Prescribing information in 26 countries: a comparative study

Comparative evaluation of drug information leaflets for non-steroidal anti-inflammatory drugs in Palestine: local versus imported products

BACKGROUND

Drug information leaflets (DILs) are written for patients and health care providers to show how to use the medications safely and effectively, in order to reach the required therapeutics outcomes. This comparative study was conducted to evaluate various DILs of non-steroidal anti-inflammatory drugs (NSAIDs) that are produced in Palestine, along with their imported equivalents.

METHODS

Thirty-five DILs of NSAIDs were analyzed and evaluated in a cross-sectional comparative study. Thirty-one statements were obtained from literature and used; evaluation was performed on basis of both any presence or absence of these statements in the leaflets. 23 of the 31 statements that were available in both local and imported DILs were also evaluated in terms of total word-counts: the median (interquartile range) word-count for each statement was determined separately for the two groups and then compared. For the remaining 8 statements, this was not performed,either because they were not present in any leaflet, or because counting the number of words would not be meaningful.

RESULTS

A total of 35 DILs for nine different active ingredients of NSAIDs were analyzed. In 97% of leaflets, "Instructions to convert medication into liquid forms" were missing and 94% did not provide any information about "Pharmacokinetics". 83% of DILs provided no information about "Mechanism of action" and 74% did not mention any reliable references. 66% of the analyzed inserts did not include any instruction about the possibility of a tablet splitting. And in 63%, the "Date of last revision" was missing. Further, "Duration of using" and "Inactive ingredients" were not found in 51% of leaflets. In terms of word-count, the related sections of the 23 selected criteria were expressed with more words by imported leaflets compared with the local ones, significant differences were found in 12 categories, the highest significance of > 42.4-fold difference was found in "Geriatric considerations" category whereas 1.4-fold difference was found in "Shelf life," being the lowest one.

CONCLUSIONS

This study shows that local products provide less information than imported products, so we recommend that appropriate measurements be taken by both Palestinian authorities and manufacturers to improve both quantity and quality of local DILs.

Analysis of the Antimicrobial Market in Pakistan: Is It Really Necessary Such a Vast Offering of "Watch" Antimicrobials?

Understanding antimicrobials (AM) on offer in a pharmaceutical market, with a particular reference to drugs categorized as “Watch” active ingredients, is one of the important first steps to prevent their potentially inappropriate use. The March 2019 data of all AM containing registered brands and presentations currently being sold in the country for the J01 Anatomical Therapeutic Chemical (ATC) subgroup from IQVIA Pakistan was used. Each AM was categorized as “Access,” “Watch,” or “Reserve,” according to the WHO AWaRe classification. There were 59 single chemical entities and 14 combinations with 1869 brands and 4648 presentations. The WHO Essential Medicines List included 35 J01 AM while an additional 38 single and combination AM with 425 brands and 977 presentations were present in the country. Looking at the whole list of marketed AM, 8 of the 10 AM with more than 60 brands were classified as “Watch”, offering 962 brands and 2418 presentations. Most AM marketed in Pakistan, of which there are an excessive number of brands, belong to the “Watch” AWaRe category. The higher the number of brands, the higher the marketing pressure on prescribers and pharmacists will be which implies more potential confusion. One vital step to rationalize the use of AM lies in reviewing their market offer.

Off-label drug prescriptions in French general practice: a cross-sectional study

OBJECTIVES

Off-label drug prescribing is a public health and economic issue. The aim of this study was to describe off-label prescription in general practice in France, in terms of frequency and nature, and to identify its main determining factors.

DESIGN

Multicentre cross-sectional study SETTING: Twenty-three training general practice offices PARTICIPANTS: All the voluntary patients coming for a medical consultation or visited at home over a cumulative period of 5 days per office between November 2015 and January 2016.

METHODS

Eleven interns, acting as observers, collected data. Two reviewers analysed the drugs prescribed by the trainers, in order to identify those prescribed off-label in terms of their indication or the age of the patient. We used a univariate, then a multivariate model, based on hierarchical mixed-effects logistic regression.

