Assessment of pediatric asthma drug use in three European countries; a TEDDY study

Prescriptions of respiratory medications in children aged 0-10 years: A longitudinal drug utilization study in the POMME database

INTRODUCTION

Respiratory tract disorders are common in children. However, there is no available data on the prescription of respiratory medications for children in France. This study aimed to provide an overview of medications for obstructive airway diseases prescriptions for children during the initial ten years of their lives within POMME, a French population-based cohort of children.

MATERIAL AND METHODS

This longitudinal, population-based study used data from the French POMME birth cohort, comprising children born in Haute Garonne between July 2010 and June 2011. Anonymous medical information, including medication reimbursement data, was collected between ages 0 and 10 years. Exposure was defined as at least one prescription for respiratory medications (ATC code R03*), focusing on specific subclasses. Data were analyzed by age, season, and prescribing physicians' specialties.

RESULTS

Out of 5956 children, 4951 (83.1 %) received respiratory medication prescriptions. Inhaled corticosteroids (ICSs) were the most prescribed (95.3 %), followed by short-acting β2-agonists (68.8 %). The number of prescriptions increased with age, except for ICSs alone, which peaked between 6 months and 2 years. The average number of prescriptions per child was relatively low.

DISCUSSION

This study highlighted high prescription rates of respiratory medications in children under 10 years, with ICSs being the most prevalent. While these medications are primarily intended for asthma management, the findings suggested a significant proportion of off-label prescriptions, especially in young children. Further research and clinical guidance are warranted to ensure appropriate medication use in the pediatric population.

Behavioural side effects of inhaled corticosteroids among children and adolescents with asthma

Background

Inhalation corticosteroids (ICS) are prescribed for treatment of asthma in approximately 3% of all children in Denmark. Despite limited evidence, case reports suggest that ICS-related behavioural adverse drug events (ADEs) may be frequent. In general, underreporting of ADEs to official databases is common, and little is known about doctor’s clinical experiences with behavioural ADEs when prescribing ICS for children with asthma. The objective was to investigate the extent of behavioural ADEs in children with asthma treated with ICS by comparing database findings to experiences of specialist doctors.

Methods

First, databases of the European Medicines Agency (EMA) and the Danish Medicines Agency (DKMA) were searched for reports made by healthcare professionals about behavioural ADEs in children from 2009 to 2018. Second, questionnaire data on behavioural ADEs were collected from eight of the 11 specialist doctors responsible for treating children with asthma at the six paediatric departments in Central Denmark Region and North Denmark Region.

Results

EMA and DKMA had registered 104 and 3 reports, respectively, on behavioural ADEs during the 10-year study period. In contrast, five of the eight specialist doctors (45.5%) had experienced patients who had developed behavioural changes during ICS treatment. However, none of the five specialist doctors had filed reports on these events to DKMA.

Conclusion

Behaviour-related ADEs to ICS in children with asthma are likely to be highly underreported in official databases and doctors treating children with ICS should be aware of potential ADEs and consider submitting ADE reports whenever appropriate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02112-8.

Airway symptoms and atopy in young children prescribed asthma medications: A large-scale cohort study

Diagnosing asthma and deciding treatment are difficult in young children. An inappropriate and too high prescription rate of inhaled corticosteroids (ICS) is suggested, but how airway symptoms are associated with prescriptions of asthma medication is less known. We studied how strongly wheeze, lower respiratory tract infections (LRTI), and atopic diseases are associated with dispensing of asthma medications during early childhood. We used data from the Norwegian Mother and Child Cohort Study and the Norwegian Prescription Database at four age-intervals (0-6, 6-18, 18-36 months, and 3-7 years). Primary outcomes were dispensed asthma medications (no medication, short-acting β-2 agonist, or ICS). Relative risks (RRs) and average attributable fractions (AAFs) were estimated. Both wheeze and LRTI were positively associated with both medication groups (0-6 months: no data on wheeze). The RRs and AAFs were higher for wheeze than LRTI. For ICS, the AAFs (95% CI) for wheeze vs LRTI were: 6 to 18 months: 69.2 (67.2, 71.2)% vs 10.4 (9.0, 11.8)%, 18 to 36 months: 33.0 (30.5, 35.5)% vs 10.0 (8.0, 12.0)%, and 3 to 7 years: 33.7 (31.0, 36.5)% vs 1.2 (0.5, 1.9)%. Except at 3 to 7 years of age, the AAFs were lower for atopic diseases than for LRTI and wheeze. Atopic diseases modified the associations between wheeze and ICS at 18 to 36 months and between LRTI or wheeze and ICS at 3 to 7 years. In conclusion, both wheeze and LRTI were associated with prescriptions of asthma medications in young children, with the strongest associations seen for wheeze. Atopic diseases contributed to these associations only in the oldest age groups.

