with focus on off-label prescriptions at Swedish hospitals - a nationwide study. Acta Paediatr 2012; 101:772-8. [PMID: 22404126 PMCID: PMC3437470 DOI: 10.1111/j.1651-2227.2012.02656.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To perform a nationwide investigation of paediatric drug use at Swedish hospitals, including an analysis of off-label drug use. METHODS All paediatric hospitals in Sweden were invited to register all prescriptions to children, aged between 0 and 18, during two separate 2-day-periods in 2008. Data were reported and analysed with respect to licence status and proportion of and reasons for off-label drug use. RESULTS Data on 11,294 prescriptions to 2947 paediatric patients were received. Drugs associated with pain relief, infection, prematurity, nutrition and surgery or anaesthesia were most commonly used. Paracetamol was the most frequently used drug on-label and also among the most commonly used off-label drugs. Nearly half (49%) of all administered prescriptions concerned unlicensed drugs, off-label drugs or extemporaneously prepared drugs. The corresponding rate among neonates was 69%. Lack of paediatric information in the Summary of Product Characteristics was the main reason for off-label classification. CONCLUSIONS Paediatric off-label drug use is common at Swedish hospitals, and nearly half of all prescriptions were not documented for use in children. The findings emphasize a need for paediatric clinical studies as well as compilation of existing clinical experience and scattered evidence, particularly for drug treatment in infants and neonates.
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Affiliation(s)
- E Kimland
- Division of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
- Medical Products Agency, Uppsala, Sweden
| | - P Nydert
- Astrid Lindgrens Childrens Hospital, Neonatal Unit, Karolinska University Hospital, Stockholm, Sweden
| | - V Odlind
- Medical Products Agency, Uppsala, Sweden
| | - Y Böttiger
- Division of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - S Lindemalm
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Division of Paediatrics, Astrid Lindgrens Children’ s Hospital, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Bygdell M, Brunlöf G, Wallerstedt SM, Kindblom JM. Psychiatric adverse drug reactions reported during a 10-year period in the Swedish pediatric population. Pharmacoepidemiol Drug Saf 2011; 21:79-86. [DOI: 10.1002/pds.2265] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 08/19/2011] [Accepted: 09/19/2011] [Indexed: 11/09/2022]
Affiliation(s)
- Maria Bygdell
- Clinical Pharmacology, Institute of Medicine; the Sahlgrenska Academy at Gothenburg University; Gothenburg Sweden
| | - Gertrud Brunlöf
- Clinical Pharmacology, Institute of Medicine; the Sahlgrenska Academy at Gothenburg University; Gothenburg Sweden
| | - Susanna M. Wallerstedt
- Clinical Pharmacology, Institute of Medicine; the Sahlgrenska Academy at Gothenburg University; Gothenburg Sweden
| | - Jenny M. Kindblom
- Clinical Pharmacology, Institute of Medicine; the Sahlgrenska Academy at Gothenburg University; Gothenburg Sweden
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Mukattash T, Trew K, Hawwa AF, McElnay JC. Children’s views on unlicensed/off-label paediatric prescribing and paediatric clinical trials. Eur J Clin Pharmacol 2011; 68:141-8. [DOI: 10.1007/s00228-011-1110-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Accepted: 07/27/2011] [Indexed: 10/17/2022]
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Wallerstedt SM, Brunlöf G, Sundström A. Rates of Spontaneous Reports of Adverse Drug Reactions for Drugs Reported in Children. Drug Saf 2011; 34:669-82. [DOI: 10.2165/11591730-000000000-00000] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Mason J, Pirmohamed M, Nunn T. Off-label and unlicensed medicine use and adverse drug reactions in children: a narrative review of the literature. Eur J Clin Pharmacol 2011; 68:21-8. [DOI: 10.1007/s00228-011-1097-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 06/29/2011] [Indexed: 12/01/2022]
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Aagaard L, Hansen EH. Prescribing of medicines in the Danish paediatric population outwith the licensed age group: characteristics of adverse drug reactions. Br J Clin Pharmacol 2011; 71:751-7. [PMID: 21241353 DOI: 10.1111/j.1365-2125.2011.03915.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIM To identify adverse drug reactions (ADRs) associated with off-label prescribing of medicines in a paediatric population. METHODS We analysed spontaneous ADR reports for children from ages 0 to 17 years submitted to the Danish national ADR database from 1998 to 2007. We defined off-label prescribing as prescriptions outside the licensed age group. Off-label ADRs were categorized by therapeutic group, age of child, type and severity. The unit of analysis was one ADR. RESULTS We analysed 4388 ADRs for children reported in the national database. Approximately 17% of reported ADRs were associated with off-label use, 60% of them serious. More than one half of off-label ADRs were reported in adolescents. Serious ADRs due to off-label prescribing are more likely to be reported for hormonal contraceptives (ATC group G), anti-acne preparations (ATC group D) and allergens (ATC group V). CONCLUSION One-fifth of all ADRs reported over a decade in Danish children was associated with off-label prescribing, and serious ADRs due to off-label prescribing were primarily present in three therapeutic groups: sex hormones, dermatologicals and allergens. There is a need for more research into the prescribing of these medicines in the teenage population, as well as tighter reporting and monitoring of ADRs for medicines prescribed off-label in the paediatric population.
