Impact of medicines regulatory risk communications in the UK on prescribing and clinical outcomes: Systematic review, time series analysis and meta-analysis

AIMS

Regulatory risk communications are important to ensure medication safety, but their impact is poorly understood. The aim was to quantify the impact of UK risk communications on medication use and other outcomes.

METHODS

We conducted a systematic review of studies reporting prescribing/health outcome data relevant to UK regulatory risk communication. Data were reanalysed using interrupted time series regression 12 months after each regulatory intervention. Mean changes were pooled using random-effects generic inverse variance examining the following subgroups: drug withdrawals; restrictions/changes in indications; be aware messages without specific recommendations for action; communication via direct healthcare practitioner communications; communication via drug bulletins.

RESULTS

Of 11 466 articles screened, 40 studies examining 25 UK regulatory risk communications were included. Product withdrawals, restriction in indications and be aware communications were associated with relative mean changes of -78% (95% confidence interval [CI] -60 to -96%), -34% (95% confidence interval [CI] -12 to -55%) and -11% (95%CI -8 to -15%) in targeted drug prescribing respectively. Direct healthcare professional communications were associated with relative mean changes of -47% (95%CI -27 to -68%) compared to -13% (95%CI -6 to -20%) for drug bulletins. Of 7 studies examining unique health outcomes related to the safety concern, risk communications were associated with a mean -10% (95%CI -3 to -16%) decrease in intended and a 7% (95%CI 4 to 10%) increase in unintended health outcomes.

DISCUSSION

UK regulatory risk communications were associated with significant changes in targeted prescribing and potential changes in clinical outcomes. Further research is needed to systematically study the impact of regulatory interventions.

The Controversial History of Hormone Replacement Therapy

The history of hormone replacement therapy (HRT) started in the 1960s, with very high popularity in the 1990s. The first clinical trials on HRT and chronic postmenopausal conditions were started in the USA in the late 1990s. After the announcement of the first results of the Women's Health Initiative (WHI) in 2002, which showed that HRT had more detrimental than beneficial effects, HRT use dropped. The negative results of the study received wide publicity, creating panic among some users and new guidance for doctors on prescribing HRT. The clear message from the media was that HRT had more risks than benefits for all women. In the following years, a reanalysis of the WHI trial was performed, and new studies showed that the use of HRT in younger women or in early postmenopausal women had a beneficial effect on the cardiovascular system, reducing coronary disease and all-cause mortality. Notwithstanding this, the public opinion on HRT has not changed yet, leading to important negative consequences for women's health and quality of life.

Measuring the impact of medicines regulatory interventions - Systematic review and methodological considerations

AIMS

Evaluating the public health impact of regulatory interventions is important but there is currently no common methodological approach to guide this evaluation. This systematic review provides a descriptive overview of the analytical methods for impact research.

METHODS

We searched MEDLINE and EMBASE for articles with an empirical analysis evaluating the impact of European Union or non-European Union regulatory actions to safeguard public health published until March 2017. References from systematic reviews and articles from other known sources were added. Regulatory interventions, data sources, outcomes of interest, methodology and key findings were extracted.

RESULTS

From 1246 screened articles, 229 were eligible for full-text review and 153 articles in English language were included in the descriptive analysis. Over a third of articles studied analgesics and antidepressants. Interventions most frequently evaluated are regulatory safety communications (28.8%), black box warnings (23.5%) and direct healthcare professional communications (10.5%); 55% of studies measured changes in drug utilization patterns, 27% evaluated health outcomes, and 18% targeted knowledge, behaviour or changes in clinical practice. Unintended consequences like switching therapies or spill-over effects were rarely evaluated. Two-thirds used before-after time series and 15.7% before-after cross-sectional study designs. Various analytical approaches were applied including interrupted time series regression (31.4%), simple descriptive analysis (28.8%) and descriptive analysis with significance tests (23.5%).

CONCLUSION

Whilst impact evaluation of pharmacovigilance and product-specific regulatory interventions is increasing, the marked heterogeneity in study conduct and reporting highlights the need for scientific guidance to ensure robust methodologies are applied and systematic dissemination of results occurs.

