1
|
AlAzmi A, Alasmari Z, Yousef C, Alenazi A, AlOtaibi M, AlSaedi H, AlShaikh A, AlObathani A, Ahmed O, Goronfolah L, Alahmari M. Off-Label Drug Use in Pediatric Out-Patient Care: A Multi-Center Observational Study. Hosp Pharm 2021; 56:690-696. [PMID: 34732923 DOI: 10.1177/0018578720942226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Prescribing a drug for a child is not an easy task and requires using the best available evidence as a guide, especially when a drug is used off-label. The practice of prescribing a drug for off-label use is fairly widespread worldwide. The FDA does not regulate prescribing patterns or practices of individual practitioners and, therefore, allows off-label use. The main objective of this study is to evaluate off-label prescribing among the pediatric population in the Kingdom of Saudi Arabia (KSA). Method This is a retrospective, simple random selection observational study of children (≤15 years) who visited pediatric clinics and had at least 1 drug prescribed over a 12-month period (January to December 2018). Results A total of 865 drugs (mean 1 and SD 0.24) were prescribed to 326 children. Off-label was identified in 39.4% of the drugs with a frequency of 512 (as 1 drug may belong to more than 1 off-label category). The most common reason for off-label prescribing was related to doses that were "higher or lower than the recommended use" (48.6%), and the most frequently identified drug class prescribed for off-label use was anti-infective drugs for systemic use (39.9%). The percentage of off-label drug use was found to be higher in girls and in the age group of 1 month to 2 years (P = .001) for both variables. In addition, a significant association was found between off label drug use and the total number of drugs prescribed, P < .001. Conclusion The findings of this study showed a high incidence of off-label prescribing mainly related to dosing and indication. The results of this observational study support the need to establish a unified national pediatric dosing formulary guide to ensure safe drug use in pediatrics.
Collapse
Affiliation(s)
- Aeshah AlAzmi
- Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
- Princes Noorah Oncology Center, Pediatric Oncology/Hematology/BMT Section, King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Jeddah, Saudi Arabia
| | - Zahra Alasmari
- Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
- Specialized Poly Clinic, King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
| | - Consuela Yousef
- Imam Abdulrahman Bin Faisal Hospital, MNGHA, Dammam, Saudi Arabia
| | - Ahmed Alenazi
- Imam Abdulrahman Bin Faisal Hospital, MNGHA, Dammam, Saudi Arabia
| | - Mohammed AlOtaibi
- Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
| | - Hani AlSaedi
- Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
| | - Adnan AlShaikh
- Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Department of Pediatrics, Chemistry Laboratory, Community Medicine, Jeddah, Saudi Arabia
| | - Amani AlObathani
- Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
| | - Omaima Ahmed
- Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
- Princes Noorah Oncology Center, Pediatric Oncology/Hematology/BMT Section, King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
| | - Loie Goronfolah
- Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
| | - Mousa Alahmari
- Ministry of National Guard Health Affairs (MNGHA), King Abdulaziz Medical City (KAMC), Jeddah, Saudi Arabia
| |
Collapse
|
2
|
Extent, reasons and consequences of off-labeled and unlicensed drug prescription in hospitalized children: a narrative review. World J Pediatr 2021; 17:341-354. [PMID: 34080130 DOI: 10.1007/s12519-021-00430-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/07/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Off-label and unlicensed prescriptions pose a severe safety concern among the pediatric population. We aimed to summarize the up-to-date evidence on the extent, reasons, and consequences of off-label and unlicensed drugs in hospitalized pediatric patients. METHODS We systematically searched PubMed, EMBASE, SCOPUS, Web of Science and Google Scholar between 1990 and 2020 in which the last search was conducted on 12 February 2021. We included studies with the following inclusion criteria: (1) observational studies in design; (2) target population was hospitalized pediatric patients whether admitted in the intensive care unit or in the general ward; (3) study reporting the prevalence of off-label, unlicensed prescriptions or both; and (4) published in English. RESULTS A total of 47 studies were eligible for inclusion. The proportion of off-label and unlicensed prescriptions ranged from 7.4% to 99.5% and 0.1% to 74.4%, respectively. The most frequent category of off-label prescriptions was prescription outside the age range, with the most commonly reported reason for off-label prescriptions being the lack of information specifically for pediatrics on the drug information leaflets. The consequences of off-label and unlicensed prescriptions ranged from minor and bearable skin reactions to debilitating renal failure, risking deaths. CONCLUSIONS Off-label and unlicensed prescriptions are extensive and require progressively meditative interventions. However, the pediatric population is currently a "therapeutic orphan". Unless adequate pediatric clinical trials and licensed drugs become available, off-label and unlicensed drug prescription should not entirely be banned but rather promoted in an organized manner.
