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de Barros Fernandes T, Ramos SF, Leitzke LRF, Júnior RGA, de Araújo JM, de Souza Júnior AS, da Silva ARO, Heineck I, de França Fonteles MM, Bracken LE, Peak M, de Lyra Junior DP, Osorio-de-Castro CGS, Lima EC. Use of antimicrobials in pediatric wards of five Brazilian hospitals. BMC Pediatr 2024; 24:177. [PMID: 38481225 PMCID: PMC10936065 DOI: 10.1186/s12887-024-04655-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
The use of antimicrobials (AMs) in pediatric infections is common practice and use may be inappropriate leading to antimicrobial resistance. Off-label AM use is also common in this group and can result in drug-related problems. There is lack of DUR data in Brazil and in Latin America, specially for AM pediatric use. The aim of this study was to describe the utilization of AMs in hospitalized children in five hospitals in Brazil. We conducted an observational study of the utilization of AMs in pediatric wards in hospitals in the states of Ceará (CE), Sergipe (SE), Rio de Janeiro (RJ), Rio Grande do Sul (RS) and the Federal District (DF). Data derived from patient medical records and prescriptions were collected over a six-month period in each hospital. The number of AMs used by each patient was recorded, and AM use was assessed using Days of therapy (DOT) and Length of therapy (LOT) per 1000 patient days according to different patient characteristics. Off-label (OL) use was described according to age. The study analyzed data from 1020 patients. The sex and age distributions were similar across the five hospitals. However, differences were found for comorbidities, history of ICU admission and length of hospital stay. The most common diseases were respiratory tract infections. There were wide variations in DOT/1000PD (278-517) and LOT/1000PD (265-390). AM utilization was highest in the hospital in SE. The consumption of second-generation penicillins and cephalosporins was high. The prevalence of OL use of AMs was higher for patients in the RJ hospital, in infants, in patients who underwent prolonged hospital stays, and in patients who used multiple AMs. The AM that showed the highest prevalence of OL use was azithromycin, in both oral and parenteral formulations. Overall AM use was high and showed differences in each setting, possibly influenced by local characteristics and by prescribing standards adopted by pediatricians.
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Affiliation(s)
- Thais de Barros Fernandes
- Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, 21041-210, Brazil.
| | - Sheila Feitosa Ramos
- Center for Biological and Health Sciences, Federal University of Western Bahia, Barreiras, Brazil
| | - Luísa Rodrigues Furtado Leitzke
- Postgraduate Program in Pharmaceutical Services, Faculty of Pharmacy, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | | | | | - Isabela Heineck
- Postgraduate Program in Pharmaceutical Services, Faculty of Pharmacy, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Louise E Bracken
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Matthew Peak
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Divaldo Pereira de Lyra Junior
- Health Sciences Graduate Program, Social Pharmacy Teaching and Research Laboratory (LEPFS), Federal University of Sergipe, São Cristóvão, Brazil
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Satir A, Pfiffner M, Meier CR, Caduff Good A. Use of unlicensed drugs in a Swiss Pediatric University Hospital and associated prescribing error rates - a retrospective observational study. Swiss Med Wkly 2024; 154:3369. [PMID: 38579321 DOI: 10.57187/s.3369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
AIMS OF THE STUDY Unlicensed drugs are frequently used in paediatric care. To what extent they are prescribed in hospital care in Switzerland is unclear. Because prescribing errors seem to occur more frequently with unlicensed drugs, we aimed to assess the prevalence of unlicensed drug prescriptions in two study periods (2018 and 2019) at the University Children's Hospital Zurich, compare these periods and investigate whether unlicensed drugs were more prone to prescribing errors than licensed drugs. METHODS We conducted a sub-analysis of a retrospective single-centre observational study and analysed 5,022 prescriptions for a total of 1,000 patients