A combined connectivity mapping and pharmacoepidemiology approach to identify existing medications with breast cancer causing or preventing properties

PURPOSE

We applied a novel combined connectivity mapping and pharmacoepidemiological approach to identify medications that alter breast cancer risk.

METHODS

The connectivity mapping process identified 6 potentially cancer-causing (meloxicam, azithromycin, rizatriptan, citalopram, rosiglitazone, and verapamil) and 4 potentially cancer-preventing (bendroflumethiazide, sertraline, fluvastatin, and budesonide) medications that were suitable for pharmacoepidemiological investigation. Within the UK Clinical Practice Research Datalink, we matched 45,147 breast cancer cases to 45,147 controls based on age, year, and general practice. Medication use was determined from electronic prescribing records. We used conditional logistic regression to calculate odds ratios (ORs) for the association between medication use and cancer risk after adjustment for comorbidities, lifestyle factors, deprivation, and other medication use.

RESULTS

Bendroflumethiazide was associated with increased breast cancer risk (OR: 1.11; 95% CI: 1.06, 1.15); however the connectivity mapping exercise predicted that this medication would reduce risk. There were no statistically significant associations for any of the other candidate medications, with ever use ORs ranging from 0.93 (95% CI: 0.78, 1.11) for azithromycin to 1.16 (95% CI: 0.99, 1.37) for verapamil.

CONCLUSIONS

In this instance, our combined connectivity mapping and pharmacoepidemiological approach did not identify any additional medications that were substantially associated with breast cancer risk. This could be due to limitations in the connectivity mapping, such as implausible dosage requirements, or the pharmacoepidemiology, such as residual confounding.

Menopausal hormone therapy and breast cancer

Observational and randomized controlled trial data have extensively examined the relationship between menopausal hormone therapy (MHT) and risk of developing breast cancer. A highly influential study from the Women's Health Initiative (WHI) in 2002 reported that a MHT regimen of conjugated equine estrogens and medroxyprogesterone acetate increased the risk of breast cancer by 26%. Later reports from the WHI indicated that a MHT regimen with conjugated equine estrogens alone decreased the risk of breast cancer by 23%. Critical re-examination of the WHI study noted that the average participant age was 63, that few women had symptoms, and that the WHI results might not apply to younger, symptomatic women shortly after menopause. Since the original publications, several post hoc analyses and observational studies have stimulated reconsideration of the WHI findings. Emphasis has been directed toward risks in younger women just entering the menopause, the subgroup who are most likely to be considering MHT use. The goal of this treatise is to integrate available mechanistic and clinical information related to the use of estrogen alone or estrogen plus a progestogen for five years or less. These data suggest that estrogen alone neither decreases nor increases risk in younger women initiating therapy close to the time of menopause but decreases risk in older women. Both younger and older women experience an excess risk with estrogen plus a progestogen. The attributable risk in younger women is less in those with a low underlying Gail Model risk score. Effects of MHT on risk largely reflect actions on pre-existing, occult, undiagnosed breast cancers. Tumor kinetic models suggest that the pro-proliferative effects of estrogen plus a progestogen on occult tumors provide a mechanistic explanation for the increased risk with this therapy. Pro-apoptotic effects of estrogen alone may explain the reduction of breast cancer in women starting this therapy at an average age of 63 as reported in the WHI study. This article is part of a Special Issue entitled 'Menopause'.

Cancer of the body of the uterus: trends in mortality and incidence in England, 1985-2008

OBJECTIVE

To report on trends in mortality and incidence for uterine cancer in England, 1985-2008.

DESIGN

Database analysis.

SETTING

England.

POPULATION

Data sets of English national mortality and cancer registration statistics.

METHODS

Analysis of data from death certificates with a mention of malignant neoplasm of corpus uteri or malignant neoplasm of uterus without specification of part, and analysis of incidence data from cancer registries in England.