Collapse
|
3
|
Vieira VC, Costa RS, Lima RCG, Queiroz DB, de Medeiros DS. Prescription of off-label and unlicensed drugs for preterm infants in a neonatal intensive care unit. Rev Bras Ter Intensiva 2021; 33:266-275. [PMID: 34231807 PMCID: PMC8275084 DOI: 10.5935/0103-507x.20210034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/01/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To evaluate the use of off-label and unlicensed medications in preterm infants hospitalized in a neonatal intensive care unit. METHODS This nonconcurrent cohort study included preterm infants admitted to 3 neonatal intensive care units in 2016 and 2017 who were followed up during the neonatal period. The type and number of medications used were recorded for the entire period and classified based on the Anatomical Therapeutic Chemical. Descriptive and bivariate data analyses were performed to assess associations between the number of drugs used (total, off-label and unlicensed) and the explanatory variables of interest. RESULTS Four hundred preterm infants received 16,143 prescriptions for 86 different pharmaceuticals; 51.9% of these medications were classified as off-label and 23.5% as unlicensed. The most prescribed drugs were gentamicin and ampicillin (17.5% and 15.5% among off-label, respectively) and caffeine (75.5% among unlicensed). The results indicated significant associations between the use of off-label drugs and lower gestational age, low birth weight, lower 5-minute Apgar score, advanced resuscitation maneuver in the delivery room and death. The prescription of unlicensed drugs was associated with lower gestational age, low birth weight and 5-minute Apgar score below 7. CONCLUSION Neonates admitted to neonatal intensive care units are highly exposed to off-label and unlicensed medications. Further studies are needed to achieve greater safety and quality of drug therapy used in neonatology.
Collapse
Affiliation(s)
- Verônica Cheles Vieira
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia - Vitória da Conquista (BA), Brazil
| | - Renart Santos Costa
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia - Vitória da Conquista (BA), Brazil
| | | | - Daiane Borges Queiroz
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia - Vitória da Conquista (BA), Brazil
| | | |
Collapse
|
4
|
Davis NL, Akinmboni TO, Mooney SM. Quantifying Medication Exposure in Very Low Birth Weight Neonates. Am J Perinatol 2021; 38:383-391. [PMID: 31683322 DOI: 10.1055/s-0039-1697669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Very low birth weight (VLBW) infants are exposed to medications with insufficient evidence describing pharmacokinetics and safety. Objective was to quantify and identify risk factors associated with the highest quartile of medication exposure. STUDY DESIGN Retrospective record review of VLBW infants admitted to a level-IV neonatal intensive care unit (NICU). We obtained baseline clinical and demographic characteristics, as well as data on all medications received during admission. Characteristics of patients within the upper quartile of medication use were compared with remaining patients. RESULTS Identified 106 infants, mean birth weight (BW) = 961 g, gestational age = 27.3 weeks. Infants received a median = 20 medications (range, 4-72). Those in the top quartile of medication use received ≥30 medications while in the NICU and had higher odds of being male sex, lower BW, longer length of hospital stay (LOHS), and bronchopulmonary dysplasia. Sepsis did not affect medication exposure. Antibiotics, opiates, and reflux medications were among the top prescribed. CONCLUSION Infants are exposed to a large number of medications during NICU hospitalization, including potentially unnecessary antibiotics and reflux medications. Male sex, the presence of certain comorbidities such as necrotizing enterocolitis, and LOHS, are associated with higher exposure. Increased awareness of this issue may assist in decreasing medication exposure in VLBW populations.
Collapse
Affiliation(s)
- Natalie L Davis
- Department of Pediatrics, Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Temitope O Akinmboni
- Department of Pediatrics, Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sandra M Mooney
- Department of Nutrition, University of North Carolina Nutrition Research Institute, University of North Carolina Chapel Hill, Kannapolis, North Carolina
| |
Collapse
|
5
|
Al-Turkait A, Szatkowski L, Choonara I, Ojha S. Review of Drug Utilization Studies in Neonatal Units: A Global Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E5669. [PMID: 32764503 PMCID: PMC7459677 DOI: 10.3390/ijerph17165669] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 12/14/2022]
Abstract
Rational prescribing is challenging in neonatology. Drug utilization studies help identify and define the problem. We performed a review of the literature on drug use in neonatal units and describe global variations. We searched databases (EMBASE, CINAHL and Medline) from inception to July 2020, screened studies and extracted relevant data (two reviewers). The search revealed 573 studies of which 84 were included. India (n = 14) and the USA (n = 13) reported the most. Data collection was prospective (n = 56) and retrospective (n = 26), mostly (n = 52) from one center only. Sixty studies described general drug use in 34 to 450,386 infants (median (IQR) 190 (91-767)) over a median (IQR) of 6 (3-18) months. Of the participants, 20-87% were preterm. The mean number of drugs per infant (range 11.1 to 1.7, pooled mean (SD) 4 (2.4)) was high with some reporting very high burden (≥30 drugs per infant in 8 studies). This was not associated with the proportion of preterm infants included. Antibiotics were the most frequently used drug. Drug use patterns were generally uniform with some variation in antibiotic use and more use of phenobarbitone in Asia. This study provides a global perspective on drug utilization in neonates and highlights the need for better quality information to assess rational prescribing.
