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Konkle B, Pierce G, Coffin D, Naccache M, Clark RC, George L, Iorio A, O’Mahony B, Pipe S, Skinner M, Watson C, Peyvandi F, Mahlangu J. Core data set on safety, efficacy, and durability of hemophilia gene therapy for a global registry: Communication from the SSC of the ISTH. J Thromb Haemost 2020; 18:3074-3077. [PMID: 33463024 PMCID: PMC7756325 DOI: 10.1111/jth.15023] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/03/2020] [Accepted: 07/15/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gene therapy for people with hemophilia (PWH) will soon become available outside current clinical trials. The World Federation of Hemophilia (WFH), in collaboration with International Society of Thrombosis and Hemostasis Scientific and Standardization Committee (ISTH SSC), the European Haemophilia Consortium (EHC), the US National Hemophilia Foundation (NHF), the American Thrombosis and Hemostasis Network (ATHN), industry gene therapy development partners and Regulatory liaisons have developed the Gene Therapy Registry (GTR), designed to collect long-term data on all PWH who receive hemophilia gene therapy. OBJECTIVE The objectives of the GTR are to record the long-term safety and efficacy data post gene therapy infusion and to assess the changes in quality of life and burden of disease post-gene-therapy infusion. METHODS The GTR is a prospective, observational, and longitudinal registry developed under the guidance of a multi-stakeholder GTR Steering Committee (GTR SC), composed of health care professionals, patient advocates, industry representatives, and regulatory agency liaisons. All PWH who receive gene therapy by clinical trial or commercial product will be invited to enrol in the registry through their hemophilia treatment centers (HTCs). The registry aims to recruit 100% of eligible post gene therapy PWH globally. Through an iterative process, and following the guidance of the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA), the GTR SC has developed a core set of data to be collected on all patients post gene therapy. RESULTS The core data set includes demographic information, vector infusion details, safety, efficacy, quality of life and burden of disease. CONCLUSIONS The GTR is a global effort to ensure that long term safety and efficacy outcomes are recorded and analysed and rare adverse events, in a small patient population, are identified. Many unknowns on the long-term safety and efficacy of gene therapy for hemophilia may also be addressed.
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Affiliation(s)
- Barbara Konkle
- Bloodworks Northwest, Research InstituteUniversity of WashingtonSeattleWAUSA
| | | | | | | | | | - Lindsey George
- The Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Alfonso Iorio
- Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonONCanada
| | | | - Steven Pipe
- PediatricsUniversity of MichiganAnn ArborMIUSA
| | - Mark Skinner
- Institute for Policy Advancement LtdWashingtonDCUSA
| | | | - Flora Peyvandi
- Internal MedicineFaculty of Medicine and SurgeryUniversity of MilanMilanItaly
| | - Johnny Mahlangu
- Faculty of Health Sciences and NHLSUniversity of the WitwatersrandJohannesburgSouth Africa
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Peyvandi F, Makris M, Collins P, Lillicrap D, Pipe SW, Iorio A, Rosendaal FR. Minimal dataset for post-registration surveillance of new drugs in hemophilia: communication from the SSC of the ISTH. J Thromb Haemost 2017; 15:1878-1881. [PMID: 28767195 DOI: 10.1111/jth.13762] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Indexed: 11/27/2022]
Affiliation(s)
- F Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Luigi Villa Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - M Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - P Collins
- Arthur Bloom Haemophilia Centre, School of Medicine, Cardiff University, Cardiff, UK
| | - D Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Canada
| | - S W Pipe
- Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
| | - A Iorio
- Department of Health Research Methods, Evidence, and Impact, and Department of Medicine, McMaster University, Hamilton, Canada
| | - F R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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Banerjee T, Nayak A. Why trash don't pass? pharmaceutical licensing and safety performance of drugs. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2017; 18:59-71. [PMID: 26781296 DOI: 10.1007/s10198-015-0758-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 12/14/2015] [Indexed: 06/05/2023]
Abstract
This paper examines how asymmetric information in pharmaceutical licensing affects the safety standards of licensed drugs. Pharmaceutical companies often license potential drug molecules at different stages of drug development from other pharmaceutical or biotechnology companies and complete the remaining of research stages before submitting the new drug application(NDA) to the food and drug administration. The asymmetric information associated with the quality of licensed molecules might result in the molecules which are less likely to succeed to be licensed out, while those with greater potential of success being held internally for development. We identify the NDAs submitted between 1993 and 2004 where new molecular entities were acquired through licensing. Controlling for other drug area specific and applicant firm specific factors, we investigate whether drugs developed with licensed molecules face higher probability of safety based recall and ultimate withdrawal from the market than drugs developed internally. Results suggest the opposite of Akerlof's (Q J Econ 84:488-500, 1970) lemons problem. Licensed molecules rather have less probability of facing safety based recalls and ultimate withdrawal from the market comparing to internally developed drug molecules. This suggests that biotechnology and small pharmaceutical firms specializing in pharmaceutical research are more efficient in developing good potential molecules because of their concentrated research. Biotechnology firms license out good potential molecules because it increases their market value and reputation. In addition, results suggest that both the number of previous approved drugs in the disease area, and also the applicant firms' total number of previous approvals in all disease areas reduce the probability that an additional approved drug in the same drug area will potentially be harmful.
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Affiliation(s)
| | - Arnab Nayak
- Stetson School of Business and Economics, Mercer University, Atlanta, GA, USA
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Tamblyn R, Girard N, Dixon WG, Haas J, Bates DW, Sheppard T, Eguale T, Buckeridge D, Abrahamowicz M, Forster A. Pharmacosurveillance without borders: electronic health records in different countries can be used to address important methodological issues in estimating the risk of adverse events. J Clin Epidemiol 2016; 77:101-111. [PMID: 27212138 DOI: 10.1016/j.jclinepi.2016.03.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 02/19/2016] [Accepted: 03/11/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Evaluate methodological advantages and limitations of an international pharmacosurveillance system based on electronic health records (EHRs). STUDY DESIGN AND SETTINGS Type 2 diabetes was used as an exemplar. Cohorts of newly treated diabetics were followed in each country (Quebec, Canada; Massachusetts, United States; Manchester, UK) from 2009 to 2012 using local EHR systems. Cox proportional hazards models were used to assess the risk of cardiovascular events. RESULTS A total of 44,913 newly treated diabetics were identified; 82.6% (United States) to 93.1% (Canada) were started on biguanides; 13% of patients failed to fill initial prescriptions. An increased risk of cardiovascular events with sulfonylureas was observed when dispensing [hazard ratio (HR): 2.83] vs. EHR prescribing (HR: 2.47) data were used. The addition of clinical data produced a threefold to 10-fold increase in comorbidity for obesity and renal disease, but had no impact on the risk of different hypoglycemic therapies. The risk of cardiovascular events with sulfonylureas was higher in the United States [HR: 3.4; 95% confidence interval (CI): 2.1, 5.5] compared to England (HR: 1.3; 95% CI: 1.1, 1.6). CONCLUSION An international surveillance system based on EHRs may provide more timely information about drug safety and new opportunities to estimate potential sources of bias and health system effects on drug-related outcomes.