Treatment Patterns of New Users of Fluticasone Furoate/Vilanterol in Asthma and COPD in UK Primary Care: Retrospective Cohort Study

Introduction

This retrospective database study explored treatment patterns and potential off-label prescribing among patients newly prescribed fluticasone furoate/vilanterol (FF/VI) in a UK primary care setting.

Methods

In Europe, FF/VI is approved in two strengths: 100/25 µg for adults with chronic obstructive pulmonary disease (COPD) and 100/25 µg or 200/25 µg for treatment of asthma in patients aged 12 or older. Using electronic health records from the Clinical Practice Research Datalink, new users of FF/VI or other inhaled corticosteroid/long-acting beta-agonist fixed-dose combination products were identified and classified into one of three groups: COPD diagnosis, asthma diagnosis, and other diagnosis (not COPD or asthma).

Results

During 2014–2015, 4373 patients initiated FF/VI: 3380 on FF/VI 100/25 (65% in the COPD diagnosis group) and 993 on FF/VI 200/25 (51% in the asthma diagnosis group). During up to 12 months of follow-up, the median number (interquartile range) of prescriptions of the index strength issued per patient was 7 (2–8) for FF/VI 100/25 and 5 (2–8) for FF/VI 200/25; most new users did not change from the index strength prescribed (93.0% COPD; 89.7% asthma, of all patients initiating treatment with FF/VI). Potential off-label FF/VI prescribing in children < 12 years old was rare (< 0.29% in the combined asthma and other diagnosis groups), and up to one in five new users of FF/VI with COPD were potentially prescribed FF/VI 200/25 off-label during the study period. Much of the potential off-label prescribing in COPD occurred in patients with a history of asthma, those presenting with greater disease severity, and/or prior treatment with high-dose steroids.

Conclusions

The prescription of FF/VI is rare in children under 12 years of age in the UK, according to our findings, but up to one in five COPD patients in the UK may have been prescribed FF/VI 200/25, some of which may have been off-label.

Funding

This study was funded by GlaxoSmithKline plc (study 205052).

Study Registration

GlaxoSmithKline plc Clinical Trial Registry study number 205052.

Electronic supplementary material

The online version of this article (10.1007/s41030-019-0092-z) contains supplementary material, which is available to authorized users.

Pharmacoepidemiological research for the development and evaluation of drugs in pediatrics

New regulations have come into force in Europe and the US establishing the pediatric development as an integral part of the early development of medicinal products. Parallel to the advances in pediatric clinical research, it became obvious that all available sources and research tools to gather valuable information for the safe and efficacious prescription of medicines in children should be used. Real-life, pharmacoepidemiological studies provide information that contribute to the better knowledge of drug utilization, effects and safety in the pediatric population and thereby, a better prescribing in children. In this paper, we suggest some possible applications, provide examples of impact of pharmacoepidemiological and pharmacovigilance studies and expose future perspectives in pediatric pharmacoepidemiology.

Gender Differences in Outpatient Pediatric Drug Utilization: A Cohort Study From Southern Italy

Objective: The aim of this retrospective population-based cohort study is to in-depth investigate gender-specific drug utilization pattern in pediatric outpatient population.

Methods: By using a large administrative database of the Local Health Unit of Caserta (Southern Italy), a pediatric cohort from the birth to 18 years was observed over 6 years (from 1st January 2010 to 31st December 2015). Yearly prevalence of drug use per 100 inhabitants as well as the median number of prescriptions was stratifying by gender. Prevalence of acute and recurrent use of the most frequently used active substances was calculated for the year 2015.

Results: A decreasing trend in prevalence of drug use (−3.2%, with a reduction of median number of drugs dispensed) was observed in children for both sexes, from 2010 to 2015. In 2015, the drug classes most commonly used among children of any age were modestly but consistently prescribed more to males than to females: systemic anti-infective drugs (M = 43.5%; F = 42.3%), respiratory tract drugs (M = 29.0%; F = 26.1%), and hormones (M = 13.1%; F = 11.3%). Irrespective of gender, beclomethasone was the most utilized active substance in the first 2 years of life, while thereafter amoxicillin/clavulanate in combination.

Conclusions: In a large population of pediatric outpatients no major difference was seen between genders, although commonly used drug classes; in particular, antibiotics, respiratory tract drugs and Hormones with corticosteroids for systemic use prescribed modestly but consistently to larger extent in males than females.