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Affiliation(s)
- Lise Aagaard
- Department of Pharmacology and Pharmacotherapy, Section for Social Pharmacy, Faculty of Pharmaceutical Sciences, University of Copenhagen, FKL-Research Centre for Quality in Medicine Use, Copenhagen, Denmark.
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Aagaard L, Christensen A, Hansen EH. Information about adverse drug reactions reported in children: a qualitative review of empirical studies. Br J Clin Pharmacol 2011; 70:481-91. [PMID: 20840440 DOI: 10.1111/j.1365-2125.2010.03682.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
AIM To review the literature on adverse drug reactions (ADRs) in children with respect to occurrence, seriousness, type, therapeutic group, age and gender of the child and category of reporter. METHODS Medline and Embase databases were searched from origin and updated until February 2010. We included empirically based articles on ADRs in populations aged 0 to 17 years. Studies monitoring ADRs in patients with particular conditions or drug exposure were excluded. We extracted information about types and seriousness of ADRs, therapeutic groups, age and gender of the child and category of reporter. ADR occurrence was calculated as incidence rate and prevalence. RESULTS We included 33 studies monitoring ADRs in general paediatric populations. The highest numbers of ADRs were reported in national ADR databases where data were collected over a longer period than in studies monitoring inpatients and outpatients. However, prevalence and incidence were much lower in the national databases. Types of reported ADRs, seriousness of ADRs and types of medicines differed substantially between studies due to differences in time periods and patient populations. Information about ADRs was mainly provided by health care professionals, although parents also contributed reports. CONCLUSIONS We found a higher incidence rate of ADRs in hospitalized children and outpatients than in national databases. There seems to be considerable potential for increasing the knowledge of ADRs by advocating the submission of reports to the spontaneous reporting systems. Our study underscores that ADRs in children constitute a significant public health problem.
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Affiliation(s)
- Lise Aagaard
- Department of Pharmacology and Pharmacotherapy, Section for Social Pharmacy, Faculty of Pharmaceutical Sciences, University of Copenhagen, FKL-Research Centre for Quality in Medicine Use, Copenhagen, Denmark.
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Nydert P, Lindemalm S, Nemeth A. Off-label drug use evaluation in paediatrics--applied to ciprofloxacin when used as treatment of cholangitis. Pharmacoepidemiol Drug Saf 2011; 20:393-8. [PMID: 21280136 DOI: 10.1002/pds.2080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 11/02/2010] [Accepted: 11/05/2010] [Indexed: 11/05/2022]
Abstract
PURPOSE To evaluate drug and indication specific off-label use in paediatrics, applied to ciprofloxacin (CPFX) in cholangitis. METHODS We collected four different sets of data for an off-label drug use evaluation. (1) Literature review from medical journals, (2) the use and safety profile from the whole Swedish paediatric population by extracting data from national registers, (3) locally performed retrospective drug chart reviews, and (4) interviews regarding paediatric patients with CPFX treated cholangitis. RESULTS The literature reviews show a lack of information for paediatric use of CPFX in cholangitis. The prescribing of CPFX to Swedish children has grown over the last decade and generated a small number of reports for adverse drug reactions. In our local biliary atresia population 32 patients had suffered from at least one episode of cholangitis and 13 patients had been prescribed CPFX. The dosing strategy had an empirical prescribing approach, since monitoring of bacterial resistance and efficacy is difficult in the biliary ducts. No clear relationship was seen between dosing and age/weight. Reports of suspected side effects could not be found in the retrospective chart reviews. The interviews show that the existing dosage forms are well accepted. CONCLUSIONS This drug use evaluation creates awareness of the off-label situation. The international and national data are sparse for the paediatric use of CPFX in cholangitis. Locally we have highlighted a heterogeneous dosing strategy of CPFX, drug/drug interactions, and the need to monitor and report the risk of short- and long-term adverse drug reactions.