MAIN OUTCOME MEASURES

Age-adjusted and age-specific trends in rates.

RESULTS

Mortality rates in the UK declined from 41.3 per million women in 1985 until about 1999 (30.0 per million), and then increased to 35.9 per million in 2008. Incidence rates for those aged 55 years and over showed little or no change from 1985 to the early 1990s, but then increased: for example, for women aged 60-64 years, the rates per million women in 1985, 1993, 2001 and 2008 were, respectively, 448, 461, 647 and 728. Rates for younger women showed a decline, followed by an increase: for example, for women aged 50-54 years the corresponding rates were 290, 254, 267 and 294. Over the period 2001-2008, the age-adjusted average annual percentage increase was 2.55% per annum (95% CI 2.13-2.98%). The increase in incidence rates, observed from the 1990s, preceded the increase in mortality by about 10 years.

CONCLUSIONS

After many years of declining rates, uterine cancer has become more common in the first decade of this century. One possible contributor to this increase may be an association with the increase in body mass index in women, but other causes are possible and are discussed.

Hormone replacement therapy in gynecologic cancer survivors: why not?

PURPOSE

As a result of treatment, many women with gynecologic malignancies will go through menopause and display climacteric symptoms at an earlier age than occurs naturally. Iatrogenic menopause may adversely affect quality of life and health outcomes in young female cancer survivors. Hormone replacement therapy (HRT) has often been withheld from women with gynecologic cancer because of concern that it might increase the risk of relapse or the development of new primary cancers. The purpose of this review was to examine the published literature on menopause management in gynecologic cancer survivors and highlight the risks and benefits of conventional and alternative HRT in this population.

METHODS

A comprehensive literature search of English language studies on menopause management in gynecologic cancer survivors and women with a hereditary predisposition to a gynecologic malignancy was performed in MEDLINE databases through December 2010.

RESULTS

Both our review and a 2008 Cochrane review of randomized trials on the effects of long-term HRT demonstrate that for menopausal women in their 40s or 50s with and without gynecologic cancer, the absolute risks of estrogen-only HRT are low. Several prospective observational studies and randomized trials on HRT use in women with a genetic predisposition for or development of a gynecologic malignancy suggest benefits in quality of life with no proven adverse oncologic effects as a result of short-term HRT use.

CONCLUSION

In select women, it is reasonable to discuss and offer conventional HRT for the amelioration of menopausal symptoms and to improve quality of life. HRT does not appear to increase the risk of gynecologic cancer recurrences; however, this conclusion was largely based on observational data and smaller prospective studies.

Current and emerging therapies for the treatment of osteoporosis

Osteoporosis represents a weakening of bone tissue due to an imbalance in the dynamic processes of bone formation and bone resorption that are continually ongoing within bone tissue. Most currently available osteoporosis therapies are antiresorptive agents. Over the past decade, bisphosphonates, notably alendronate and risedronate, have become the dominant agents with newer bisphosphonates such as ibandronate and zoledronic acid following a trend of less frequent dosing regimens. Synthetic estrogen receptor modulators (SERMs) continue to be developed as drugs that maintain the bone-protective effects of estrogen while avoiding its associated adverse side effects. Currently available agents of this class include raloxifene, the only SERM available in the United States (US), and lasofoxifene and bazedoxifene, available in Europe. Calcitonin, usually administered as a nasal spray, completes the list of currently approved antiresorptive agents, while parathyroid hormone analogs represent the only anabolic agents currently approved in both the US and Europe. Strontium ranelate is an additional agent available in Europe but not the US that has both anabolic and antiresorptive activity. New agents expected to further expand therapeutic options include denosumab, a monoclonal antibody inhibitor of the resorptive enzyme cathepsin K, which is in the final stages of Food and Drug Administration approval. Other agents in preclinical development include those targeting specific molecules of the Wnt/β-catenin pathway involved in stimulating bone formation by osteoblast cells. This review discusses the use of currently available agents as well as highlighting emerging agents expected to bring significant changes to the approach to osteoporosis therapy in the near future.