RESULTS

Among the 4932 drug prescriptions registered, 911 (18.5%[95% CI17.4% to 19.6%]) were off-label, of which 865 (17.6%) due to the indication of the drug and 58 (1.2%) due to the age of the patient. The prescription never mentioned the off-label use, neither was the patient informed of it, as required by the French law. With the multivariate analysis, variables contributing to off-label prescription were the number of drugs (OR=1.05 for each additional drug), the initiation of new drug therapy (OR=1.26) and the non-specific goal of the prescription (OR=1.43); the age of the patient ≤14 years (OR=1.42); the rural location of the physician's practice (OR=1.38) and the low frequency of the visits of national health insurance representatives (OR=0.93).

CONCLUSION

Almost one out of five drugs prescribed in French general practice was off-label. It seems necessary to better train physicians in clinical pharmacology, to provide them with more effective drug prescription software, to reinforce postmarketing surveillance and to clearly define off-label use by consensus.

Assessment of Consistency of Drug Interaction Information in Drug Labels Among the United States, the United Kingdom, China, Japan, and Korea

Information gap in drug labeling among countries create challenges in therapeutic use of drugs. We aimed to evaluate the consistency of drug interaction information in drug labels among five countries. The study drugs were chosen from the commonly approved drug list in the US, UK, China, Japan, and Korea. The degree of agreement of drug interaction data was evaluated by kappa coefficient. Thirty-eight drugs were evaluated, and moderate degree of agreement was observed among all countries' labeling (κ = 0.43, 95% confidence interval (CI) = 0.41-0.46). The degree of agreement was the highest for the UK and Korea (κ = 0.71, 95% CI = 0.67-0.75) and the lowest for the UK and Japan (κ = 0.02, 95% CI = 0.00-0.04). Information regarding drug interactions listed in the studied drug labels was not in high agreement. International standardization of drug labeling is required to ensure safe drug therapy.

ADHD medications and cardiovascular adverse events in children and adolescents: cross-national comparison of risk communication in drug labeling

PURPOSE

Regulators approve written medical information for healthcare professionals and consumers, but the consistency of these sources has not been studied. We investigated the consistency of information regarding four cardiovascular risks of attention-deficit/hyperactivity disorder (ADHD) medications approved in four countries.

METHODS

Professional and consumer product labeling for five ADHD medications approved in Australia, Canada, the UK, and the USA were obtained in March/April 2016. Language describing the relationship between medication and elevated blood pressure and/or heart rate, myocardial infarction, stroke, and sudden death was extracted verbatim and classified into one of four categories based on the described relationship between medication and adverse event: "confirmed," "unconfirmed," "mixed," and "not mentioned." We judged the consistency of messages delivered to healthcare professionals and consumers as either "consistent" or "inconsistent."

RESULTS

We obtained 20 healthcare professional labels and 20 corresponding consumer labels for the five ADHD medications registered in all four countries. Not all professional and consumer labeling contained language regarding all four adverse events. Of the 80 theoretically evaluable drug-risk pairs, 38 (48%) were not evaluable because of absence of mention of the adverse event in the consumer label. For the remaining 42, the potential causal relationship was expressed consistently in professional and consumer labeling in 25 (60%) cases. The cardiovascular risk profile was not described consistently across all four countries for any of the five drugs.

CONCLUSIONS

Product labeling provides healthcare professionals and consumers with inconsistent messages regarding the potential causal relationship between stimulant use and specific cardiovascular risks in children and adolescents. Copyright © 2017 John Wiley & Sons, Ltd.

Liquid Medication Dosing Errors by Hispanic Parents: Role of Health Literacy and English Proficiency

OBJECTIVE

Hispanic parents in the United States are disproportionately affected by low health literacy and limited English proficiency (LEP). We examined associations between health literacy, LEP, and liquid medication dosing errors in Hispanic parents.

METHODS

Cross-sectional analysis of data from a multisite randomized controlled experiment to identify best practices for the labeling/dosing of pediatric liquid medications (SAFE Rx for Kids study); 3 urban pediatric clinics. Analyses were limited to Hispanic parents of children aged ≤8 years with health literacy and LEP data (n = 1126). Parents were randomized to 1 of 5 groups that varied by pairing of units of measurement on the label/dosing tool. Each parent measured 9 doses (3 amounts [2.5, 5, 7.5 mL] using 3 tools [2 syringes in 0.2 or 0.5 mL increments, and 1 cup]) in random order. Dependent variable was a dosing error of >20% dose deviation. Predictor variables included health literacy (Newest Vital Sign) (limited = 0-3; adequate = 4-6) and LEP (speaks English less than "very well").