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Affiliation(s)
- Per Nydert
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
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Abstract
Postmarketing drug surveillance refers to the monitoring of drugs once they reach the market after clinical trials. It evaluates drugs taken by individuals under a wide range of circumstances over an extended period of time. Such surveillance is much more likely to detect previously unrecognized positive or negative effects that may be associated with a drug. The majority of postmarketing surveillance concern adverse drug reactions (ADRs) monitoring and evaluation. Other important postmarketing surveillance components include unapproved or off-label drug use, problems with orphan drugs, and lack of paediatric formulations, as well as issues concerning international clinical trials in paediatric population. The process of evaluating and improving the safety of medicines used in paediatric practice is referred to as paediatric pharmacovigilance. It requires special attention. Childhood diseases and disorders may be qualitatively and quantitatively different from their adult equivalents. This may affect either benefit or risk of therapies (or both), with a resulting impact on the risk/benefit balance. In addition, chronic conditions may require chronic treatment and susceptibility to ADRs may change throughout the patient's lifetime according to age and stage of growth and development. Therefore, paediatric pharmacovigillance aspects need to be tailored to a number of variables based on heterogeneity of paediatric population. This chapter will summarize and discuss the key issues.
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Affiliation(s)
- Vera Vlahović-Palčevski
- Department for Clinical Pharmacology, University of Rijeka Medical School, University Hospital Center Rijeka, Krešimirova 42, 51000 Rijeka, Croatia.
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Ragupathy R, Tordoff J, Norris P, Reith D. Access to children’s medicines in the United Kingdom, Australia and New Zealand in 1998, 2002 and 2007. ACTA ACUST UNITED AC 2010; 32:386-93. [DOI: 10.1007/s11096-010-9383-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Accepted: 03/16/2010] [Indexed: 11/24/2022]
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Bavdekar SB, Sadawarte PA, Gogtay NJ, Jain SS, Jadhav S. Off-label drug use in a Pediatric Intensive Care Unit. Indian J Pediatr 2009; 76:1113-8. [PMID: 20092023 DOI: 10.1007/s12098-009-0238-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the extent and nature of off-label drug use in children admitted to a Pediatric Intensive Care Unit (PICU) METHODS: This prospective exploratory study was conducted in a tertiary care hospital in a metropolitan city in India after obtaining clearance from the institutional ethics committee. Subjects admitted in PICU from February-August 2006 were enrolled in the study. In addition to the demographic data and diagnosis, details of drugs prescribed (name, dose and route and frequency of administration) were obtained from hospital records. British National Formulary 2005 was used to determine if the prescriptions were off-label and if so, they were categorized as off-label for age, indication, dosage or frequency and route of administration. Descriptive statistics was used to determine the proportion of off-label drug use. Fischer's exact test was used to determine if there was significant difference (P<0.05) in off-label use between patients with multiple system affection and those with single system affection and between those requiring artificial ventilatory support and those not requiring it. RESULTS Three hundred subjects received 2237 analyzable prescriptions. Of these 1579 (70.58%) prescriptions were offlabel in nature. Off-label drug use was prevalent in all age-groups and in all systemic afflictions. The proportion of off-label drug use was not influenced by severity of illness, as judged by involvement of multiple systems or need for ventilatory support. The list of off-label drugs used included old as well as new molecules. Most commonly used drugs in PICU were also the most common off-label drugs. CONCLUSION Off-label drug use is highly prevalent in PICU settings.
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Affiliation(s)
- S B Bavdekar
- Department of Pediatrics, Seth GS Medical College & KEM Hospital, Acharya Donde Road, Parel, Mumbai, India.