from 2018 and 2019 in paediatric general wards. The rate of unlicensed drugs, consisting of imported or formula drugs, was investigated. The prescriptions from 2019 were further analysed on prescribing errors to see whether errors occurred more often in unlicensed or licensed drug use. RESULTS Of all prescriptions, 10.8% were unlicensed drugs, with around half each being imported and formula drugs. Among all patients, 34% were prescribed at least one unlicensed drug. Younger paediatric patients were prescribed more unlicensed drugs than older paediatric patients (newborns: 15.8% of prescriptions, infants: 13.4%, children: 10.6%, adolescents: 7.1%). Ibuprofen suppositories, midazolam oral solution and gentamicin i.v. solution were the most frequently prescribed imported drugs. Macrogol powder, lisinopril oral suspension and potassium chloride i.v. solution were the most frequently prescribed formula drugs. The most common drug forms in unlicensed use were oral liquid forms and i.v. SOLUTIONS Unlicensed drugs had a significantly higher rate of prescribing errors than licensed drugs (31.6 errors per 100 prescriptions [95% CI: 26.1-37.0] versus 24.3 errors per 100 prescriptions [95% CI: 22.3-26.2], p = 0.024). In particular, formula drugs carried a higher risk (36.4 errors per 100 prescriptions, p = 0.012). CONCLUSIONS Unlicensed drugs are frequently prescribed in this paediatric hospital setting in Switzerland. Around every tenth prescription is an unlicensed drug. Because unlicensed drugs showed a significantly higher rate of prescribing errors, licensed drugs are favourable in terms of medication safety and should be prescribed whenever possible. If no licensed drug is available, imported drugs should be favoured over formula drugs due to lower prescribing error rates. To increase medication safety in paediatrics in Switzerland, efforts are necessary to increase the number of suitable licensed drug formulations for paediatric patients, including developing new innovative drug formulations for children.
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Affiliation(s)
- Aylin Satir
- Department of Hospital Pharmacy, University Children's Hospital Zurich, Zurich, Switzerland
| | - Miriam Pfiffner
- Department of Hospital Pharmacy, University Children's Hospital Zurich, Zurich, Switzerland
| | - Christoph R Meier
- Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Angela Caduff Good
- Department of Hospital Pharmacy, University Children's Hospital Zurich, Zurich, Switzerland
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Jaberi E, Boussaha I, Dode X, Grenet G, Kassai B, Nguyen KA. Unlicensed/Off-Label Drug Prescriptions at Hospital Discharge in Children: An Observational Study Using Routinely Collected Health Data. Healthcare (Basel) 2024; 12:208. [PMID: 38255096 PMCID: PMC10815156 DOI: 10.3390/healthcare12020208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/23/2023] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Unlicensed and off-label (UL/OL) prescriptions have been associated with an increased risk of drug-related problems. Data of their prevalence at hospital discharge remain insufficient. We aimed to describe the prevalence of UL/OL drugs in outpatient prescriptions at discharge in children. METHODS We conducted a retrospective study using the routinely collected health data of children at discharge from 2014 to 2016. The primary reference source for determining licensed labelling was the summaries of product characteristics (SPCs) in a French industry-independent formulary named Thériaque. We described the characteristics of UL/OL prescriptions at discharge and looked for predictors of UL/OL prescriptions. RESULTS We included 2536 prescriptions of 479 children. Licensed, OL, and UL prescriptions accounted for 58.6% (95% CI: 56.7-60.5), 39.2% (95% CI: 37.3-41.1), and 2.3% (95% CI: 1.7-2.9), respectively. A total of 323 (74%) children received at least one UL/OL drug. Among the licensed drugs, bronchodilators (8.8%) and analgesics (8.6%), and among the OL drugs, antibiotics (2.8%), were the most prescribed. The younger age of the children and higher number of drugs they received increased the probability of UL/OL prescriptions (unadjusted p-value of ≤0.05). CONCLUSION The prevalence of UL/OL prescriptions is about 40% at discharge from a pediatric university hospital in France.
