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Drogou F, Netboute A, Giai J, Dode X, Darmon D, Kassai B, Letrilliart L. Off-label drug prescriptions in French general practice: a cross-sectional study. BMJ Open 2019; 9:e026076. [PMID: 30967407 PMCID: PMC6500201 DOI: 10.1136/bmjopen-2018-026076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/18/2019] [Accepted: 03/12/2019] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- François Drogou
- Univ. Lyon, Université Claude Bernard Lyon 1, Université Saint-Étienne, Collège universitaire de médecine générale, F-69008 Lyon, F-42023 Saint-Étienne, Département de médecine générale, Lyon, France
| | - Allison Netboute
- Univ. Lyon, Université Claude Bernard Lyon 1, Université Saint-Étienne, Collège universitaire de médecine générale, F-69008 Lyon, F-42023 Saint-Étienne, Département de médecine générale, Lyon, France
| | - Joris Giai
- Service de Biostatistique, Centre Hospitalier Universitaire de Lyon, Lyon, France
| | - Xavier Dode
- Département de pharmacie, Centre Hospitalier Universitaire de Lyon, Lyon, France
| | - David Darmon
- Département d’enseignement et de recherche en Médecine Générale, Universite de Nice Faculte de Medecine, Nice, France
| | - Behrouz Kassai
- EPICIME-Centre d’Investigation Clinique, INSERM CIC201/UMR5558, Hôpital Louis Pradel, Lyon, France
- UMR 5558, CNRS Lyon, University of Lyon 1, Lyon, France
| | - Laurent Letrilliart
- Univ. Lyon, Université Claude Bernard Lyon 1, Université Saint-Étienne, Collège universitaire de médecine générale, F-69008 Lyon, F-42023 Saint-Étienne, Département de médecine générale, Lyon, France
- Univ. Lyon, Université Claude Bernard Lyon 1, Université Saint-Étienne, HESPER EA 7425, F-69008 Lyon, F-42023 Saint-Étienne, France, E.A. 4129 « Santé, Individu, Société », Lyon, France
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Langedijk J, Whitehead CJ, Slijkerman DS, Leufkens HG, Schutjens MHD, Mantel-Teeuwisse AK. Extensions of indication throughout the drug product lifecycle: a quantitative analysis. Drug Discov Today 2016; 21:348-55. [DOI: 10.1016/j.drudis.2015.11.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 10/22/2015] [Accepted: 11/20/2015] [Indexed: 11/29/2022]
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Falabregues A, Daul M, Pourroy B, Gauthier-Villano L, Pisano P, Rathelot P, Vialettes B. Pertinence des prescriptions « hors AMM/RTU » des molécules onéreuses dans un hôpital universitaire. Therapie 2015; 70:385-402. [DOI: 10.2515/therapie/2015008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 11/28/2014] [Indexed: 11/20/2022]
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Aagaard L. Off-Label and Unlicensed Prescribing of Medicines in Paediatric Populations: Occurrence and Safety Aspects. Basic Clin Pharmacol Toxicol 2015; 117:215-8. [DOI: 10.1111/bcpt.12445] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Lise Aagaard
- Institute of Public Health; Clinical Pharmacology; Faculty of Health Sciences; University of Southern Denmark; J.B. Winsløws Vej 19 DK-5000 Odense C. Denmark
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O'Connor K, Burke R, Riminton S. Hospital Supply of Off-label Immunomodulatory Drugs. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2009.tb00437.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Kate O'Connor
- Department of Immunology and Allergy; Concord Hospital, Westmead Hospital; Concord New South Wales
| | - Rosemary Burke
- Department of Immunology and Allergy; Concord Hospital, Westmead Hospital; Concord New South Wales
| | - Sean Riminton
- Department of Immunology and Allergy; Concord Hospital, Westmead Hospital; Concord New South Wales
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Skledar SJ, Corman SL, Smitherman T. Addressing innovative off-label medication use at an academic medical center. Am J Health Syst Pharm 2015; 72:469-77. [DOI: 10.2146/ajhp140306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Susan J. Skledar
- Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, and Clinical Pharmacy Specialist, Health System Formulary Management and Drug Use Policy, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; at the time of the project described herein, she was Director, Drug Use and Disease State Management Program, UPMC–Presbyterian, Pittsburgh
| | - Shelby L. Corman
- Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, and Clinical Pharmacy Specialist, Health System Formulary Management and Drug Use Policy, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; at the time of the project described herein, she was Director, Drug Use and Disease State Management Program, UPMC–Presbyterian, Pittsburgh
| | - Thomas Smitherman
- Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, and Clinical Pharmacy Specialist, Health System Formulary Management and Drug Use Policy, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; at the time of the project described herein, she was Director, Drug Use and Disease State Management Program, UPMC–Presbyterian, Pittsburgh
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O'Connor K, Liddle C. Prospective data collection of off-label use of rituximab in Australian public hospitals. Intern Med J 2014; 43:863-70. [PMID: 23735074 DOI: 10.1111/imj.12206] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 05/16/2013] [Indexed: 01/03/2023]
Abstract
BACKGROUND Rituximab is a chimeric, anti-CD20 monoclonal antibody registered for the treatment of B-cell malignancies and refractory rheumatoid arthritis in Australia. In addition to these approved indications, there has been growing interest in the use of off-label rituximab in the management of a variety of diseases. AIMS To determine the current usage of off-label rituximab in Australia, we collected nationwide data. METHODS Information regarding patients receiving rituximab for off-label indications was prospectively collected for a 6-month period from Australian public hospitals. Data recorded included clinical indication, dosing schedule, previous therapy and efficacy assessment. The level of evidence for the use of rituximab was determined for each off-label indication. RESULTS During the 6-month period, a total of 364 instances of off-label rituximab use was recorded in the national database. A total of 63 underlying diagnoses was identified. These were subclassified into haematological disorders (19%), autoimmune connective tissue diseases (12%), vasculitis (12%), neurological disorders (12%), transplant-related uses (12%), haematological malignancies (11%), muscle disorders (8%), renal diseases (6%), dermatological conditions (5%), other conditions (2%) and ocular diseases (1%). Forty percent of these requests were supported only by level 4 evidence of benefit. Data highlighted the non-standardised approaches to drug approval mechanisms, dosing schedules and monitoring for efficacy. CONCLUSIONS Off-label rituximab is prescribed for a diverse range of clinical conditions. Determining a safe and effective means of regulating this use within an evidence-based framework remains an ongoing challenge.
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Affiliation(s)
- K O'Connor
- Department of Clinical Pharmacology, University of Sydney and Westmead Hospital, Sydney, New South Wales, Australia.
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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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Off-label prescriptions for adult neurological patients: a pilot survey in China. Int J Clin Pharm 2011; 34:81-7. [DOI: 10.1007/s11096-011-9590-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Accepted: 11/21/2011] [Indexed: 10/14/2022]
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MELLOR JD, BENSTED KE, CHAN PL. Off label and unlicensed prescribing in a specialist oncology center in Australia. Asia Pac J Clin Oncol 2009. [DOI: 10.1111/j.1743-7563.2009.01239.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Reimer P, Vosshenrich R. Off-label use of contrast agents. Eur Radiol 2008; 18:1096-101. [PMID: 18274752 DOI: 10.1007/s00330-008-0886-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 01/10/2008] [Accepted: 01/22/2008] [Indexed: 01/28/2023]
Abstract
When contrast agents are approved, the label describes the approved indications and particular circumstances of use such as age, organ function or pregnancy. The use of contrast agents outside their labelled indications is increasing, namely with contrast agents used for MRI. The aim of this paper is to improve the knowledge about this topic. The basis for off-label use is the physician's prerogative, which finds its basis in the "Declaration of Helsinki". Off-label use is allowed under special conditions and might be even the medical state of the art. The necessity for off-label use will continue to increase for MR-contrast agents, as the regulatory requirements for approval of new indications continuously increase, and clinical trials for registration purposes are quite costly and time consuming. As a consequence, manufacturers will concentrate on clinical studies for the essential indications.
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Affiliation(s)
- P Reimer
- Radiology, Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Moltkestrasse 90, 76133 Karlsruhe, Germany.
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Off-label drug use among hospitalised children: identifying areas with the highest need for research. ACTA ACUST UNITED AC 2008; 30:497-502. [DOI: 10.1007/s11096-008-9193-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Accepted: 01/09/2008] [Indexed: 10/22/2022]
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