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Lindell-Osuagwu L, Korhonen MJ, Saano S, Helin-Tanninen M, Naaranlahti T, Kokki H. Off-label and unlicensed drug prescribing in three paediatric wards in Finland and review of the international literature. J Clin Pharm Ther 2009; 34:277-87. [PMID: 19650250 DOI: 10.1111/j.1365-2710.2008.01005.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In paediatric pharmacotherapy, many drugs are prescribed to be given in ways and for conditions not approved in the marketing authorization (MA). Thus, off-label prescribing of drugs with no MA is widespread in paediatric wards. However, drug MA status and clinical practices differ across countries. In this prospective study, we studied the prescribing of off-label and unlicensed drugs in three paediatric wards in a tertiary hospital in Finland. Furthermore, we reviewed previous published studies to provide an up-to-date international perspective on prescribing of off-label and unlicensed drugs for hospitalized children. METHODS During a 2-week period, prescriptions for patients under 18 years of age (median age 1*6 years) in three wards; neonatal intensive care unit (NICU), general paediatric ward and paediatric surgical ward were recorded daily and drug-licensing status of all prescriptions was determined according to the approved summary of product characteristics. Published studies were retrieved through electronic searches, including MEDLINE (PubMed). RESULTS Of the 141 children, 108 received 629 prescriptions. Of the 108 children with a prescription, 82 (76%) had at least one off-label or unlicensed drug prescribed; 79% in the NICU, 63% in the general ward and 91% in the surgical ward (P = 0*014). Of the 108 children with a prescription, 26 (24%) received prescriptions for licensed drugs, 71 (66%) received prescriptions off-label and 36 (33%) for unlicensed drugs. Of all 629 prescriptions, 321 (51%) were for licensed drugs, 226 (36%) for off-label and 82 (13%) for unlicensed drugs. International studies showed similar extents of off-label and unlicensed-drug prescribing. CONCLUSION This study indicates that the use of off-label and unlicensed drugs is widespread in all the different paediatric wards surveyed and was as extensive as those reported for other countries.
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Affiliation(s)
- L Lindell-Osuagwu
- Department of Social Pharmacy, University of Kuopio, Kuopio, Finland.
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Bazzano ATF, Mangione-Smith R, Schonlau M, Suttorp MJ, Brook RH. Off-label prescribing to children in the United States outpatient setting. Acad Pediatr 2009; 9:81-8. [PMID: 19329098 DOI: 10.1016/j.acap.2008.11.010] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Revised: 11/19/2008] [Accepted: 11/21/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to determine the frequency of off-label prescribing to children at United States outpatient visits and to determine how drug class, patient age, and physician specialty relate to off-label prescribing. METHODS Data from the 2001 through 2004 National Ambulatory Medical Care Surveys (NAMCS) consisted of a sample of 7901 outpatient visits by children aged 0 through 17 years in which prescriptions were given, representative of an estimated 312 million visits. We compared FDA-approved age and indication to the child's age and diagnoses. We used multivariate logistic regression to determine adjusted differences in probabilities of off-label prescribing. RESULTS Sixty-two percent of outpatient pediatric visits included off-label prescribing. Approximately 96% of cardiovascular-renal, 86% of pain, 80% of gastrointestinal, and 67% of pulmonary and dermatologic medication prescriptions were off label. Visits by children aged <6 years had a higher probability of off-label prescribing (P < .01), especially visits by children aged <1 year (74% adjusted probability). Visits to specialists also involved a significantly increased probability (68% vs 59% for general pediatricians, P < .01) of off-label prescribing. CONCLUSIONS Despite recent studies and labeling changes of pediatric medications, the majority of pediatric outpatient visits involve off-label prescribing across all medication categories. Off-label prescribing is more frequent for younger children and those receiving care from specialist pediatricians. Increased dissemination of pediatric studies and label information may be helpful to guide clinical practice. Further research should be prioritized for the medications most commonly prescribed off label and to determine outcomes, causes, and appropriateness of off-label prescribing to children.