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Affiliation(s)
- Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, Purvis Hall, McGill University, 1020 Pine Avenue West, Montreal, Quebec H3A 1A2, Canada; Department of Medicine, McGill University Health Center, 1001 Decarie Boulevard, Montreal, Quebec H4A 3J1, Canada; Clinical and Health Informatics Research Group, McGill University, 1140 Pine Avenue, Montreal, Quebec H3A 1A3, Canada.
| | - Nadyne Girard
- Clinical and Health Informatics Research Group, McGill University, 1140 Pine Avenue, Montreal, Quebec H3A 1A3, Canada
| | - William G Dixon
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, 2nd Floor, Stopford Building, Oxford Road, Manchester M13 9PT, UK
| | - Jennifer Haas
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - David W Bates
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Thérèse Sheppard
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, Manchester Academic Health Science Centre, The University of Manchester, 2nd Floor, Stopford Building, Oxford Road, Manchester M13 9PT, UK
| | - Tewodros Eguale
- Department of Epidemiology, Biostatistics and Occupational Health, Purvis Hall, McGill University, 1020 Pine Avenue West, Montreal, Quebec H3A 1A2, Canada
| | - David Buckeridge
- Department of Epidemiology, Biostatistics and Occupational Health, Purvis Hall, McGill University, 1020 Pine Avenue West, Montreal, Quebec H3A 1A2, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, Purvis Hall, McGill University, 1020 Pine Avenue West, Montreal, Quebec H3A 1A2, Canada
| | - Alan Forster
- The Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
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Campbell JE, Gossell-Williams M, Lee MG. A Review of Pharmacovigilance. W INDIAN MED J 2014; 63:771-4. [PMID: 25867582 PMCID: PMC4668980 DOI: 10.7727/wimj.2013.251] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 09/27/2013] [Indexed: 01/23/2023]
Abstract
Pharmacovigilance supports safe and appropriate use of drugs. Spontaneous reporting of adverse drug reactions (ADRs) is an essential component of pharmacovigilance. However, there is significant underreporting of ADRs. Adverse drug reactions have become a major problem in developing countries. Knowledge of pharmacovigilance could form the basis for interventions aimed at improving reporting rates and decreasing ADRs.
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Affiliation(s)
- J E Campbell
- Pharmacology Section, Department of Basic Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica.
| | - M Gossell-Williams
- Pharmacology Section, Department of Basic Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica
| | - M G Lee
- Department of Medicine, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica
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Pillans PI. Clinical perspectives in drug safety and adverse drug reactions. Expert Rev Clin Pharmacol 2014; 1:695-705. [PMID: 24422739 DOI: 10.1586/17512433.1.5.695] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Adverse drug reactions (ADRs) remain a common clinical problem since they can mimic many diseases and cause significant morbidity and mortality. Judicious prescribing is important to minimize their occurrence. Apart from the recent identification of a few pharmacogenomic biomarkers for serious reactions, many remain unpredictable. Spontaneous reporting continues to play an important role in pharmacovigilance and the value of astute clinical observation and well-documented reports of suspicions of a causal link cannot be underestimated. Many national reporting schemes have developed considerable experience and expertise over many years and have large ADR databases, which are national assets. Despite advances in pharmacovigilance, numerous deficiencies have been identified; postmarketing surveillance remains the weakest link in the regulatory process. Regulatory authorities have tended to act later rather than sooner in response to safety signals, and this, when combined with under-reporting, may have led to exposure of a large number of patients to drug-related harm before restriction or withdrawal. In an attempt to improve vigilance, international surveillance may benefit by moving from its current passive/reactive mode toward active surveillance systems with a prospective, comprehensive and systematic approach to monitoring, collecting, analyzing and reporting data on ADRs. This will include increased pressure on pharmaceutical companies to conduct postmarketing studies. Such an active/proactive approach, while maintaining focus on ADR detection, could also aim to extend knowledge of safety, such that emerging changes in risk-benefit during a drug's marketed life are effectively communicated to clinicians and patients. Drug safety monitoring and its regulation are now undergoing an overhaul and it is hoped that vigilance, public safety and trust will improve as a result.
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Affiliation(s)
- Peter Ian Pillans
- Princess Alexandra Hospital, Woolloongabba, Brisbane, 4102, Queensland, Australia.
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Hilmer SN, Gazarian M. Clinical pharmacology in special populations: the extremes of age. Expert Rev Clin Pharmacol 2014; 1:467-9. [PMID: 24410547 DOI: 10.1586/17512433.1.4.467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital and University of Sydney; Ward 11C Main Building, Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065, Australia.
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Hershman DL, Wright JD, Lim E, Buono DL, Tsai WY, Neugut AI. Contraindicated use of bevacizumab and toxicity in elderly patients with cancer. J Clin Oncol 2013; 31:3592-9. [PMID: 24002522 DOI: 10.1200/jco.2012.48.4857] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Drugs are approved on the basis of randomized trials conducted in selected populations. However, once approved, these treatments are usually expanded to patients ineligible for the trial. PATIENTS AND METHODS We used the SEER-Medicare database to identify subjects older than 65 years with metastatic breast, lung, and colon cancer, diagnosed between 2004 and 2007 and undergoing follow-up to 2009, who received bevacizumab. We defined a contraindication as having at least two billing claims before bevacizumab for thrombosis, cardiac disease, stroke, hemorrhage, hemoptysis, or GI perforation. We defined toxicity as first development of one of these conditions after therapy. RESULTS Among 16,085 metastatic patients identified, 3,039 (18.9%) received bevacizumab. Receipt of bevacizumab was associated with white race, later year of diagnosis, tumor type, and decreased comorbid conditions. Of patients who received bevacizumab, 1,082 (35.5%) had a contraindication. In multivariate analysis, receipt of bevacizumab with a contraindication was associated with black race (odds ratio [OR] = 2.6; 95% CI, 1.4 to 4.9), increased age, comorbidity, later year of diagnosis, and lower socioeconomic status. Patients with lung (OR = 1.7; 95% CI, 1.1 to 2.4) and colon cancer (OR = 1.4; 95% CI, 1.1 to 1.9) were more likely to have a contraindication. In the group with no contraindication, 30% had a complication after bevacizumab; black patients were more likely to have a complication than were white patients (OR = 1.9; 95% CI, 1.21 to 2.93). CONCLUSION Our study demonstrates widespread use of bevacizumab among patients who had contraindications. Black patients were less likely to receive the drug, but those who did were more likely to have a contraindication. Efforts to understand toxicity and efficacy in populations excluded from clinical trials are needed.
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Affiliation(s)
- Dawn L Hershman
- Dawn L. Hershman, Jason D. Wright, Emerson Lim, Donna L. Buono, Wei Yann Tsai, and Alfred I. Neugut, Columbia University; and Dawn L. Hershman, Jason D. Wright, Emerson Lim, and Alfred I. Neugut, New York Presbyterian Hospital, New York, NY
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Yom-Tov E, Gabrilovich E. Postmarket drug surveillance without trial costs: discovery of adverse drug reactions through large-scale analysis of web search queries. J Med Internet Res 2013; 15:e124. [PMID: 23778053 PMCID: PMC3713931 DOI: 10.2196/jmir.2614] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 04/26/2013] [Accepted: 05/23/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Postmarket drug safety surveillance largely depends on spontaneous reports by patients and health care providers; hence, less common adverse drug reactions--especially those caused by long-term exposure, multidrug treatments, or those specific to special populations--often elude discovery. OBJECTIVE Here we propose a low cost, fully automated method for continuous monitoring of adverse drug reactions in single drugs and in combinations thereof, and demonstrate the discovery of heretofore-unknown ones. METHODS We used aggregated search data of large populations of Internet users to extract information related to drugs and adverse reactions to them, and correlated these data over time. We further extended our method to identify adverse reactions to combinations of drugs. RESULTS We validated our method by showing high correlations of our findings with known adverse drug reactions (ADRs). However, although acute early-onset drug reactions are more likely to be reported to regulatory agencies, we show that less acute later-onset ones are better captured in Web search queries. CONCLUSIONS Our method is advantageous in identifying previously unknown adverse drug reactions. These ADRs should be considered as candidates for further scrutiny by medical regulatory authorities, for example, through phase 4 trials.