Relationship Between Gender and the Effectiveness of Montelukast: An Italian/Danish Register-Based Retrospective Cohort Study

Rationale: Gender-related differences in asthma prevalence, pathophysiology and clinical features induced by sex steroids have been investigated, however, how gender influences response to asthma treatments in routine clinical practice have not yet been elucidated fully. This aspect is crucial for montelukast considering the jeopardization of asthmatic patients that benefit from this treatment and the existence of evidence of gender differences in leukotriene levels. Therefore, to fulfill this medical need, we investigated the role of gender on a set of montelukast' effectiveness surrogates in adults and pediatric patients with asthma. Methods: The study settings were Napoli 2 Local Health Unit (southern Italy) and the entire Danish territory. The study population was composed of adult and pediatric patients with asthma. Cumulative incidence curves, unadjusted and adjusted Cox regression were used as statistical models to compare aforementioned outcomes between genders. Results: Adult Italian male users of montelukast had a statistically lower persistence in montelukast treatment compared to female users. In the adjusted analyses, they had a higher hazard of montelukast' withdrawal (Hazard Ratio [HR] 1.07; 95% Confidence Interval [CI] 1.01-1.14), add-on/switch to a long-term treatment for asthma following montelukast withdrawal (HR 1.72; 95%CI 1.39-2.12), and rescue therapy with short-acting β2 agonist (HR 1.24; 95%CI 1.04-1.47). In the adult Danish cohort, we also found that male users had higher a hazard of rescue therapy with oral corticosteroids (HR 1.10; 95%CI 1.04-1.16). In the pediatric cohorts, no statistically significant differences were observed between genders for aforementioned outcomes. Conclusions: In adults, male gender was associated with increased hazards of montelukast discontinuation, add-on/switch to a long-term treatment for asthma following montelukast withdrawal, and rescue therapy with oral corticosteroids or short-acting β2 agonist when compared to the female gender. As expected, these associations were reversed or absent in pediatric patients.

Electronic health record (EHR) based postmarketing surveillance of adverse events associated with pediatric off-label medication use: A case study of short-acting beta-2 agonists and arrhythmias

PURPOSE

Use electronic health record (EHR) data to (1) estimate the risk of arrhythmia associated with inhaled short-acting beta-2 agonists (SABA) in pediatric patients and (2) determine whether risk varied by on-label versus off-label prescribing.

METHODS

Retrospective cohort study of 335 041 children ≤18 years using EHR primary care data from 2 pediatric health systems (2011-2013). A series of monthly pseudotrials were created, using propensity score methodology to balance baseline characteristics between SABA-exposed (identified by prescription) and SABA-unexposed children. Association between SABA and subsequent arrhythmia for each health system was estimated through pooled logistic regression with separate estimates for children initiating under and over 4 years old (off-label and on-label, respectively).

RESULTS

Eleven percent of the cohort received a SABA prescription, 57% occurred under the age of 4 years (off-label). During the follow-up period, there were 283 first arrhythmia events, most commonly atrial tachyarrhythmias and premature ventricular/atrial contractions. In 1 health system, adjusted risk for arrhythmia was increased among exposed children (OR 1.89, 95% CI 1.31-2.73) without evidence of interaction between label status and risk. The absolute adjusted rate difference was 3.6/10 000 person-years of SABA exposure. The association between SABA exposure and arrhythmias was less strong in the second system (OR 1.26, 95% CI 0.30-5.33).

CONCLUSION

Using EHR data, we could estimate the risk of a rare event associated with medication use and determine difference in risk related to on-label versus off-label status. These findings support the value of EHR-based data for postmarketing drug studies in the pediatric population.

Antibiotic-Induced Liver Injury in Paediatric Outpatients: A Case-Control Study in Primary Care Databases

Introduction

Antibiotics are the most commonly prescribed drug class in children. Real-world data mining on the paediatric population showed potential associations between antibiotic use and acute liver injury.

Objective

We assessed risk estimates of liver injury associated with antibiotic use in children and adolescent outpatients.

Methods

A large, multi-database, population-based, case-control study was performed in people <18 years of age from two European countries (Italy and The Netherlands) during the period 2000–2008. All potential cases of liver injury were automatically extracted from three databases and then manually validated based on Council for International Organizations of Medical Sciences (CIOMS) criteria and by exclusion of all competing causes for liver injury. Up to 100 control participants were sampled for each case and were matched on index date of the event, age, sex and database. Based on prescription data, antibiotic exposure was categorized as current, recent or past use by calculating the time period between the end of prescription and the index date. Multivariate conditional logistic regression analyses were applied to calculate odds ratios (ORs) as a measure of the association (with 95% confidence interval [CI]).

Results

We identified 938 cases of liver injury and matched to 93,665 controls. Current use of overall antibiotics is associated with a threefold increased risk of liver injury compared with past use (adjusted OR [OR_adj] 3.22, 95% CI 2.57–4.03). With regard to individual antibiotics, the risk is significantly increased for current use of each antibiotic (p < 0.005), except for azithromycin. Risk estimates vary from the lowest OR_adj of 1.86 (95% CI 1.08–3.21) for amoxicillin to the highest OR_adj of 24.16 (95% CI 11.78–49.54) for cotrimoxazole (i.e. sulphamethoxazole/trimethoprim) and 26.70 (95% CI 12.09–58.96) for ceftriaxone. Sensitivity analyses confirm the associations for ceftriaxone, cotrimoxazole, and clarithromycin.

Conclusion

Antibiotic-induced liver injury in children is heterogeneous across the use of individual antibiotics. When prescribing ceftriaxone, cotrimoxazole and clarithromycin in children, paediatricians should definitely be aware of their potential risk of liver injury, even if for short periods.