RESULTS

A total of 83.1% made dosing errors (mean [SD] errors per parent = 2.2 [1.9]). Parents with limited health literacy and LEP had the greatest odds of making a dosing error compared to parents with adequate health literacy who were English proficient (trials with errors per parent = 28.8 vs 12.9%; adjusted odds ratio = 2.2 [95% confidence interval 1.7-2.8]). Parents with limited health literacy who were English proficient were also more likely to make errors (trials with errors per parent = 18.8%; adjusted odds ratio = 1.4 [95% confidence interval 1.1-1.9]).

CONCLUSIONS

Dosing errors are common among Hispanic parents; those with both LEP and limited health literacy are at particular risk. Further study is needed to examine how the redesign of medication labels and dosing tools could reduce literacy- and language-associated disparities in dosing errors.

Differences between the United States and Japan in labels of oncological drugs

PURPOSE

Our study addresses how the information in the labels differed between United States (US) and Japan, what factors were associated with the decision to place the boxed warning on the label, and the relation of both countries in terms of drug label policy.

METHODS

We investigated adverse drug reactions (ADRs) in boxed warnings for 44 oncological drug labels approved from 2004 to 2014 in both Japan and the US. We applied conditional logistic regression to examine how likely it was for each ADR to be included in a boxed warning.

RESULTS

There were substantial differences in all sections of the labels. The concordance rate between US and Japanese labels was 44.1% for serious adverse reactions and 30.5% for boxed warnings. Our regression analysis indicated that deaths and/or terminations related to specific ADRs reported in clinical trials were significantly associated with inclusion of the ADR in boxed warnings in Japan, but not in the US. The boxed warnings of similar drugs seemed to affect those of follow-on drugs in both countries. US drug labels were likely to influence Japanese labels, but not vice versa.

CONCLUSION

This study suggests that the observed differences are not solely due to differences in clinical outcomes between the two countries, but rather due to differences in regulatory considerations and historical factors in both local and global contexts. Further research is needed to examine the impact of these differences on public health and to determine how and to what extent we should intervene with this status quo. Copyright © 2016 John Wiley & Sons, Ltd.

Inconsistencies and misleading information in officially approved prescribing information from three major drug markets

The summary of product characteristics (SPC) should provide information for the safe prescription and use of a drug. We evaluated the consistency of critical interaction warnings, the quality of presentation of undesirable effects as well as concordance of critical information of representative drugs marketed in the United States, the UK, and Germany. Reciprocal warnings regarding drug-drug interactions that constitute contraindications were frequently missing in the SPCs of the drugs concerned (all countries >40%). Most SPCs did not explicitly exclude adverse reactions considered not reasonably attributable to the use of the drug. Comparing SPCs of different generic brands of the same drug, only 60, 10, and 20% of the US, UK, and German SPCs, respectively, provided identical contraindications. Current SPCs contain inconsistencies and misleading data that are not compatible with the purpose of SPCs, which is to provide a basis for the safe prescription and use of drugs.

Discrepancies in listed adverse drug reactions in pharmaceutical product information supplied by the regulatory authorities in Denmark and the USA

Pharmaceutical product information (PI) supplied by the regulatory authorities serves as a source of information on safe and effective use of drugs. The objectives of this study were to qualitatively and quantitatively compare PIs for selected drugs marketed in both Denmark and the USA with respect to consistency and discrepancy of listed adverse drug reaction (ADR) information. We compared individual ADRs listed in PIs from Denmark and the USA with respect to type and frequency. Consistency was defined as match of ADRs and of ADR frequency or match could not be ruled out. Discrepancies were defined as ADRs listed only in one country or listed with different frequencies. We analyzed PIs for 40 separate drugs from ten therapeutic groups and assigned the 4003 identified ADRs to System Organ Classes (Medical Dictionary for Regulatory Activities [MedDRA] terminology). Less than half of listed ADRs (n = 1874; 47%) showed consistency. Discrepancies (n = 2129; 53%) were split into ADRs listed only in the USA (n = 1558; 39%), ADRs listed only in Denmark (n = 325; 8%) and ADRs listed with different frequencies (n = 246; 6%). The majority of listed ADRs were of the type “gastrointestinal disorders” and “nervous system disorders”. Our results show great differences in PIs for drugs approved in both Denmark and the USA illuminating concerns about the credibility of the publicly available PIs. The results also represent an argument for further harmonization across borders to improve consistency between authority-supplied information.