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Lexchin J, Wiktorowicz M, Moscou K, Eggertson L. Provincial drug plan officials' views of the Canadian drug safety system. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2013; 38:545-571. [PMID: 23418364 DOI: 10.1215/03616878-2079514] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The Canadian constitution divides the responsibility for pharmaceuticals between the federal and provincial governments. While the provincial governments are responsible for establishing public formularies, the majority of the safety and efficacy information that the provinces use comes from the federal government. We interviewed drug plan officials from eight of the ten provinces and two of three territories regarding their views on the Canadian drug safety system. Here we report on the following categories: the federal drug approval system; the strengths and weaknesses of the federal system of postmarket pharmaceutical safety (i.e., pharmacosurveillance); resources available to support provincial formulary decision making; provincial roles in pharmacosurveillance; how the drug safety system could be improved; and the role of the Drug Safety and Effectiveness Network, a recently established virtual network designed to connect researchers throughout Canada who conduct postmarket drug research. Next, we place the Canadian system within an international context by comparing informational asymmetry between government institutions in the United States and the European Union and by looking at how institutions support each other's roles in sharing information and in jointly developing policy through the International Conference on Harmonization. Finally, we draw on international experiences and suggest potential solutions to the concerns that our key informants have identified.
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Kataria BC, Mehta DS, Chhaiya SB. Drug lag for cardiovascular drug approvals in India compared with the US and EU approvals. Indian Heart J 2012; 65:24-9. [PMID: 23438609 DOI: 10.1016/j.ihj.2012.12.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 07/26/2012] [Accepted: 12/19/2012] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE Age-standardized burden of cardiovascular diseases is substantially higher in low and middle-income countries than in high-income countries. However, Indian patients are not getting access to the new cardiovascular drugs at the same time as patients in the developed nations. The objective of this study was to assess the drug lag for new cardiovascular drugs in India compared with that in the United States (US) or European Union (EU). METHODS The information regarding approval of new cardiovascular drugs in the United States, European Union and India between 1999 and 2011 were obtained primarily from the online databases of regulatory agencies. The approval lag was obtained for all new cardiovascular drugs approved in each region, and the median approval lag was calculated for each region. RESULTS Of the 75 new cardiovascular drugs, 61 (81.33%) were approved in the United States, 65 (86.66%) in the European Union and 56 (74.66%) in India. The US was the first to approve 35 (56.45%) out of the 75 new cardiovascular drugs, the EU was the first to approve 24 (38.71%) and India was the first to approve 3 (4.84%). The median approval lag for India (44.14 months) was substantially higher as compared to the United States (0 month) and European Union (2.99 months). CONCLUSION This study confirms that there is a substantial drug lag in approval of new cardiovascular drugs in India compared with the United States and European Union. The impact of drug lag on health outcomes remains to be established.
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Affiliation(s)
- Bhaven C Kataria
- Department of Pharmacology, C.U. Shah Medical College, Surendranagar, Gujarat, India.
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13
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El Emam K, Samet S, Arbuckle L, Tamblyn R, Earle C, Kantarcioglu M. A secure distributed logistic regression protocol for the detection of rare adverse drug events. J Am Med Inform Assoc 2012; 20:453-61. [PMID: 22871397 PMCID: PMC3628043 DOI: 10.1136/amiajnl-2011-000735] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background There is limited capacity to assess the comparative risks of medications after they enter the market. For rare adverse events, the pooling of data from multiple sources is necessary to have the power and sufficient population heterogeneity to detect differences in safety and effectiveness in genetic, ethnic and clinically defined subpopulations. However, combining datasets from different data custodians or jurisdictions to perform an analysis on the pooled data creates significant privacy concerns that would need to be addressed. Existing protocols for addressing these concerns can result in reduced analysis accuracy and can allow sensitive information to leak. Objective To develop a secure distributed multi-party computation protocol for logistic regression that provides strong privacy guarantees. Methods We developed a secure distributed logistic regression protocol using a single analysis center with multiple sites providing data. A theoretical security analysis demonstrates that the protocol is robust to plausible collusion attacks and does not allow the parties to gain new information from the data that are exchanged among them. The computational performance and accuracy of the protocol were evaluated on simulated datasets. Results The computational performance scales linearly as the dataset sizes increase. The addition of sites results in an exponential growth in computation time. However, for up to five sites, the time is still short and would not affect practical applications. The model parameters are the same as the results on pooled raw data analyzed in SAS, demonstrating high model accuracy. Conclusion The proposed protocol and prototype system would allow the development of logistic regression models in a secure manner without requiring the sharing of personal health information. This can alleviate one of the key barriers to the establishment of large-scale post-marketing surveillance programs. We extended the secure protocol to account for correlations among patients within sites through generalized estimating equations, and to accommodate other link functions by extending it to generalized linear models.
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Pharmacovigilance in Europe and North America: divergent approaches. Soc Sci Med 2012; 75:165-70. [PMID: 22521677 DOI: 10.1016/j.socscimed.2011.11.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 10/13/2011] [Accepted: 11/29/2011] [Indexed: 11/24/2022]
Abstract
Although international medicines regulators adopt a common system to assess the safety and efficacy of new drugs, pre-market evaluation is recognized as incomplete given the much larger post-market experience to follow. Adverse drug reactions contribute to more than 100,000 deaths in the United States annually and are among the top 10 leading causes of death. Regulators are developing active surveillance approaches to assess the risks of medicines in the post-market phase to enhance passive adverse drug reaction reporting systems that capture only one to ten percent of ADRs. The objective of this study is to compare international approaches to active surveillance and the manner in which regulatory agencies access and use post-market evidence in their decisions. A conceptual framework is used to guide the comparative analysis of pharmacovigilance governance and policy in the United Kingdom, France, the European Union, the United States and Canada using data gathered from key informant interviews and document review. While research networks are emerging internationally, we found a greater reliance on industry funding and oversight of post-market research in Europe compared to an emphasis on publicly funded programs in North America.
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Quartey G, Wang J. Statistical aspects in comparative benefit-risk assessment: challenges and opportunities for pharmaceutical statisticians. Pharm Stat 2011; 11:82-5. [PMID: 21997832 DOI: 10.1002/pst.497] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 01/13/2011] [Accepted: 05/04/2011] [Indexed: 11/10/2022]
Abstract
Benefit-risk assessment is a fundamental element of drug development with the aim to strengthen decision making for the benefit of public health. Appropriate benefit-risk assessment can provide useful information for proactive intervention in health care settings, which could save lives, reduce litigation, improve patient safety and health care outcomes, and furthermore, lower overall health care costs. Recent development in this area presents challenges and opportunities to statisticians in the pharmaceutical industry. We review the development and examine statistical issues in comparative benefit-risk assessment. We argue that a structured benefit-risk assessment should be a multi-disciplinary effort involving experts in clinical science, safety assessment, decision science, health economics, epidemiology and statistics. Well planned and conducted analyses with clear consideration on benefit and risk are critical for appropriate benefit-risk assessment. Pharmaceutical statisticians should extend their knowledge to relevant areas such as pharmaco-epidemiology, decision analysis, modeling, and simulation to play an increasingly important role in comparative benefit-risk assessment.