Electronic supplementary material

The online version of this article (doi:10.1007/s40264-016-0493-y) contains supplementary material, which is available to authorized users.

Prescription patterns of inhaled corticosteroids for preschool children--A Norwegian register study

BACKGROUND

Although guidelines for treatment of wheeze and asthma in preschool children are available, symptoms are overlapping and it may be difficult to decide which children should be given inhaled corticosteroids (ICS). Previous studies suggest an inappropriate prescription pattern of ICS in this age group. We studied time trends of ICS use in preschool children in Norway during 2004-2013 by age, gender and physician specialty, and the persistence of ICS use during preschool years.

METHODS

Data were drawn from the Norwegian Prescription Database. The study population consisted of children ≤5 years who were prescribed ICS (alone or in combination) during 2004-2013.

RESULTS

The one-year prevalence of ICS use was generally high, and increased from 2004 to 2010, but decreased thereafter. The prevalence was highest in 2-year-olds (boys 12.9% and girls 9.3% in 2010) and declined by age, and higher among boys in all ages. 40-50% of ICS users received only one prescription per year. The share of children with persistent use of ICS over several preschool years was low, irrespective of the age at the first prescription. The majority of prescriptions were given by general practitioners, increasing during the study period.

CONCLUSIONS

The prevalence of ICS prescription for preschool children was high, but with low persistence, suggesting that ICS are frequently given for intermittent asthma-like symptoms. Asthma guidelines suggest a restrictive use of ICS during the first years of life, and the results may call for actions to better implement these guidelines.

Drug use in French children: a population-based study

BACKGROUND AND OBJECTIVE

To provide an overview of drug use in outpatient children in France, a population-based study using a national reimbursement claims database representative of 90% of the French population was conducted.

DESIGN

Cross-sectional study performed between January and December 2011 using the EGB database (Echantillon Généraliste de Bénéficiaires), a 1/97th sample of the national healthcare insurance system beneficiaries. Drug use in children <18 years old was estimated through reimbursements for prescribed drugs excluding vaccines. Prevalences of use were calculated for different levels of the Anatomical Therapeutic Chemical classification by considering as users children who had at least one reimbursement during the study period.

RESULTS

In 2011, 133,800 children were included in the study. The overall prevalence of drug use was 84% and the median number of different drugs per child was 5. Drug use was greatest in children aged <2 years. The most widely used drugs were paracetamol, systemic anti-infectives, nasal corticosteroids and decongestants, and anti-histamines. 21% children <2 years received domperidone.

CONCLUSIONS

There is widespread use of medicines that are unlikely to be effective and may have significant toxicity in French children. Irrational use of medicines appears to be greatest in children aged 5 years and under.

The ADAM33 S2 polymorphism is associated with susceptibility to pediatric asthma in the Chinese Han population

BACKGROUND

The disintegrin and metalloprotease domain containing protein 33 (ADAM33) is a novel susceptibility gene for asthma and airway hyperresponsiveness, particularly in the Asian population. We investigated the influence of ADAM33 polymorphisms on the serum levels of ADAM33 and the susceptibility to pediatric asthma in the Chinese Han population.

METHODS

Polymerase chain reaction-restriction fragment length polymorphism analysis was employed to study the genotypic distribution of F+1, T1, and S2 in ADAM33 in a cohort of 120 pediatric asthma patients and 105 healthy controls. The serum levels of secreted ADAM33 protein were measured in all the study subjects using the enzyme-linked immunosorbent assay (ELISA).

RESULTS

This case-control study showed that the distribution of F+1 and T1 genotypes of ADAM33 was not significantly different between pediatric asthma patients and healthy controls (p > 0.05); however, the genotype and allele frequencies of the S2 polymorphism were significantly different between asthmatic patients and healthy controls (both p < 0.05). In addition, the frequency of CGC and CGG haplotypes exhibited statistically significant differences, with lower CGC and higher CGG frequencies found in the case group compared to the control group. Finally, in comparison to healthy controls, the serum levels of ADAM33 protein were significantly lower in patients carrying the S2 polymorphism.

CONCLUSION

Our results provide evidence that the ADAM33 S2 polymorphism is associated with increased susceptibility to pediatric asthma and that the CGG haplotype for the F+1, T1, and S2 polymorphisms is associated with an elevated risk of pediatric asthma in the Han population, whereas the CGC haplotype appears to confer a protective effect. Our results may prove useful for population-based screening to affect early intervention.

Anti-asthmatic prescription variability in children according to age

INTRODUCTION

There is little research in the Spanish paediatric population about the consumption of anti-asthmatic agents. The aim of this study was to describe the current pattern of anti-asthmatic drug prescription in the paediatric population from a region of Spain, using the prescribed daily dose as a unit of measurement.