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Affiliation(s)
- Elham Jaberi
- UMR CNRS 5558, Laboratoire de Biométrie et Biologie Humaine, Équipe Évaluation et Modélisation des Effets Thérapeutiques, rue Guillaume-Paradin, BP8071, CEDEX 08, F-69376 Lyon, France
| | - Inesse Boussaha
- Department of Clinical Epidemiology, Hospices Civils de Lyon, CIC 1407 de Lyon, Inserm, CHU-Lyon, F-69677 Bron, France
| | - Xavier Dode
- Pharmacy Department, Hospices Civils de Lyon University Hospital, F-69002 Lyon, France
| | - Guillaume Grenet
- UMR CNRS 5558, Laboratoire de Biométrie et Biologie Humaine, Équipe Évaluation et Modélisation des Effets Thérapeutiques, rue Guillaume-Paradin, BP8071, CEDEX 08, F-69376 Lyon, France
- Department of Pharmacotoxicology, Hospices Civils de Lyon, CHU-Lyon, F-69677 Bron, France
| | - Behrouz Kassai
- UMR CNRS 5558, Laboratoire de Biométrie et Biologie Humaine, Équipe Évaluation et Modélisation des Effets Thérapeutiques, rue Guillaume-Paradin, BP8071, CEDEX 08, F-69376 Lyon, France
| | - Kim An Nguyen
- UMR CNRS 5558, Laboratoire de Biométrie et Biologie Humaine, Équipe Évaluation et Modélisation des Effets Thérapeutiques, rue Guillaume-Paradin, BP8071, CEDEX 08, F-69376 Lyon, France
- Department of Pharmacotoxicology, Hospices Civils de Lyon, CHU-Lyon, F-69677 Bron, France
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Petkova V, Georgieva D, Dimitrov M, Nikolova I. Off-Label Prescribing in Pediatric Population-Literature Review for 2012-2022. Pharmaceutics 2023; 15:2652. [PMID: 38139994 PMCID: PMC10747118 DOI: 10.3390/pharmaceutics15122652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/05/2023] [Accepted: 11/17/2023] [Indexed: 12/24/2023] Open
Abstract
Off-label prescribing is widespread among pediatricians, and it is unlikely that this trend will soon be bound by a uniform legal framework. This is necessitated by the fact that there are four variables: the patient's health condition, the physician's experience and knowledge, the legislative measures (laws, directives, guidelines, and recommendations), and finally, the pharmaceutical industry. There is considerable concern worldwide about the use of off-label medicines in children. We may call it an enormous global problem that is much talked about and written about; however, we should not forget that the goal around which everyone should unite is the patient's life. For healthcare providers, the most important thing will always be the health and preservation of the patient's life, particularly when it comes to children with life-threatening conditions in neonatal and pediatric intensive care units (NICU and PICU). The study aimed to examine the prevalence of off-label drug use in pediatrics. Literature research was conducted, and we included studies from 2012 to 2022 that evaluated off-label drug prevalence in various pediatric patient populations.
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Affiliation(s)
- Valentina Petkova
- Department of Social Pharmacy, Faculty of Pharmacy, Medical University of Sofia, 1000 Sofia, Bulgaria
| | - Dilyana Georgieva
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Medical University of Sofia, 1000 Sofia, Bulgaria; (D.G.); (M.D.)
| | - Milen Dimitrov
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Medical University of Sofia, 1000 Sofia, Bulgaria; (D.G.); (M.D.)
| | - Irina Nikolova
- Department of Pharmacology, Pharmacotherapy and Toxicology, Faculty of Pharmacy, Medical University of Sofia, 1000 Sofia, Bulgaria;
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Mathevula H, Schellack N, Orubu S, Godman B, Matlala M. Off-Label and Unlicenced Medicine Use among Hospitalised Children in South Africa: Practice and Policy Implications. PHARMACY 2023; 11:174. [PMID: 37987384 PMCID: PMC10661306 DOI: 10.3390/pharmacy11060174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/25/2023] [Accepted: 11/05/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Information regarding off-label and unlicensed medicine use among South African children is limited. This is a concern as the prescribing of off-label and unlicensed medicines can lead to issues of effectiveness and safety as well as raise liability issues in the event of adverse events. This potentially exposes physicians to legal penalties. Consequently, we sought to determine the prevalence of off-label and unlicensed medicine use among paediatric patients in South Africa to provide future direction. METHODS This study retrospectively examined the use of medicine in a point-prevalence survey study (PPS) involving paediatric patients aged (0-2 years) admitted to selected public hospitals in Gauteng Province, South Africa. Data were collected per hospital over two days between February 2022 and July 2022. Demographics, duration of treatment, diagnosis, and medicines prescribed were collected from patient medical records using a mobile application. Prescribed medicines were reviewed against the medicine formularies and other databases to assess their appropriateness. RESULTS From three academic hospitals, 184 patient records were reviewed. A total of 592 medicines were dispensed, of which 379 (64.0%) were licensed and 213 (36.0%) were used off-label/unlicensed for paediatric patients 0-2 years of age. The most prevalent off-label and unlicensed medicines were multivitamins (n = 32, 15.0%) and ampicillin injections (n = 15, 7.0%). CONCLUSION The frequency of unlicensed and off-label medicine prescribing shown in this study is consistent with the literature and can be considered high. This practice can pose a risk because it adversely affects patients if not properly regulated. Attention is needed to ensure future high-quality, safe, and effective use of medicines.