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Affiliation(s)
- George Quartey
- Statistics Methods and Research Group, F. Hoffmann-La Roche, Welwyn Garden City, UK.
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van Luijn JCF, Danz M, Bijlsma JWJ, Gribnau FWJ, Leufkens HGM. Post-approval trials of new medicines: widening use or deepening knowledge? Analysis of 10 years of etanercept. Scand J Rheumatol 2010; 40:183-91. [DOI: 10.3109/03009742.2010.509102] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Guo JJ, Pandey S, Doyle J, Bian B, Lis Y, Raisch DW. A review of quantitative risk-benefit methodologies for assessing drug safety and efficacy-report of the ISPOR risk-benefit management working group. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2010; 13:657-66. [PMID: 20412543 DOI: 10.1111/j.1524-4733.2010.00725.x] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Although regulatory authorities evaluate the risks and benefits of any new drug therapy during the new drug-approval process, quantitative risk-benefit assessment (RBA) is not typically performed, nor is it presented in a consistent and integrated framework when it is used. Our purpose is to identify and describe published quantitative RBA methods for pharmaceuticals. METHODS Using MEDLINE and other Internet-based search engines, a systematic literature review was performed to identify quantitative methodologies for RBA. These distinct RBA approaches were summarized to highlight the implications of their differences for the pharmaceutical industry and regulatory agencies. RESULTS Theoretical models, parameters, and key features were reviewed and compared for the 12 quantitative RBA methods identified in the literature, including the Quantitative Framework for Risk and Benefit Assessment, benefit-less-risk analysis, the quality-adjusted time without symptoms and toxicity, number needed to treat (NNT), and number needed to harm and their relative-value-adjusted versions, minimum clinical efficacy, incremental net health benefit, the risk-benefit plane (RBP), the probabilistic simulation method, multicriteria decision analysis (MCDA), the risk-benefit contour (RBC), and the stated preference method (SPM). Whereas some approaches (e.g., NNT) rely on subjective weighting schemes or nonstatistical assessments, other methods (e.g., RBP, MCDA, RBC, and SPM) assess joint distributions of benefit and risk. CONCLUSIONS Several quantitative RBA methods are available that could be used to help lessen concern over subjective drug assessments and to help guide authorities toward more objective and transparent decision-making. When evaluating a new drug therapy, we recommend the use of multiple RBA approaches across different therapeutic indications and treatment populations in order to bound the risk-benefit profile.
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Affiliation(s)
- Jeff J Guo
- University of Cincinnati Health Academic Center, College of Pharmacy, Cincinnati, OH, USA.
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Ferris LE, Lemmens T. Governance of conflicts of interest in postmarketing surveillance research and the Canadian Drug Safety and Effectiveness Network. OPEN MEDICINE : A PEER-REVIEWED, INDEPENDENT, OPEN-ACCESS JOURNAL 2010; 4:e123-8. [PMID: 21686301 PMCID: PMC3116687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 03/01/2010] [Accepted: 03/01/2010] [Indexed: 11/29/2022]
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Tafuri G, Leufkens HG, Laing R, Trotta F. Therapeutic indications in oncology: Emerging features and regulatory dynamics. Eur J Cancer 2010; 46:471-5. [DOI: 10.1016/j.ejca.2009.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Accepted: 11/24/2009] [Indexed: 11/15/2022]
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Hershman DL, Buono DL, Malin J, McBride R, Tsai WY, Neugut AI. Patterns of use and risks associated with erythropoiesis-stimulating agents among Medicare patients with cancer. J Natl Cancer Inst 2009; 101:1633-41. [PMID: 19903808 DOI: 10.1093/jnci/djp387] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Erythropoiesis-stimulating agents (erythropoietin and darbepoietin) have been approved to reduce the number of blood transfusions required during chemotherapy; however, concerns about the risks of venous thromboembolism and mortality exist. METHODS We identified patients who were aged 65 years or older in the Surveillance, Epidemiology, and End Results-Medicare database; who were diagnosed with colon, non-small cell lung, or breast cancer or with diffuse large B-cell lymphoma from January 1, 1991, through December 31, 2002; and who received chemotherapy. The main outcome measures were claims for use of an erythropoiesis-stimulating agent, blood transfusion, venous thromboembolism (ie, deep vein thrombosis or pulmonary embolism), and overall survival. We used multivariable logistic regression models to analyze the association of erythropoiesis-stimulating agent use with clinical and demographic variables. We used time-dependent Cox proportional hazards models to analyze the association of time to receipt of first erythropoiesis-stimulating agent with venous thromboembolism and overall survival. All statistical tests were two-sided. RESULTS Among 56,210 patients treated with chemotherapy from 1991 through 2002, 15,346 (27%) received an erythropoiesis-stimulating agent. The proportion of patients receiving erythropoiesis-stimulating agents increased from 4.8% in 1991 to 45.9% in 2002 (P < .001). Use was associated with more recent diagnosis, younger age, urban residence, comorbidities, receipt of radiation therapy, female sex, and metastatic or recurrent cancer. The rate of blood transfusion per year during 1991-2002 remained constant at 22%. Venous thromboembolism developed in 1796 (14.3%) of the 12,522 patients who received erythropoiesis-stimulating agent and 3400 (9.8%) of the 34,820 patients who did not (hazard ratio = 1.93, 95% confidence interval = 1.79 to 2.07). Overall survival was similar in both groups. CONCLUSION Use of erythropoiesis-stimulating agent increased rapidly after its approval in 1991, but the blood transfusion rate did not change. Use of erythropoiesis-stimulating agents was associated with an increased risk of venous thromboembolism but not of mortality.
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Affiliation(s)
- Dawn L Hershman
- Columbia University Medical Center, 161 Fort Washington Ave, 10-1068, New York, NY 10032, USA.
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Rosenau PV, Lal LS, Glasser JH. U.S. pharmacy policy: a public health perspective on safety and cost. SOCIAL WORK IN PUBLIC HEALTH 2009; 24:543-567. [PMID: 19821192 DOI: 10.1080/19371910802679457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A public health perspective based on social justice and a population health point of view emphasizes pharmacy policy innovations regarding safety and costs. Such policies that effectively reduce costs include controlling profits, establishing profit targets, extending prescription providers, revising prescription classification schemes, emphasizing generic medications, and establishing formularies. Public education and universal programs may reduce costs, but co-pays and "cost-sharing" do not. Switching medications to over-the-counter (OTC) status, pill splitting, and importing medication from abroad are poor substitutes for authentic public health pharmacy policy. Where policy changes yield savings, public health insists that these savings should be used to increase access and improve population health. In the future, pharmacy policies may emphasize public health accountability more than individual liberty because of potential cost savings to society. Fear of litigation, as an informal mechanism of focusing manufacturer's attention on safety, is inefficient; public health pharmacy policy regarding safety looks toward a more active regulatory role on the part of government. A case study of direct-to-consumer advertising illustrates the complexity of public health pharmacy policy.