METHODS

We analysed the requirements of R03 therapeutic subgroup (anti-asthmatic agents) in children less than 14 years of age in the Public Health System of Castilla y León from 2005 to 2010. Consumption data are presented in prescribed daily doses per thousand inhabitants per day (PDHD) and compared with defined daily doses per thousand inhabitants per day (DHD).

RESULTS

394 876 prescriptions of anti-asthmatics were given to a population of 1 580 229 persons/year. Bronchodilators, leukotriene receptor antagonists, single inhaled corticosteroids (ICS) and long-acting β2-adrenergics associated with inhaled corticosteroids were the most commonly prescribed drugs: 7.5, 5.2, 4.9 and 2.2 PDHD, respectively. The maximum prescription of bronchodilators (15.9 PDHD/9.8 DHD) occurred in children under 12 months, with montelukast (8.9 PDHD/3.6 DHD) and single inhaled corticosteroids (7.9 PDHD/2.9 DHD) at one year of age.

CONCLUSIONS

Between 2005 and 2010, children under four years received a high prescription of anti-asthmatic drugs. The use of maintenance therapy was poorly aligned with the recommendations of asthma guidelines. The PDHD was more accurate for measuring consumption than DHD, especially in younger children.

Initial step-up treatment changes in asthmatic children already prescribed inhaled corticosteroids: a historical cohort study

Background:

When standard doses of inhaled corticosteroids (ICS) fail to control symptoms in children aged >4 years, guidelines recommend the addition of a long-acting β₂-agonist (LABA), with other treatment options being available if symptoms persist.

Aims:

To determine the proportion of initial ‘step-up’ episodes where LABAs were prescribed and to describe characteristics of individuals not stepped up with LABA.

Methods:

Between 1999 and 2011, initial step-up episodes from ICS monotherapy were identified in children aged 5–12 years with asthma and in receipt of ICS. Data sources were the Clinical Practice Research Datalink and Optimum Patient Care Research Database.

Results:

Initial step-up episodes were identified in 10,793 children. ICS dose was increased in 6,252 children (58%), LABA was introduced in 3,436 (32%; including 1,107 where fixed dose combination inhaler (FDC) replaced the ICS inhaler), and leukotriene receptor antagonist (LTRA) was added in 1,105 (10%). Compared with children stepped up to any LABA, others were younger and prescribed lower doses of ICS and reliever medication. ICS dose increase was more likely in obese children and LTRA prescribing was more likely in children with rhinitis and in receipt of antibiotics. Compared with FDC, step-up to separate LABA inhaler was more likely in younger, obese children who were using less oral steroids.

Conclusions:

One-third of initial step-up episodes in children with asthma treated with ICS are to add LABA. Different characteristics of children prescribed therapies other than LABA suggest that prescribers tailor treatment in some clinical settings.

Time trends of period prevalence rates of patients with inhaled long-acting beta-2-agonists-containing prescriptions: a European comparative database study

BACKGROUND

Inhaled, long-acting beta-2-adrenoceptor agonists (LABA) have well-established roles in asthma and/or COPD treatment. Drug utilisation patterns for LABA have been described, but few studies have directly compared LABA use in different countries. We aimed to compare the prevalence of LABA-containing prescriptions in five European countries using a standardised methodology.

METHODS

A common study protocol was applied to seven European healthcare record databases (Denmark, Germany, Spain, the Netherlands (2), and the UK (2)) to calculate crude and age- and sex-standardised annual period prevalence rates (PPRs) of LABA-containing prescriptions from 2002-2009. Annual PPRs were stratified by sex, age, and indication (asthma, COPD, asthma and COPD).

RESULTS

From 2002-2009, age- and sex-standardised PPRs of patients with LABA-containing medications increased in all databases (58.2%-185.1%). Highest PPRs were found in men ≥ 80 years old and women 70-79 years old. Regarding the three indications, the highest age- and sex-standardised PPRs in all databases were found in patients with "asthma and COPD" but with large inter-country variation. In those with asthma or COPD, lower PPRs and smaller inter-country variations were found. For all three indications, PPRs for LABA-containing prescriptions increased with age.

CONCLUSIONS

Using a standardised protocol that allowed direct inter-country comparisons, we found highest rates of LABA-containing prescriptions in elderly patients and distinct differences in the increased utilisation of LABA-containing prescriptions within the study period throughout the five European countries.

Ketotifen-induced nocturnal bruxism

Nocturnal bruxism is a common oromandibular movement disorder highly prevalent in children, but its pathophysiological mechanism has not been fully explained. Iatrogenic sleep bruxism has been described following treatment with several psychotropic medications. However, no case of antihistamine-induced bruxism has been reported to date. Herein, we describe a 4-year-old child who experienced nocturnal bruxism during treatment for bronchospasm and rhinitis with the antihistamine ketotifen. Drug rechallenge was also performed.

CONCLUSION

The present case adds useful information to our knowledge of bruxism. Complex and poorly understood interactions between multiple central nervous system neurotransmitters, such as histamine, serotonin, and dopamine, are involved.

Utilisation and off-label prescriptions of respiratory drugs in children

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.