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Affiliation(s)
- Alicia T F Bazzano
- UCLA School of Public Health, Department of Health Services, University of California, Los Angeles, Los Angeles, California 90095, USA
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Planchamp F, Nguyen KA, Vial T, Nasri S, Javouhey E, Gillet Y, Ranchin B, Villard F, Floret D, Cochat P, Gueyffier F, Kassaï B. Recueil systématique et actif des évènements indésirables médicamenteux chez les enfants admis aux urgences pédiatriques. Arch Pediatr 2009; 16:106-11. [DOI: 10.1016/j.arcped.2008.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Revised: 06/25/2008] [Accepted: 11/17/2008] [Indexed: 12/01/2022]
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Brunlöf G, Tukukino C, Wallerstedt SM. Individual case safety reports in children in commonly used drug groups - signal detection. BMC CLINICAL PHARMACOLOGY 2008; 8:1. [PMID: 18366638 PMCID: PMC2279106 DOI: 10.1186/1472-6904-8-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Accepted: 03/17/2008] [Indexed: 11/26/2022]
Abstract
Background Due to few paediatric drug safety studies, knowledge on risks of drug treatment in children is limited. The knowledge needs to be increased to make proper risk-benefit analyses possible when treating paediatric patients with drugs. The aim of the present study was to investigate drug groups commonly used in children concerning type and frequency of individual case safety reports in children. Methods Number and type of individual case safety reports in the 30 groups of drugs (5th level ATC-code) most sold (number of defined daily doses) in outpatient treatment to children (<15 years old) during 2005 were obtained. Descriptive analyses of the adverse drug reactions reported in children were performed. Results The number of individual case safety reports per million defined daily doses in children varied in the groups of drug between 0 and 24. The largest number was found in the drug group R03DC, the leukotriene receptor antagonist montelukast; the majority of the children being <5 years old and experiencing psychiatric adverse drug reactions. Conclusion The number of individual case safety reports per million defined daily doses varies in different groups of drugs. A possible signal for montelukast and psychiatric adverse drug reactions was found, which should be further explored.
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Affiliation(s)
- Gertrud Brunlöf
- Department of Clinical Pharmacology and Regional Pharmacovigilance Centre, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden.
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Patel H, Bell D, Molokhia M, Srishanmuganathan J, Patel M, Car J, Majeed A. Trends in hospital admissions for adverse drug reactions in England: analysis of national hospital episode statistics 1998-2005. BMC CLINICAL PHARMACOLOGY 2007; 7:9. [PMID: 17894876 PMCID: PMC2093926 DOI: 10.1186/1472-6904-7-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Accepted: 09/25/2007] [Indexed: 12/01/2022]
Abstract
Background Adverse drug reactions (ADRs) are a frequent cause of mortality and morbidity to patients worldwide, with great associated costs to the healthcare providers including the NHS in England. We examined trends in hospital admissions associated with adverse drug reaction in English hospitals and the accuracy of national reporting. Methods Data from the Hospital Episode Statistics database (collected by the Department of Health) was obtained and analysed for all English hospital episodes (1998–2005) using ICD-10 codes with a primary (codes including the words ('drug-induced' or 'due to') or secondary diagnosis of ADR (Y40–59). More detailed analysis was performed for the year 2004–2005 Results Between 1998 and 2005 there were 447 071 ADRs representing 0.50% of total hospital episodes and over this period the number of ADRs increased by 45%. All ADRs with an external code increased over this period. In 2005 the total number of episodes (all age groups) was 13,706,765 of which 76,692 (0.56%) were drug related. Systemic agents, which include anti-neoplastic drugs, were the most implicated class (15.7%), followed by analgesics (11.7%) and cardiovascular drugs (10.1%). There has been a 6 fold increase in nephropathy secondary to drugs and a 65% decline in drug induced extra-pyramidal side effects. 59% of cases involving adverse drug reactions involved patients above 60 years of age. Conclusion ADRs have major public health and economic implications. Our data suggest that national Hospital Episode Statistics in England have recognised limitations and that consequently, admissions associated with adverse drug reactions continue to be under-recorded. External causes of ADR have increased at a greater rate than the increase in total hospital admissions. Improved and more detailed reporting combined with educational interventions to improve the recording of ADRs are needed to accurately monitor the morbidity caused by ADRs and to meaningfully evaluate national initiatives to reduce adverse drug reactions.