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Affiliation(s)
- Pauline Vaillancourt Rosenau
- Division of Management, Policy, and Community Health, School of Public Health, University of Texas, Houston, Texas 77030, USA.
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Ray A. Beyond debacle and debate: developing solutions in drug safety. Nat Rev Drug Discov 2009; 8:775-9. [DOI: 10.1038/nrd2988] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Patwardhan B, Mashelkar RA. Traditional medicine-inspired approaches to drug discovery: can Ayurveda show the way forward? Drug Discov Today 2009; 14:804-11. [PMID: 19477288 DOI: 10.1016/j.drudis.2009.05.009] [Citation(s) in RCA: 163] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2008] [Revised: 05/01/2009] [Accepted: 05/13/2009] [Indexed: 11/18/2022]
Abstract
Drug discovery strategies based on natural products and traditional medicines are re-emerging as attractive options. We suggest that drug discovery and development need not always be confined to new molecular entities. Rationally designed, carefully standardized, synergistic traditional herbal formulations and botanical drug products with robust scientific evidence can also be alternatives. A reverse pharmacology approach, inspired by traditional medicine and Ayurveda, can offer a smart strategy for new drug candidates to facilitate discovery process and also for the development of rational synergistic botanical formulations.
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Affiliation(s)
- Bhushan Patwardhan
- Interdisciplinary School of Health Sciences, University of Pune, Pune 411 007, India.
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Huff-Rousselle M, Simooya O, Kabwe V, Hollander I, Handema R, Mwango A, Mwape E. Pharmacovigilance and new essential drugs in Africa: Zambia draws lessons from its own experiences and beyond. Glob Public Health 2009; 2:184-203. [PMID: 19280399 DOI: 10.1080/17441690601063299] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Jolted into action by the thalidomide tragedy, developed Western countries began to establish national systems for identifying and responding to adverse drug reactions and events (or pharmacovigilance systems) about 40 years ago. These systems focus on side effects, adverse reactions, and drug interactions. In developing countries, especially in Africa, the scope for pharmacovigilance needs to be broader (despite the additional challenges this brings) because of growing problems with substandard and counterfeit drugs and the need to have an early warning signal system for the development of antimicrobial resistance to the 'new essential drugs' that are barely beyond the clinical trial stage in Africa, e.g. artemisinin-combination therapy (ACT) for malaria and antiretrovirals (ARV) for HIV/AIDS. Zambia learned important lessons from its own initial experiences in attempting to use ACT as a pathfinder for pharmacovigilance, as well as its experience with other drug information systems. In preparing its own renewed plans, it also drew lessons from international experience, including the weaknesses of the Food and Drug Administration's approach to pharmacovigilance in the USA, the UK's 'yellow card scheme', Brazil's fledgling pharmacovigilance systems for AIDS treatment, and the guidance provided by the World Health Organization and the Uppsala Monitoring Centre. These lessons are relevant for other African countries and even for developed countries seeking to improve pharmacovigilance systems.
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Affiliation(s)
- M Huff-Rousselle
- Social Sectors Development Strategies, Inc, Boston, MA 02118, USA.
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25
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Telekes A. Off-label therapies in oncology. Orv Hetil 2009; 150:363-72. [DOI: 10.1556/oh.2009.28522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Az indikáción kívüli (off-label) kezelések speciális problémát jelentenek az onkológiában, mivel a jogi szabályozás és a szabad orvosi gyakorlat határterületén állnak. Bár Magyarországon az off-label kezelés a 2008. október végén életbe léptetett rendelet megjelenéséig engedély nélküli klinikai vizsgálatnak minősült, egyes szakemberek mégis azzal érveltek alkalmazása mellett, hogy a klinikai gyakorlat gyorsabban változik, mint az alkalmazási előirat. Mi több, a gyártók még megfelelő evidencia esetén sem kötelesek az indikáció bővítésére. Az off-label kezelések szabályozása egyaránt meg kell hogy feleljen a szabad orvosi gyakorlatnak, az evidencián alapuló medicinának, a betegek új esélyekhez való igényének és a hatóságok elvárásainak. A közleményben a hazai helyzet és a törvény bírálata, illetve a nemzetközi gyakorlat áttekintése után egy, a fenti szempontoknak megfelelő lehetséges szabályozás kereteit vázolja a szerző, külön-külön kifejtve a kezelőorvos és a hatóságok szerepét.
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Affiliation(s)
- András Telekes
- 1 Országos Onkológiai Intézet (2009. január 1-jétől: Bajcsy-Zsilinszky Kórház és Rendelőintézet) III. Belgyógyászati Ambulancia (2009. január 1-jétől: Onkológiai Osztály) 1106 Budapest Maglódi u. 89–91
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Errors in the approval process and post-marketing evaluation of drotrecogin alfa (activated) for the treatment of severe sepsis. THE LANCET. INFECTIOUS DISEASES 2009; 9:67-72. [DOI: 10.1016/s1473-3099(08)70306-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Use of a drug outside the terms of its official labelling is referred to as off-label prescription. Many categories of use exist because labelling of anticancer agents is very precise in terms of type or subtype of tumour, association, line, and duration of treatment. Off-label prescription of anticancer drugs is thought to be frequent but, in fact, very few surveys have been done to ascertain its real extent. Findings of prospective studies undertaken between 1990 and 2002 showed proportions of off-label drug use in children and adults of 6.7-33.2%. Most off-label prescription was reported in patients treated with palliative intent, some was associated with clinical benefits, and in specific cancers it formed the standard of care. Off-label use can lead to reimbursement restrictions. Regulatory agencies have created incentives to extend indications for approved drugs to remove them from the off-label area. Proposals have also been made to gather and disseminate accurate and unbiased information on off-label use and to record unapproved indications.
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Affiliation(s)
- Dominique Levêque
- Department of Pharmacy-Pharmacology, Hôpitaux Universitaires de Strasbourg, Hôpital Hautepierre, 67000 Strasbourg, France
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Teschke R, Schwarzenboeck A, Hennermann KH. Causality assessment in hepatotoxicity by drugs and dietary supplements. Br J Clin Pharmacol 2008; 66:758-66. [PMID: 19032721 PMCID: PMC2675778 DOI: 10.1111/j.1365-2125.2008.03264.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Accepted: 07/01/2008] [Indexed: 12/18/2022] Open
Abstract
Structured causality assessment of hepatotoxicity by drugs and dietary supplements (DDS) is a major clinical challenge, since temporal associations as the sole criteria for a valid evaluation are not acceptable. Initially, a clear intuition for an ad hoc evaluation is necessary, but only provisional, and must be followed by a diagnostic algorithm using a pretest, main test and post test. The evaluation is based on a variety of items such as latency period, course of alanine aminotransferase and alkaline phosphatase after DDS discontinuation, risk factors, co-medication, previous information on hepatotoxicity of the DDS, response to rechallenge, and exclusion of other diseases. It is essential that practising and hospital physicians as well as other key health professionals, such as pharmacists, gather all information required for a sound causality assessment, obviating major discussions by expert panels, manufacturers and health agencies in face of scanty and fragmentary data. Because pharmacogenetic alterations may trigger metabolic hepatotoxicity by a few DDS, levels in plasma and urine should be measured and may be helpful for diagnosis. Concomitant genotyping of cytochrome P450 and other enzymes may also be useful in future to minimize the risk of unwanted side-effects, including toxic liver disease elicited by DDS.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Teaching Hospital of the Johann Wolfgang Goethe-University of Frankfurt/Main, Hanau, Germany.