Off-label prescribing for allergic diseases in pre-school children

BACKGROUND

Several studies have demonstrated that medication is commonly used off-label in children with allergic diseases. The aim of this study was to characterise off-label use of prescriptions for allergic diseases in pre-school children from an allergology outpatient unit.

METHODS

The clinical files of children aged ≤ 6 years seen in a reference allergology consultation with asthma, allergic rhinitis, and/or atopic eczema were reviewed. A total of 500 patients were consecutively observed from January to June 2012. The data collected included gender, age, diagnosis, and prescriptions with the respective daily dosage.

RESULTS

A total of 1224 prescriptions were registered. The most prescribed medications were oral antihistamines (34.6%), antileukotrienes (22.6%), topical nasal corticosteroids (20.3%), and inhaled corticosteroids (17.7%). From all prescriptions, 422 (34.5%) were considered off-label for age (62.6%), dosage (31.7%), or clinical indication (5.7%). Off-label use was more frequent in children aged <2 years, with 73.5% prescribed for children of this age.

CONCLUSIONS

Off-label use of drugs for the treatment of paediatric allergic diseases is high. However, these prescriptions are not necessarily wrong, and are recommended in many guidelines. Randomised controlled studies are limited by methodological difficulties creating the need for more observational studies in order to further evaluate the safety and efficacy of drugs used in children.

Risk assessment of neonatal excipient exposure: lessons from food safety and other areas

Newborn babies can require significant amounts of medication containing excipients intended to improve the drug formulation. Most medicines given to neonates have been developed for adults or older children and contain excipients thought to be safe in these age groups. Many excipients have been used widely in neonates without obvious adverse effects. Some excipients may be toxic in high amounts in which case they need careful risk assessment. Alternatively, it is conceivable that ill-founded fears about excipients mean that potentially useful medicines are not made available to newborn babies. Choices about excipient exposure can occur at several stages throughout the lifecycle of a medicine, from product development through to clinical use. Making these choices requires a scalable approach to analysing the overall risk. In this contribution we examine these issues.

Idiopathic acute liver injury in paediatric outpatients: incidence and signal detection in two European countries

BACKGROUND

Acute liver failure is idiopathic and drug-related in, respectively, around 50 and 15 % of children. Population-based, epidemiologic data about the pattern of disease manifestation and incidence of less severe acute liver injury, either idiopathic or potentially drug-attributed are limited in children and adolescents.

OBJECTIVES

(i) To assess the incidence of idiopathic acute liver injury (ALI) and its clinical features in children and adolescent outpatients; and (ii) to investigate the role of the drug as a potential cause of ALI which is considered idiopathic.

METHODS

A retrospective cohort study was performed during the years 2000-2008. Data were retrieved from three longitudinal electronic healthcare databases in two European countries: Pedianet and Health Search/CSD Longitudinal Patient Database from Italy and the Integrated Primary Care Information database from The Netherlands. Cases of idiopathic acute liver injury in population aged <18 years were identified by exclusion of all competing causes of liver injury (e.g. viral, autoimmune hepatitis), according to CIOMS criteria. The potential role of drug exposure as actual underlying cause of idiopathic ALI was detected through signal detection mining techniques. Both pooled and country-specific incidence rates [IR/100,000 person-years (PYs)] of idiopathic ALI and pooled adjusted rate ratios (RR) of drugs identified as a potential cause of idiopathic ALI, plus 95 % confidence intervals (CI) were estimated using the custom-built software Jerboa.

RESULTS

Among 785 definite cases of idiopathic ALI, the pooled IR was 62.4/100,000 PYs (95 % CI 58.1-66.8). The country-specific IR was higher in Italy (73.0/100,000 PYs, 95 % CI 67.8-78.4) than in The Netherlands (21.0/100,000 PYs, 95 % CI 16.0-27.2) and increased with age in both countries. Isolated elevations of liver enzymes were reported in around two-thirds of cases in Italy, while in The Netherlands the cases were more often identified by a combination of signs/symptoms. Among drugs detected as potential underlying cause of idiopathic ALI, clarithromycin (RR 25.9, 95 % CI 13.4-50), amoxicillin/clavulanic acid (RR 18.6, 95 % CI 11.3-30.6), and amoxicillin (RR 7.5, 95 % CI 3.4-16.8) were associated with the highest risk compared to non-use.

CONCLUSION

The incidence of idiopathic ALI in paediatrics is relatively low and comparable with adults. Clinical presentations differ between the two European countries. Signal detection in healthcare databases allowed identifying antibiotics as the drugs mostly associated with ALI with apparently unknown aetiology.

Effectiveness of nebulized beclomethasone in preventing viral wheezing: an RCT

OBJECTIVE

The goal of this study was to evaluate the effectiveness of nebulized beclomethasone in preventing the recurrence of viral wheezing.