Agreement of label information of cardiovascular drugs in pregnancy among Korea, the USA, the UK, and Japan

Drug label is a common source of information; however, the content varies widely. This study aims to evaluate label information on cardiovascular drugs regarding pregnancy for their similarities in Korea, USA, UK, and Japan. Study drugs were selected as following (1) cardiovascular drugs according to the WHO ATC code (C01-C09) and (2) drugs currently marketed in all four countries were included. Evidence level was classified into five categories ('Definite', 'Probable', 'Possible', 'Unlikely', and 'Unclassified') and recommendation level was classified into four categories ('Contraindicated', 'Cautious', 'Compatible', and 'Unclassified'). Frequency and proportion were presented. Percent agreement and kappa coefficient with 95% confidence interval (CI) were calculated using SAS ver. 9.3. Total of 50 cardiovascular drugs were included. 'Unclassified' was represented the most in Korea, followed by Japan and UK (58%, 54%, and 46%, p<0.05). For recommendation level, the majority of drugs in all four countries were classified as 'contraindicated' or 'cautious'. Japanese labels had the largest proportion of 'contraindicated' level (62%), and Korea and UK followed (58%, 44%, p<0.05). Only in the USA, 10.0% of the drugs were 'compatible' whereas, there were none in Korea, UK, and Japan (p<0.01). Korea and Japan showed a substantial agreement in evidence and recommendation level (kappa=0.69, 0.67). Labels of cardiovascular drugs in pregnancy differed widely. Reliable safety information in pregnancy should be provided through regular updates.

Worldwide analysis of factors associated with medicines compendia publishing

BACKGROUND

Medicines compendia, also called formularies, are the most commonly used drug information source among health care professionals.

OBJECTIVE

The aim was to identify the countries publishing medicines compendia and the socio-demographic factors associated to this fact. Additionally, we sought to determine the use of foreign compendia in countries lacking their own.

SETTING

Global web-based survey.

METHOD

Healthcare practitioners and researchers from 193 countries worldwide were invited to complete a web-based survey. The questionnaire investigated the existence of a national compendium, or the use of foreign compendia in the absence of one. Demographic and socioeconomic variables were used to predict compendia publishing through a multivariate analysis.

MAIN OUTCOME MEASURE

Existence of national medicines compendia and foreign compendia used.

RESULTS

Professionals from 132 countries completed the survey (response rate at a country level 68.4%, comprising 90.9% global population). Eighty-four countries (63.6%) reported publishing a medicines compendium. In the multivariate analysis, only two covariates had significant association with compendia publishing. Being a member of the Organisation for the Economic Cooperation and Development was the only variable positively associated with compendia publishing (OR = 37.5; 95% CI = 2.3:599.8). In contrast, the countries that listed French as an official language were less likely to publish a compendium (OR = 0.07; 95% CI = 0.007:0.585). Countries without national compendia reported using the British National Formulary most commonly, followed by the Dictionnaire Vidal.

CONCLUSION

Publication of medicines compendia is associated with socio-economic development. Countries lacking a national compendium, use foreign compendia from higher-income countries. Creating an international medicines compendium under the leadership of the World Health Organisation, rather than merely a 'model', would reduce the risks of using information sources not-adapted to the necessities of developing countries.

Different indications, warnings and precautions, and contraindications for the same drug--an international comparison of prescribing information for commonly used psychiatric drugs

PURPOSE

We aim to derive an internationally applicable data set to improve prescription safety of psychiatric drugs.

METHODS

We performed an in-depth analysis of the concordance of prescribing information of 10 key psychiatric drugs across four major drug markets with regard to indications, warnings and precautions, and contraindications.