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Affiliation(s)
- Hlayiseka Mathevula
- School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria 0204, South Africa; (B.G.); (M.M.)
| | - Natalie Schellack
- Department of Pharmacology, University of Pretoria, Pretoria 0084, South Africa;
| | - Samuel Orubu
- Pharmacy Department, Niger Delta University, Yenagoa P.O. BOX 72, Nigeria;
- Global Strategy Lab, York University, Toronto, ON 4700, Canada
| | - Brian Godman
- School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria 0204, South Africa; (B.G.); (M.M.)
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Science (SIPBS), University of Strathclyde, Glasgow G4 0RE, UK
| | - Moliehi Matlala
- School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Pretoria 0204, South Africa; (B.G.); (M.M.)
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Lee S, Yang MH, Kim JS, Cho Y, Choi N, Cho EJ, Park JD, Choi YH, Choi KH. Evaluation of off-label medication use and drug safety in a pediatric intensive care unit. Saudi Pharm J 2023; 31:101704. [PMID: 37520675 PMCID: PMC10382926 DOI: 10.1016/j.jsps.2023.101704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/11/2023] [Indexed: 08/01/2023] Open
Abstract
Safety and efficacy are essential in the process of disease treatment. However, off-label medication use is inevitable because various medications do not contain regulatory labels for pediatric use. We aimed to examine off-label medication use and analyze the risk factors correlated with adverse drug reactions (ADRs). This study was performed retrospectively using electronic medical data from a pediatric intensive care unit (PICU) of a tertiary hospital in Korea from July 2019 to June 2020. A total 6,183 prescribed medications from 502 PICU patients were examined in the present study. A total of 80% were infants or children, and 96.0% of them were treated with off-label medications. It was discovered that 4,778 off-label cases (77.2%) of the top 100 drugs had prescriptions with dosage (67.8%). Drugs prescribed to patients admitted to the cardiothoracic department (odds ratio [OR], 3.248; p = 0.019), total number of medications (OR, 1.116; p = 0.001), and length of PICU stay of ≥ 7 days (OR, 4.981; p = 0.008) were significantly associated with ADRs. ADRs were noted to be more severe in off-label use (p = 0.0426). For appropriate medication use, evidence regarding the safety of off-label medications is required and ultimately reflected in the official regulation.
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Affiliation(s)
- Soojin Lee
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea
- College of Pharmacy, Seoul National University, Seoul 03080, Korea
| | - Mi Hee Yang
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea
| | - Jung Sun Kim
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul 03760, Korea
| | - Yoonsuk Cho
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea
| | - Nigh Choi
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea
| | - Eun Jung Cho
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Yu Hyeon Choi
- Department of Pediatrics, Seoul Medical Center, Seoul 02054, Korea
| | - Kyung Hee Choi
- College of Pharmacy, Gachon University, Incheon 21936, Korea
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Chachlioutaki K, Gioumouxouzis C, Karavasili C, Fatouros DG. Small patients, big challenges: navigating pediatric drug manipulations to prevent medication errors - a comprehensive review. Expert Opin Drug Deliv 2023; 20:1489-1509. [PMID: 37857515 DOI: 10.1080/17425247.2023.2273838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/18/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Medication errors during drug manipulations in pediatric care pose significant challenges to patient safety and optimal medication management. Epidemiological studies have revealed a high prevalenceof medication errors throughout the medication process. Due to the lack of age-appropriate dosage forms, medication manipulation is common in pediatric drug administration. The consequences of these manipulations on drug efficacy and safety could be devastating, highlighting the need for evidence-based guidelines and standardized compounding practices. AREAS COVERED This review focuses on examining medication errors in pediatric care and delving into the manipulation of medicinal products. EXPERT OPINION The observed prevalence of medication errors and manipulations underscores the importance of addressing these issues to enhance patient safety and improve medication outcomes in pediatric care. Overall, the development of age-appropriate formulations and the dissemination of comprehensive clinical guidelines are essential steps toward improving medication safety and minimizing manipulations in pediatric healthcare settings.