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Reed SD, Anstrom KJ, Seils DM, Califf RM, Schulman KA. Use of larger versus smaller drug-safety databases before regulatory approval: the trade-offs. Health Aff (Millwood) 2008; 27:w360-70. [PMID: 18682441 DOI: 10.1377/hlthaff.27.5.w360] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although efforts to revamp the drug-safety system have been directed at strengthening postmarketing surveillance, strategies for the preapproval stage may be useful. One strategy would be to require larger sample sizes in preapproval safety databases. To evaluate the potential benefits and costs of this approach, we developed a hypothetical model to estimate the expected incremental number of adverse drug events that could be avoided in a postapproval population. We found that the potential to limit adverse events can be an important consideration in sample-size determinations for preapproval trials. Requiring larger preapproval databases could be a cost-effective means of reducing adverse events in postapproval populations.
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Affiliation(s)
- Shelby D Reed
- Duke University School of Medicine in Durham, North Carolina, USA
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JOB OPPORTUNITIES. Am J Public Health 2008. [DOI: 10.2105/ajph.98.8.1520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Shamoo AE, Katzel LI. How Should Adverse Events Be Reported in US Clinical Trials?: Ethical Considerations. Clin Pharmacol Ther 2008; 84:275-8. [DOI: 10.1038/clpt.2008.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Berlin JA, Glasser SC, Ellenberg SS. Adverse event detection in drug development: recommendations and obligations beyond phase 3. Am J Public Health 2008; 98:1366-71. [PMID: 18556607 DOI: 10.2105/ajph.2007.124537] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Premarketing studies of drugs, although large enough to demonstrate efficacy and detect common adverse events, cannot reliably detect an increased incidence of rare adverse events or events with significant latency. For most drugs, only about 500 to 3000 participants are studied, for relatively short durations, before a drug is marketed. Systems for assessment of postmarketing adverse events include spontaneous reports, computerized claims or medical record databases, and formal postmarketing studies. We briefly review the strengths and limitations of each. Postmarketing surveillance is essential for developing a full understanding of the balance between benefits and adverse effects. More work is needed in analysis of data from spontaneous reports of adverse effects and automated databases, design of ad hoc studies, and design of economically feasible large randomized studies.
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Affiliation(s)
- Jesse A Berlin
- Johnson & Johnson Pharmaceutical Research & Development, 1125 Trenton-Harbourton Rd, PO Box 200, Mail Stop K-304, Titusville, NJ 08560, USA.
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Pharmacovigilance: methods, recent developments and future perspectives. Eur J Clin Pharmacol 2008; 64:743-52. [DOI: 10.1007/s00228-008-0475-9] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2008] [Accepted: 02/14/2008] [Indexed: 10/22/2022]
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Abstract
BACKGROUND The Prescription Drug User Fee Act (PDUFA) imposes deadlines for the completion of drug reviews by the Food and Drug Administration (FDA). Critics have suggested that these deadlines may result in rushed approvals and the emergence of unanticipated safety problems once a product is in clinical use. METHODS We assessed the association between the PDUFA deadlines and the timing of FDA drug approval by constructing dynamic Cox proportional-hazards models of review times for all new molecular entities approved between 1950 and 2005. To determine whether the deadlines were associated with postmarketing safety problems, we focused on drugs submitted since January 1993, when the deadlines were first imposed. We used exact logistic regression to determine whether drugs approved immediately before the deadlines were associated with a higher rate of postmarketing safety problems (e.g., withdrawals and black-box warnings) than drugs approved at other times. RESULTS Initiation of the PDUFA requirements concentrated the number of approval decisions made in the weeks immediately preceding the deadlines. As compared with drugs approved at other times, drugs approved in the 2 months before their PDUFA deadlines were more likely to be withdrawn for safety reasons (odds ratio, 5.5; 95% confidence interval [CI], 1.3 to 27.8), more likely to carry a subsequent black-box warning (odds ratio, 4.4; 95% CI, 1.2 to 20.5), and more likely to have one or more dosage forms voluntarily discontinued by the manufacturer (odds ratio, 3.3; 95% CI, 1.5 to 7.5). CONCLUSIONS PDUFA deadlines have appreciably changed the approval decisions of the FDA. Once medications are in clinical use, the discovery of safety problems is more likely for drugs approved immediately before a deadline than for those approved at other times.
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Affiliation(s)
- Daniel Carpenter
- Department of Government, Faculty of Arts and Sciences, Harvard University, Cambridge, MA 02138, USA.
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van Luijn JCF, Stolk P, Gribnau FWJ, Leufkens HGM. Gap in publication of comparative information on new medicines. Br J Clin Pharmacol 2008; 65:716-22. [PMID: 18294324 DOI: 10.1111/j.1365-2125.2007.03092.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Randomized active control trials are used by health care professionals and reimbursement authorities for the assessment of the added value of a new medicine. Failing to publish the results of clinical trials limits making an evidence based assessment and conducting systematic reviews. WHAT THIS STUDY ADDS About one-third of the comparative trials used in the authorization process are published at the moment of market authorization and about four out of five within 2 or 3 years. Most of the rest remain unpublished. Unpublished trials contain information regarding a different therapeutic use or a different comparator of the same medicine and, in some cases, have influenced the risk : benefit assessment of the registration authorities. A standardized public registration of results of the main premarketing trials is advocated to fill the publication gap. AIMS To determine the time-lag between the EU authorization of new medicines and the publications of the main randomized active control trials (RaCTs) used in the authorization process and to compare unpublished with published RaCTs of the same medicine. METHODS All RaCTs for new medicines with a new active substance, authorized between 1999 and 2003, were extracted from the European Public Assessment Reports (EPAR). Information about the publication status of RaCTs was obtained from the MEDLINE and EMBASE databases. RESULTS We identified 116 RaCTs for 42 new medicines; 28% of the RaCTs had been published at the moment of market authorization, 59% after 1 year, 78% after 2 and 83% after 3 years. Most of the rest of the studies remained unpublished after 3 years of follow-up. Unpublished RaCTs differed from published trials of the same medicine especially regarding therapeutic use and/or comparator. In some cases unpublished trials have influenced the risk : benefit asssessment of the registration authorities. CONCLUSIONS Most of the main RaCTs, relevant for assessing the added value of a new medicine, are published subsequent to market entry; some of these trials remain unpublished. We argue for a standardized public registration of the results of the main premarketing clinical trials as a condition for market authorization.
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Affiliation(s)
- Johan C F van Luijn
- Division of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences (UIPS), Faculty of Science, Utrecht, The Netherlands
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Thornton RG. Preemption, tort reform, and pharmaceutical claims: Part two: Has the Food and Drug Administration shown it is solely responsible for the protection of patients? Can it do so? Will it do so? Proc AMIA Symp 2008; 21:82-92. [PMID: 18209762 PMCID: PMC2190559 DOI: 10.1080/08998280.2008.11928368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Nair V, Salmon JW, Kaul AF. Iatrogenic disease management: moderating medication errors and risks in a pharmacy benefit management environment. DISEASE MANAGEMENT : DM 2007; 10:337-346. [PMID: 18163862 DOI: 10.1089/dis.2007.106617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Disease Management (DM) programs have advanced to address costly chronic disease patterns in populations. This is in part due to the programs' significant clinical and economical value, coupled with interest by pharmaceutical manufacturers, managed care organizations, and pharmacy benefit management firms. While cost containment realizations for many such interventions have been less than anticipated, this article explores potentials in marrying Medication Error Risk Reduction into DM programs within managed care environments. Medication errors are an emergent serious problem now gaining attention in US health policy. They represent a failure within population-based health programs because they remain significant cost drivers. Therefore, medication errors should be addressed in an organized fashion, with DM being a worthy candidate for piggybacking such programs to achieve the best synergistic effects.