RESULTS

The individual prescribing information covered on average 71.4 ± 30.3% of all named indications, 59.5 ± 17.1% of all potential warnings and precautions and 70.1 ± 24.4% of all applicable contraindications.

CONCLUSION

This substantial variation in key prescribing information across countries highlights the need for a better international cooperation and standardization of prescribing information.

Attitudes of consumers and healthcare professionals towards the patient package inserts - a study in Palestine

Reading the patient package inserts (PPIs) is a key source of information about medications for patients. They should be clear and understandable to the general population.

Objective

The aims of this study were to obtain base-line data on the extent of reading PPIs by consumers and possible factors that might affect this; to explore the attitude of the Palestinian public and healthcare professionals towards the patient package inserts (PPIs); and to review a random sample of PPIs for the availability of different information.

Methods

The first part of the study was a cross-sectional self-administered questionnaire. The questionnaire for consumers included 15 items. The questionnaire for healthcare professionals included 10 items and it was very similar to that of consumers with some modifications. In the second part, a random sample of PPIs was reviewed. In our community pharmacies, where medications are arranged according to their producing company, a researcher was asked to choose randomly 10-15 medications for every company to check for the availability of pharmacological, pharmaceutical and clinical information.

Results

A total of 304 healthcare professionals out of 320 (95.0%) and 223 consumers out of 240 (92.9%) accepted to answer the survey. Forty five percent consumers reported that they always read the PPIs, and 29.3% said that they read the PPIs most of the times. Increased rate of reading the leaflet was found among females (P = 0.047). The preferred language for the PPIs was Arabic for most of the consumers (89.6%) while it was English for most of the healthcare professionals (80.8%). 35.9% of the consumers and 43.6% of the healthcare professionals found the font size suitable. 42.3% of the consumers and 25.5% of the healthcare professionals said that they found the information in the PPIs useful and enough. The PPIs of 135 randomly sampled medications were reviewed. Many important sections were not found in the PPIs' sample.

Conclusions

A high percentage of consumers read the PPIs, but still this needs to be improved. People would appreciate a more detailed and clear PPI. Pharmacists should advocate reading the PPIs but they need to provide consumers with detailed counseling to compensate for the missing information in some of the PPIs. Authorities and manufacturers should implement appropriate measures to regulate the quality and quantity of information in the PPIs.

Comparative analysis of patient package inserts of local and imported anti-infective agents in palestine

BACKGROUND AND OBJECTIVE

The patient package insert is an important source of drug information. The aim of this study was to evaluate and compare the PPI of the anti-infective agents manufactured in Palestine with the imported equivalents.

METHOD

The selection criteria generated 15 different anti-infective agents available as 36 locally manufactured products and 15 imported equivalents. The design of the patient package insert was evaluated in terms of the number of words used in eight main headings and the presence or absence of certain information regarding nine statements.

RESULTS

Inserts of locally manufactured products have significantly fewer words than those of imported products with respect to warnings, dosage and administration, and side effects. The most significant difference was found in the warnings. Moreover, differences were found between inserts of local and imported products in terms of the presence of the nine informative statements. Locally manufactured products did not mention inactive ingredients, clinical pharmacology or date of last revision, but all of them provided information on the use of the drug during pregnancy and lactation and on the duration of therapy. However, in general they provided less information than the imported equivalents.

CONCLUSION

Palestinian authorities and local manufacturers should implement appropriate measures to regulate the quality and quantity of information in the patient package insert of locally produced anti-infective agents. PPI improvement will better direct health practices to the benefit of the patients.

Contraindication labelling changes in the United States and Germany

OBJECTIVE

Communication of a drug's benefits and risks through drug labelling is an important tool in the risk management of prescription drugs. Contraindication labelling provides the strongest safety-based guidance for the health care practitioner. In this study, the labelling of new contraindications between the United States (US) and Germany was compared.

METHODS

We assessed whether contraindications that were newly labelled in the US between January 2003 and May 2005 had been incorporated into the German Summary of Product Characteristics (SPC) by October 2005 (end of the study period). We classified the results of our comparison as no difference, a slight difference (more detailed contraindication in one country or the other) or as a relevant difference (new US contraindication not contraindicated in the German SPC). We assessed the time difference between the date of the labelling change in the US and October 2005.