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Affiliation(s)
| | - Derek Bell
- Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Mariam Molokhia
- Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, WC1E 7HT, UK
| | | | | | - Josip Car
- Department of Primary Care and Social Medicine, Imperial College, London W6 8RF, UK
| | - Azeem Majeed
- Department of Primary Care and Social Medicine, Imperial College, London W6 8RF, UK
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Kimland E, Bergman U, Lindemalm S, Böttiger Y. Drug related problems and off-label drug treatment in children as seen at a drug information centre. Eur J Pediatr 2007; 166:527-32. [PMID: 17195069 DOI: 10.1007/s00431-006-0385-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Accepted: 11/23/2006] [Indexed: 11/27/2022]
Abstract
The aim of this work was to analyse the characteristics of Questions and Answers (Q&As) at a drug information centre (DIC) regarding drug related problems and off-label drug treatment in children. All questions concerning children 15 years or younger at a DIC in Stockholm, Sweden during the years 1995-2004 were analysed with respect to the main drug related problem, drug/s and drug group/s, whether the drugs were licensed or not, pediatric labelling of the drug/s and age and sex of the patient. Q&As were classified as whether or not they included evaluated literature information, adding to the labelling of the drugs. We identified 249 Q&As concerning pediatric drug treatment. Each question addressed an average of 1.5 drugs. More than two-thirds of the Q&As concerned adverse drug reactions and pediatric drug choice or dosing. Every second question was classified as off-label, psychotropic drugs being the most common. In half of all off-label Q&As, pediatric documentation on drug efficacy and safety outside the Swedish catalogue of medical products was found. Most Q&As concerned newborns and infants. However, the off-label proportion among questions was highest in adolescence as well as the evaluated literature information, adding to the labelling of the drugs. It was thus found that off-label drug treatment is common among pediatric questions at a DIC. This service can provide additional literature based information contributing to a safer use of drugs in children. There is still, however, a substantial need for clinical documentation of drug use in children.
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Affiliation(s)
- Elin Kimland
- Karolinska Institutet, Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
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Baer GR, Nelson RM. Ethical challenges in neonatal research: Summary report of the ethics group of the newborn drug development initiative. Clin Ther 2007; 28:1399-407. [PMID: 17062312 DOI: 10.1016/j.clinthera.2006.09.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Newborn Drug Development Initiative (NDDI) was established to address the lack of substantive data supporting efficacy and safety of drugs in the neonate. OBJECTIVE This commentary summarizes some of the ethical issues involved in neonatal drug development. METHODS At the NDDI workshop held March 29 and 30, 2004, in Baltimore, Maryland, members of the Ethics Group were dispersed among the subspecialty groups before convening to discuss common ethical themes. The Ethics Group then met together to identify and discuss those ethical themes that were both important and shared among the groups. These themes are discussed and illustrated with the other NDDI group reports. This workshop was cosponsored by the National Institute of Child Health and Human Development and the US Food and Drug Administration. RESULTS Neonatal drug research is scientifically and ethically necessary to establish the efficacy and safety of drugs widely used in newborn medicine. However, research involving neonates must be carefully designed to balance potential risks and benefits, with consideration given to the component analysis of risk. The protocols proposed by the NDDI groups would be considered greater than minimal risk and offering prospect for direct benefit, thus adhering to the Department of Health and Human Services' pediatric research regulations (Subpart D). The NDDI groups all proposed randomized controlled clinical trials, with careful attention to scientifically and ethically appropriate control groups. Multiple regulatory bodies have affirmed that in the absence of proven effective treatment or when a proven treatment offers marginal benefits, study designs with placebo controls are ethical. Obtaining parental permission is a complex issue, with a paucity of evidence describing the feasibility of informed and voluntary consent under conditions of duress and a short therapeutic window. The Subpart D regulations offer sufficient protection to critically ill neonates. The application of the revised Subpart B regulations would restrict the use of a waiver of consent for minimal risk research and for emergency research, and would not allow research that offers no direct benefit and no more than a minor increase over minimal risk. CONCLUSIONS Multisite collaboration involving standards of care and institutional review board procedures may be important for establishing scientific and ethical consistency. Ongoing dialogue among researchers, clinicians, parents, and other interested parties is essential to promoting ethically and scientifically sound neonatal clinical research.
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Affiliation(s)
- Gerri R Baer
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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