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Abstract
Current European licensing regulations give precedence to the interests of drug companies. Silvio Garattini and Vittorio Bertele' suggest changes to ensure they meet the needs of patients and doctors
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Affiliation(s)
- Silvio Garattini
- Mario Negri Institute for Pharmacological Research, Via Eritrea 62, 20157 Milano, Italy.
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Grijalva CG, Chung CP, Arbogast PG, Stein CM, Mitchel EF, Griffin MR. Assessment of Adherence to and Persistence on Disease-Modifying Antirheumatic Drugs (DMARDs) in Patients With Rheumatoid Arthritis. Med Care 2007; 45:S66-76. [PMID: 17909386 DOI: 10.1097/mlr.0b013e318041384c] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Biologic disease-modifying antirheumatic drugs (DMARDs) are efficacious for treating rheumatoid arthritis (RA). However, measurements of relative effectiveness, including treatment adherence and persistence, are lacking. We evaluated adherence and persistence during new episodes of use of traditional and biologic DMARDs. METHODS Using Tennessee Medicaid databases (1995-2004), we assembled a retrospective cohort of patients diagnosed with RA, and identified new episodes of use for 12 DMARD regimens. We evaluated persistence through survival analyses, and adherence within episodes through the medication possession ratio. A risk score was included in the analyses to account for measured confounders. RESULTS We identified 14,932 patients with RA; 6018 patients had 10,547 episodes of new use of DMARDs. Considering methotrexate as the reference and after adjustment for measured confounders, episodes of new use of sulfasalazine [adjusted hazard ratio (aHR) = 1.59; 95% confidence interval (CI) = 1.47-1.72] and infliximab alone (aHR = 1.37, 95% CI = 1.09-1.73) were more likely to be discontinued; and new episodes of etanercept (aHR = 0.82, 95% CI = 0.73-0.92) and methotrexate + adalimumab (aHR = 0.63, 95% CI = 0.48-0.84) were less likely to be discontinued. Compared with methotrexate, adherence was higher for leflunomide, infliximab, etanercept, and adalimumab and lower for sulfasalazine and all combined therapies. CONCLUSIONS We developed an approach to assess persistence on and adherence to the most common DMARD therapies. In this large cohort, persistence and adherence to leflunomide and most biologic DMARD therapies were at least comparable to methotrexate. Adherence was lower for sulfasalazine and all combined therapies.
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Affiliation(s)
- Carlos G Grijalva
- Department of Preventive Medicine, Division of Pharmacoepidemiology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Brownstein JS, Sordo M, Kohane IS, Mandl KD. The tell-tale heart: population-based surveillance reveals an association of rofecoxib and celecoxib with myocardial infarction. PLoS One 2007; 2:e840. [PMID: 17786211 PMCID: PMC1950690 DOI: 10.1371/journal.pone.0000840] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2007] [Accepted: 08/08/2007] [Indexed: 12/13/2022] Open
Abstract
Background COX-2 selective inhibitors are associated with myocardial infarction (MI). We sought to determine whether population health monitoring would have revealed the effect of COX-2 inhibitors on population-level patterns of MI. Methodology/Principal Findings We conducted a retrospective study of inpatients at two Boston hospitals, from January 1997 to March 2006. There was a population-level rise in the rate of MI that reached 52.0 MI-related hospitalizations per 100,000 (a two standard deviation exceedence) in January of 2000, eight months after the introduction of rofecoxib and one year after celecoxib. The exceedence vanished within one month of the withdrawal of rofecoxib. Trends in inpatient stay due to MI were tightly coupled to the rise and fall of prescriptions of COX-2 inhibitors, with an 18.5% increase in inpatient stays for MI when both rofecoxib and celecoxib were on the market (P<0.001). For every million prescriptions of rofecoxib and celecoxib, there was a 0.5% increase in MI (95%CI 0.1 to 0.9) explaining 50.3% of the deviance in yearly variation of MI-related hospitalizations. There was a negative association between mean age at MI and volume of prescriptions for celecoxib and rofecoxib (Spearman correlation, −0.67, P<0.05). Conclusions/Significance The strong relationship between prescribing and outcome time series supports a population-level impact of COX-2 inhibitors on MI incidence. Further, mean age at MI appears to have been lowered by use of these medications. Use of a population monitoring approach as an adjunct to pharmacovigilence methods might have helped confirm the suspected association, providing earlier support for the market withdrawal of rofecoxib.
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Affiliation(s)
- John S Brownstein
- Children's Hospital Informatics Program at the Harvard-MIT Division of Health Sciences and Technology, Boston, Massachusetts, United States of America.
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Faunce TA. Reference pricing for pharmaceuticals: is the Australia–United States Free Trade Agreement affecting Australia's Pharmaceutical Benefits Scheme? Med J Aust 2007; 187:240-2. [PMID: 17564579 DOI: 10.5694/j.1326-5377.2007.tb01209.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2007] [Accepted: 06/05/2007] [Indexed: 11/17/2022]
Affiliation(s)
- Thomas A Faunce
- Medical School and College of Law, Australian National University, Canberra, ACT, Australia.
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Bertele' V, Banzi R, Capasso F, Tafuri G, Trotta F, Apolone G, Garattini S. Haematological anticancer drugs in Europe: any added value at the time of approval? Eur J Clin Pharmacol 2007; 63:713-9. [PMID: 17530236 DOI: 10.1007/s00228-007-0296-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Accepted: 03/07/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Current European regulations only require drugs to be safe and effective, although there is heavy demand for comparative efficacy data to demonstrate the added value of new drugs. The objective of the analysis reported here was to assess the added value of new anticancer drugs for haematological malignancies that have been approved by the European Medicines Agency (EMEA) based on the clinical data provided at the time of submission. METHODS Information on the evidence supporting the approval was extracted from the European Public Assessment Reports (EPARs). Documents were surveyed for new applications and for subsequent extensions between January 1995, when the EMEA was set up, and May 2006. The added value of newly approved drugs was assessed by an algorithm that evaluates the strength of evidence based on methodological appropriateness (randomised comparison) and the importance of clinical advantage (in terms of the magnitude of benefit, hardness of outcome measures, adequacy of comparator). RESULTS Eleven anticancer drugs were analysed. Of 17 indications, nine (53%) were approved on the basis of single-arm trials (SATs), and eight (47%) were approved on the basis of randomised controlled (clinical) trials (RCTs). The most frequently used endpoint was response rate (12 of 17 indications, 70%). On the basis of our criteria, only four of the 11 drugs show a consistent added value. CONCLUSION We were unable to establish an added value for about two thirds of the drugs evaluated in this study, primarily due to methodological aspects related to study design and endpoint robustness.
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Affiliation(s)
- Vittorio Bertele'
- Laboratory of Regulatory Policies, Mario Negri Institute for Pharmacological Research, Via Eritrea 62, 20157 Milan, Italy.