METHODS

The study was designed as a randomized, double-blind, placebo-controlled trial. Outpatient children aged 1 to 5 years with at least 1 episode of viral wheezing in the last 12 months, presenting to any of 40 Italian pediatricians for an upper respiratory tract infection, were randomly allocated to receive beclomethasone 400 μg or placebo twice daily for 10 days. Medications were administered through a nebulizer. A clinical evaluation was performed by the pediatrician at the start and end of the treatment period. A subjective evaluation of symptoms and efficacy of treatment was performed by the parents. The primary endpoint was the incidence of viral wheezing diagnosed by the pediatricians during the 10-day treatment period.

RESULTS

A total of 525 children were enrolled in the study, 521 of whom were visited at the end of the treatment period. Wheezing was diagnosed by the pediatricians in 47 children (9.0% [95% confidence interval: 6.7 to 11.3]), with no statistically significant differences between treatment groups (beclomethasone versus placebo relative risk: 0.61 [95% confidence interval: 0.35 to 1.08]).The treatment was considered helpful by 63% of parents (64% in the beclomethasone group vs 61% in the placebo group). In all, 46% of children still had infection symptoms at the end of the treatment period, with no differences between groups.

CONCLUSIONS

The findings from this study confirm that inhaled steroids are not effective in preventing recurrence of viral wheezing. Moreover, no benefits were found in reducing symptoms of respiratory tract infections.

Off-label prescribing for allergic diseases in children

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.

What drives prescribing of asthma medication to preschool wheezing children? A primary care study

There is limited information on which data primary care pediatricians (PCPs) use to decide whether to prescribe or not asthma maintenance treatment, and what drives prescribing a specific therapy. The study aim was to investigate how prescribing anti-asthma maintenance treatment to preschool wheezing children is influenced by patient, family, environmental, and PCP characteristics. We conducted a cross-sectional study at 32 PCPs sites in Campania, Italy. Medical, family, and environmental information of 376 preschool wheezy children, and characteristics of the enrolled PCPs were collected. Main outcome measures of multilevel multivariate logistic regression analyses were the prescribing of maintenance treatment, and the prescription of a combined therapy as opposed to monotherapy. Variables significantly associated with long-term inhaled corticosteroids (ICS) and/or leukotriene modifiers prescription included frequent wheezing (OR = 7.19), emergency department (ED) visits (OR = 2.21), personal allergic diseases (OR = 8.49), day-care/kindergarten attendance (OR = 2.67), a high PCP prescribing volume (OR = 2.74), and a low proportion of 0- to 5-year-old patients with wheezing diagnosis (OR = 1.16). Leukotriene modifiers plus ICS were much more likely prescribed than ICS or leukotriene modifiers alone to older children (OR = 1.06) and to patients experiencing frequent wheezing (OR = 3.00), ED visits (OR = 3.12), or tobacco smoke exposure during the first 2 years of life (OR = 2.04). Finally, PCP's characteristics significantly associated with ICS plus leukotriene modifiers prescription were group practice (OR = 4.16) and a high prescribing volume (OR = 1.45). Our findings suggest that child characteristics alone are not sufficient to explain how PCPs decide to prescribe maintenance treatment and which therapy to assign, but variables associated to PCPs are crucial as well.

Asthma prevalence and risk factors among children and adolescents living around an industrial area: a cross-sectional study

Background

The exposure to air pollution has negative effects on human health, increasing the risk of respiratory diseases, such as asthma. Few data are yet available on the epidemiology of childhood asthma in some areas of Italy. The aim of the study was to estimate asthma prevalence and related risk factors in children and adolescents residents around the industrial area of Termoli, Molise region, Central-South Italy.

Methods

Prevalence was assessed through the administration of modified ISAAC questionnaires filled out by parents of 89 children and adolescents for the identification of confirmed and probable cases, and by analyzing pediatricians’ databases on drug prescriptions for symptoms control and treatment of assisted population in the study area (n = 1,004), compared to a control area (n = 920) with lower industrialization. The association of asthma with risk factors was evaluated by univariate (Chi-square or Fisher’s Exact test) and regression logistic analysis.

Results

A total of 22 (24.7%) asthmatics were identified, including both confirmed (n = 7; 7.9%) and probable cases (n = 15; 16.8%), most of them (n = 17; 77.3%) resident of Termoli town. All asthma cases were georeferenced based on the residence, however clusters were not found. Using drug prescriptions analysis, a higher prevalence (n = 138; 13.7%) of diagnosed cases was found. Lifetime history of both atopic dermatitis and bronchitis were significantly relateds to asthma cases, as well as an elevated body mass index, whose association is consistent with prevalence data of overweight/obese children living in the study area. Moreover, being resident of the town of Termoli was associated to the occurrence of cases.