Collapse
Affiliation(s)
- Asma Al-Turkait
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (A.A.-T.); (I.C.)
| | - Lisa Szatkowski
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK;
| | - Imti Choonara
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (A.A.-T.); (I.C.)
| | - Shalini Ojha
- Division of Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK; (A.A.-T.); (I.C.)
- Neonatal Unit, University Hospitals of Derby and Burton NHS Trust, Derby DE22 3NE, UK
| |
Collapse
|
6
|
AbuAlsaud Z, Alshayban D, Joseph R, Pottoo FH, Lucca JM. Off-label Medications Use in the Eastern Province of Saudi Arabia: The Views of General Practitioners, Pediatricians, and Other Specialists. Hosp Pharm 2020; 55:37-43. [PMID: 31983765 DOI: 10.1177/0018578718817861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Off-label drug prescribing remains a major pediatric health concern worldwide. The lack of studies in this vulnerable population causes many practitioners to prescribe drugs outside their license. This study aims to investigate and compare the current knowledge and views of general practitioners, pediatricians, and other specialists toward off-label pediatric prescribing. Methods: A descriptive, cross-sectional-based study conducted on a random sample of physicians who work in three different hospitals in the Eastern Province of Saudi Arabia. Results: Data were obtained from three hospitals, comprising a total of 160 practitioners. Overall, more than half of the participated practitioners (54%) were familiar with the definition of off-label prescribing. Thirty percentage of participated practitioners agreed that more than 10% of their prescribed medicines to children were off-labeled. A majority of participants expressed concerns over the efficacy (83%) and safety (92%) of off-label prescribing to children. Importantly, a noticeable proportion of the responders claimed that they sometimes observed an adverse drug reaction (n = 23; 20%) or treatment failure (n = 43; 37%) following off-label prescribing medicines to children. Only 46% participants have always informed the parents or guardian about the off-label prescription of medications to their children. Conclusion: A Large number of physicians are familiar with the concept of off-label prescribing of medicines to children in the Eastern Province of Saudi Arabia. Safety and efficacy are the main concerns of prescribing such medications. Policies toward improving pediatric clinical research and supporting the safety and efficacy of the drugs should be encouraged.
Collapse
Affiliation(s)
- Zainab AbuAlsaud
- Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Dhfer Alshayban
- Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Royes Joseph
- Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Faheem Hyder Pottoo
- Department of Pharmacology, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Jisha Myalil Lucca
- Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| |
Collapse
|
7
|
Allegaert K, Simons S, Van Den Anker J. Research on medication use in the neonatal intensive care unit. Expert Rev Clin Pharmacol 2019; 12:343-353. [PMID: 30741041 DOI: 10.1080/17512433.2019.1580569] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Research on medication use aims at assessing how much of current pharmacotherapy is rational. In neonates, this is hampered by extensive off-label drug use and limited knowledge. Areas covered: We report on medication use research and have conducted a systematic review of observational studies on medication use to provide an updated overview on characteristics, objectives, methods, and patterns in hospitalized neonates. Moreover, a review on aspects of medication use for opioids, anti-epileptics, gastric acid-related disorders and respiratory stimulants with emphasis on trends and impact of interventions is presented, illustrating how research on medication use can contribute to improved neonatal pharmacotherapy and more focused research. Medication use reports describe patterns and provide signals on irrational use, benchmarking, or can guide research priorities. Moreover, this may generate information on how neonatal health topics and their pharmacotherapy are handled over time or across regions. Expert opinion: Research on medicine utilization is relevant, since it will inform us on aspects like trends, variability, or about the impact and pattern of implementation of guidelines in neonates. Further progress necessitates to merge datasets on medication use with clinical characteristics, and perinatal drug use remains an area in need of additional research.
Collapse
Affiliation(s)
- Karel Allegaert
- a Department of Pediatrics, Division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Sinno Simons
- a Department of Pediatrics, Division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - John Van Den Anker
- c Division of Clinical Pharmacology, Department of Pediatrics , Children's National Health System , Washington , DC , USA.,d Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland.,e Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| |
Collapse
|