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Garrison LP, Towse A, Bresnahan BW. Assessing A Structured, Quantitative Health Outcomes Approach To Drug Risk-Benefit Analysis. Health Aff (Millwood) 2007; 26:684-95. [PMID: 17485745 DOI: 10.1377/hlthaff.26.3.684] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Regulatory authorities make difficult risk-benefit decisions when approving new drugs. Food and Drug Administration (FDA) advisory committees and reviewers must consider a complex body of evidence, including efficacy and safety results of trials, disease epidemiology, potential side effects, and patients' needs. However, this menu of information is not usually presented in a consistent and integrated framework. The members of an FDA review panel vote with some unobserved, implicit weighting of the evidence. This paper argues that outcomes research tools for modeling long-term health outcomes, measuring health preferences, and establishing the value of additional information could provide a more structured, transparent, and quantitative process of assessing risk-benefit balance.
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Abstract
A surrogate outcome measure is a laboratory measurement, a physical sign, or another intermediate substitute that is able to predict an intervention's effect on a clinically meaningful outcome. A clinical outcome detects how a patient feels, functions, or survives. Surrogate outcome measures occur faster or more often, are cheaper, and/or are less invasively achieved than the clinical outcome. In practice, validation is surprisingly often overlooked, especially if a biologic plausible rationale is proposed. Surrogate outcomes must be validated before use. The first step in validation is to demonstrate a correlation between the putative surrogate and the clinical outcome, e.g., the higher the surrogate the shorter time to death. However, a correlation is not sufficient to validate the surrogate. The second step is to establish if the intervention's effect on the surrogate outcome accurately predicts the intervention's effect on the clinical outcome. In hepatology a number of putative surrogate outcomes are used both in clinical research and in clinical practice without having been properly validated. Sustained virological response to interferons and ribavirin in patients with chronic hepatitis C, serum bilirubin concentration following ursodeoxycholic acid or immunosuppressants for patients with primary biliary cirrhosis, and nutritional outcomes following artificial nutrition for liver patients may not be valid surrogates for morbidity or mortality. The challenge is to develop reliable surrogates, both to facilitate the development of new interventions and to ensure our patients and us that these interventions are effective clinically.
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Affiliation(s)
- Christian Gluud
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, DK-2100 Copenhagen, Denmark.
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Faunce TA. Nanotherapeutics: new challenges for safety and cost-effectiveness regulation in Australia. Med J Aust 2007; 186:189-91. [PMID: 17309421 DOI: 10.5694/j.1326-5377.2007.tb00860.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Accepted: 10/18/2006] [Indexed: 11/17/2022]
Abstract
Nanotechnology is a revolutionary field of micro-manufacturing involving manipulation, by chemical or physical processes, of individual atoms and molecules. Pharmaceutical and medical device manufacturers, both in Australia and internationally, have significant investments in nanotechnology research and development. It is important that safety regulation of nanotherapeutics keep pace with this growing level of industry interest. A recent senate inquiry recommended the establishment of a working party, including representatives of the Therapeutic Goods Administration, to consider whether bulk materials classified as safe should be routinely reassessed for use at the nanoscale level by a permanent, distinct nanotechnology regulator. Safety regulation of nanotherapeutics may present unique risk assessment challenges, given the novelty and variety of products, high mobility and reactivity of engineered nanoparticles, and blurring of the diagnostic and therapeutic classifications of "medicines" and "medical devices". Nanotherapeutics is likely to make increasing claims on a particular area of Australian health care regulatory strength: scientific cost-effectiveness assessment of innovation in medical products. Any review of Australian regulation of nanotechnology should include a critical analysis of both safety issues and cost-effectiveness assessment systems for nanotherapeutics.
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Affiliation(s)
- Thomas A Faunce
- Medical School and Faculty of Law, Australian National University, Canberra, ACT.
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Hershman D, Neugut AI, Jacobson JS, Wang J, Tsai WY, McBride R, Bennett CL, Grann VR. Acute myeloid leukemia or myelodysplastic syndrome following use of granulocyte colony-stimulating factors during breast cancer adjuvant chemotherapy. J Natl Cancer Inst 2007; 99:196-205. [PMID: 17284714 DOI: 10.1093/jnci/djk028] [Citation(s) in RCA: 206] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recently, increasing numbers of women receiving adjuvant chemotherapy for breast cancer have also received granulocyte colony-stimulating factors (G-CSFs) or granulocyte-macrophage colony-stimulating factors (GM-CSFs). Although these growth factors support chemotherapy, their long-term safety has not been evaluated. We studied the association between G-CSF use and incidence of leukemia in a population-based sample of breast cancer patients. METHODS Among women aged 65 years or older in the Surveillance, Epidemiology, and End Results-Medicare database who were diagnosed with stages I-III breast cancer from January 1, 1991, to December 31, 1999, we identified those who received G-CSF or GM-CSF concurrently with chemotherapy. We used Cox proportional hazards models to estimate hazard ratios for the association of treatment with G-CSF or GM-CSF and subsequent (through December 31, 2003) diagnosis of acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). All statistical tests were two-sided. RESULTS Of 5510 women treated with chemotherapy, 906 (16%) received G-CSF or GM-CSF therapy, and 64 (1.16%) were subsequently diagnosed with either MDS or AML before a cancer recurrence. Use of G-CSF and GM-CSF was associated with more recent diagnosis, younger age, urban residence, fewer comorbidities, receipt of radiation therapy, positive lymph nodes, and cyclophosphamide treatment. Of the 906 patients who were treated with G-CSF, 16 (1.77%) developed AML or MDS; of the 4604 patients not treated with G-CSF, 48 (1.04%) developed AML or MDS. The hazard rate ratio for AML or MDS among those treated with G-CSF or GM-CSF compared with those who were not was 2.14 (95% confidence interval [CI] = 1.12 to 4.08). AML or MDS developed within 48 months of breast cancer diagnosis in 1.8% of patients who received G-CSF or GM-CSF but only in 0.7% of patients who did not (hazard ratio = 2.59, 95% CI = 1.30 to 5.15). CONCLUSIONS The use of G-CSF was associated with a doubling in the risk of subsequent AML or MDS among the population that we studied, although the absolute risk remained low. Even if this association is confirmed, the benefits of G-CSF may still outweigh the risks. Meanwhile, however, G-CSF use should not be assumed to be risk free.
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Affiliation(s)
- Dawn Hershman
- Department of Medicine and Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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Kelman CW, Pearson SA, Day RO, Holman CDJ, Kliewer EV, Henry DA. Evaluating medicines: let's use all the evidence. Med J Aust 2007; 186:249-52. [PMID: 17391088 DOI: 10.5694/j.1326-5377.2007.tb00883.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Accepted: 09/20/2006] [Indexed: 11/17/2022]
Abstract
The current drug regulatory system is outdated and relies primarily on a process of premarketing evaluation, followed by periodic reviews of reported adverse events. While long-term medicine use for chronic conditions is now commonplace, current drug evaluation systems do not incorporate the comprehensive evidence accruing over time in clinical practice. Good quality, routinely collected data on medicines use are now available in some countries. Consistent with international opinion, we propose an expanded and integrated system of medicines regulation for Australia, based on a surveillance system that improves safety monitoring by complementing existing systems, making best use of routinely collected data, and leveraging the power of information technology. Australia is well placed to pilot such a model system.
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Affiliation(s)
- Chris W Kelman
- National Centre for Epidemiology and Population Health and ANU Medical School, Australian National University, Canberra, ACT, Australia.
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