Conclusions

Although our data indicated a prevalence concordance with previous national studies in pediatric population, a definitive correlation with environmental industrial factors present in the study area was not established. However, asthma outcome was significantly associated to individuals living in the town of Termoli that, despite the industrial/manufacturing activities, is also subjected to a higher environmental pressure due to the presence of toll road, state highway, railroad, and seaport which may cause air pollution from motor vehicle traffic and increase asthma induction. This study provides hitherto unavailable data on asthma in childhood population living in an industrialized area which was never investigated before, could be part of a systematic review or meta-analysis procedure, might suggest significant findings for larger observational studies, and contribute to complete the frame of disease epidemiology in Italy.

Drug use profile in outpatient children and adolescents in different Italian regions

BACKGROUND

Large differences exist in the prevalence rate of drugs prescribed to children and adolescents between and within countries. The aim of this study was to evaluate child and adolescent drug prescription patterns in Italy in an extra-hospital setting at the regional and Local Health Unit (LHU) levels.

METHODS

Data sources were three regional prescription databases. Data concerning the year 2008 were evaluated. A total of 3.3 million children and adolescents were included. Drug prevalence and prescription rates were evaluated at the regional and LHU levels. The correlation between mean latitude, average annual income, hospitalisation rate, number of paediatricians per 1,000 resident children, and prevalence rate was evaluated by LHU using a linear multiple regression analysis.

RESULTS

Large differences were found across Italian regions and LHUs. The mean prevalence rate was 56.4% (95% CI 56.3-56.5%; 51.2-65.4% among regions) and, at the LHU level, ranged from 43.1% to 70.0% (higher in the South). A total of 878 drugs were prescribed, 175 of which were shared by all LHUs. Amoxicillin clavulanate was the most used drug in all regions and in 31 of 33 LHUs. Amoxicillin was the drug with the highest variability in use between LHUs (9.1-52.1% of treated children). An inverse correlation was found between prevalence rate and both latitude (p < 0.0001) and average annual income (p = 0.0002).

CONCLUSIONS

The use of drugs in children and adolescents is higher in southern Italy and is inversely related to latitude and average annual income. More efforts should be devoted to informing physicians, patients and policy makers in order to plan effective initiatives to improve the situation.

An inventory of European data sources for the long-term safety evaluation of methylphenidate

To compile an inventory of European healthcare databases with potential to study long-term effects of methylphenidate (MPH) in patients with attention deficit hyperactivity disorder (ADHD). Potential databases were identified through expert opinion, the website of the European Network of Centres for Pharmacoepidemiology and Pharmacovigilance, and literature search. An online survey was conducted among database providers/coordinators to ascertain the databases' appropriateness for inclusion into the inventory. It included questions about database characteristics, sample size, availability of information on drug exposure, clinical data and accessibility. Forty-two databases from 11 countries were identified and their coordinators invited to participate; responses were obtained for 22 (52.4 %) databases of which 15 record ADHD diagnoses. Eleven had sufficient data on ADHD diagnosis, drug exposure, and at least one type of outcome information (symptoms/clinical events, weight, height, blood pressure, heart rate) to assess MPH safety. These were Aarhus University Prescription Database, Danish National Birth Cohort (Denmark); German Health Interview and Examination Survey for Children and Adolescents; Health Search Database Thales, Italian ADHD Register, Lombardy Region ADHD Database (Italy); Avon Longitudinal Study of Parents and Children, General Practice Research Database, The Health Improvement Network, QResearch (UK) and IMS Disease Analyzer (UK, Germany, France). Of the 20 databases with no responses, information on seven from publications and/or websites was obtained; Pedianet and the Integrated Primary Care Information database were considered suitable. Many European healthcare databases can be used for multinational long-term safety studies of MPH. Methodological research is underway to investigate the feasibility of their pooling and analysis.

Assessing paediatric asthma occurrence through dispensed prescription data and questionnaires

BACKGROUND

The prevalence of asthma, a common disorder in childhood, is often estimated by cross-sectional studies based on questionnaires, with the drawback that estimates are limited to certain age groups and areas. The use of electronic health data is increasingly allowing researchers to overcome these limitations. This study is aimed at assessing asthma occurrence of a school-aged population in Northeast Italy using two different data sources.

METHODS

In 2004, a population-based survey using a standardized questionnaire was conducted to estimate asthma occurrence among a resident population of children aged 6-7 years and adolescents aged 13 years. A selection of dispensed asthma medications was extracted from electronic databases for a 4-year period prior to questionnaire completion (2000-03). Asthma prevalence was estimated by commonly used questionnaire classifications and compared with use of inhaled bronchodilators (alone or in combination) in various time periods. Correlations between the two approaches were calculated.

RESULTS

A total of 10 252 subjects were eligible for analysis (85% of the resident population). A total of 4747 subjects (38% of the resident population) were registered in the drug database during 2000-03. Asthma prevalence was higher in males and in children. Congruence between the two enquiry methods varied according to criteria applied and improved with the protraction of the observation period.

CONCLUSION

A longer period for the capture of medication data yielded higher congruence. A degree of mismatch was observed between the two methods most likely related to factors of drug use and questionnaire reliability. Nonetheless, the benefits of using easily accessible population data prevail, and further studies are warranted.