RESULTS

During the study period, 66 new contraindications were evaluable for analysis. We found no difference in labelling between the US and Germany with regard to 30 contraindications (45.5%) and slight differences with regard to 14 contraindications (21.2%). In 22 instances (33.3%), the new contraindication in the US had not been incorporated into the German SPC. The median delay between the date of labelling in the US and October 2005 was 14 months and ranged between 5 and 31 months. In 77.3% of the relevant differences in contraindication labelling, the pharmaceutical manufacturer was the same in the US and Germany.

CONCLUSION

Our study shows a remarkable discrepancy in the labelling of new contraindications between the US and Germany. The underlying reasons for this discrepancy were discussed, but need to be explored further.

Assessment of prescribing information for generic drugs manufactured in the Middle East and marketed in Saudi Arabia

BACKGROUND

Little research has assessed the quality of manufacturer-provided prescribing information or documented differences in key aspects of drug information among different marketed generic products of the same drug, particularly in the Middle East and Arabian Gulf. We assessed the quality of written prescribing information for selected generic drugs marketed in Saudi Arabia and manufactured in various countries of the Middle East.

METHODS

We assessed the correctness and completeness of information pertaining to indications, dosage, cautions/contraindications, side effects and drug interactions in 37 package inserts for generic products registered in Saudi Arabia and manufactured in the Middle East, including atenolol (6 inserts), fluoxetine (4 inserts), ciprofloxacin (11 inserts), metformin (7 inserts), and omeprazole (9 inserts). We also described deficiencies in the quality and quantity of manufacturer-provided information that could be misleading to patients and prescribers.

RESULTS

We found substantial disagreement in information between generic package inserts versus the British National Formulary and the package insert of the brand product marketed in Saudi Arabia. A cumulative average of 63 +/- 16% of drug information indicators were in agreement with these standard references. Section headings with the least conformity with study references were those related to dosage (57 +/- 28%) and side effects (54 +/- 30%).

CONCLUSION

Our results indicate that national authorities should implement appropriate measures aimed at removing misleading and incorrect information in generic package inserts and incorporating crucial prescribing information that is missing. National authorities in the Middle East and Arabian Gulf should strengthen collaboration and information interchange among each other and with international agencies to maintain common quality standards for delivering information through package inserts.

Information deficits in the summary of product characteristics preclude an optimal management of drug interactions: a comparison with evidence from the literature

OBJECTIVE

To compare comprehensiveness and accuracy of drug interaction information in the German summary of product characteristics (SPC) with current evidence from the literature and to evaluate the SPC's usefulness with respect to management of drug interactions.

METHODS

Information on clinically relevant drug interactions was compared between the SPC and three standard information sources on drug interactions (DRUGDEX, Hansten/Horn's Drug Interactions Analysis and Management, Stockley's Drug Interactions) according to five consecutive criteria (inclusion, appropriateness of class labelling, effect description, management recommendation, explicit dose adjustment). Using medication data of an outpatient population (n=4,949), we determined what percentage of insufficiently characterized combinations indeed occurred in outpatients treated with combination drug therapy.

RESULTS

Only for 33% (192/579) of the evaluated combinations did SPCs provide drug interaction information equivalent to the evidence from the published literature. Of the clinically relevant drug interactions, 16% were completely missing and 51% were insufficiently characterized compared with standard sources. Explicit management recommendations were either missing or differed from standard sources in 18% of the evaluated pairs of compounds. Of these missing or insufficiently characterized combinations, 12% (47/387) were indeed prescribed to outpatients. Those drug combinations for which the interaction potential was not mentioned in the SPC were received by 0.6% (32/4,949) of patients, and 4% (192/4,949) of patients received combinations that had insufficiently characterized drug interactions.

CONCLUSIONS

If physicians only rely on SPC information for drug interactions, adverse events due to lacking management recommendations may occur. To meet the SPCs claim of being the basis of information for health professionals on how to use medicinal products safely and effectively, information on drug interactions should be thoroughly up-dated and expanded.