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Affiliation(s)
- Konstantina Chachlioutaki
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Center for Interdisciplinary Research and Innovation (CIRI-AUTH), Thessaloniki, Greece
| | - Christos Gioumouxouzis
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christina Karavasili
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Fatouros
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Center for Interdisciplinary Research and Innovation (CIRI-AUTH), Thessaloniki, Greece
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Schaffer AL, Bruno C, Buckley NA, Cairns R, Litchfield M, Paget S, Zoega H, Nassar N, Pearson S. Prescribed medicine use and extent of off-label use according to age in a nationwide sample of Australian children. Paediatr Perinat Epidemiol 2022; 36:726-737. [PMID: 35172017 PMCID: PMC9540111 DOI: 10.1111/ppe.12870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/16/2022] [Accepted: 01/25/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND Medicine prescribing for children is impacted by a lack of paediatric-specific dosing, efficacy and safety data for many medicines. OBJECTIVES To estimate the prevalence of medicine use among children and the rate of 'off-label' prescribing according to age at dispensing. METHODS We used population-wide primarily outpatient dispensing claims data for 15% of Australian children (0-17 years), 2013-2017 (n = 840,190). We estimated prescribed medicine use and 'off-label' medicine use according to the child's age (<1 year, 1-5 years, 6-11 years, 12-17 years) defined as medicines without age-appropriate dose recommendations in regulator-approved product information. Within off-label medicines, we also identified medicines with and without age-specific dose recommendations in a national prescribing guide, the Australian Medicines Handbook Children's Dosing Companion (AMH CDC). RESULTS The overall dispensing rate was 2.0 dispensings per child per year. The medicines with the highest average yearly prevalence were systemic antibiotics (435.3 per 1000 children), greatest in children 1-5 years (546.9 per 1000). Other common medicine classes were systemic corticosteroids (92.7 per 1000), respiratory medicines (91.2 per 1000), acid-suppressing medicines in children <1 year (47.2 per 1000), antidepressants in children 12-17 years (40.3 per 1000) and psychostimulants in children 6-11 years (27.0 per 1000). We identified 12.2% of dispensings as off-label based on age, but 66.3% of these had age-specific dosing recommendations in the AMH CDC. Among children <1 year, off-label dispensings were commonly acid-suppressing medicines (35.5%) and topical hydrocortisone (33.1%); in children 6-11 years, off-label prescribing of clonidine (16.0%) and risperidone (13.1%) was common. Off-label dispensings were more likely to be prescribed by a specialist (21.7%) than on-label dispensings (7.5%). CONCLUSIONS Prescribed medicine use is common in children, with off-label dispensings for medicines without paediatric-specific dosing guidelines concentrated in classes such as acid-suppressing medicines and psychotropics. Our findings highlight a need for better evidence to support best-practice prescribing.
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Affiliation(s)
- Andrea L. Schaffer
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia
| | - Claudia Bruno
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia
| | - Nicholas A. Buckley
- Biomedical Informatics and Digital HealthThe University of SydneySydneyNew South WalesAustralia,NSW Poisons Information CentreThe Children’s Hospital at WestmeadSydneyNew South WalesAustralia
| | - Rose Cairns
- NSW Poisons Information CentreThe Children’s Hospital at WestmeadSydneyNew South WalesAustralia,Faculty of PharmacyThe University of SydneySydneyNew South WalesAustralia
| | - Melisa Litchfield
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia
| | - Simon Paget
- The Children’s Hospital at Westmead Clinical SchoolThe University of SydneySydneyNew South WalesAustralia
| | - Helga Zoega
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia,Centre of Public Health SciencesFaculty of MedicineUniversity of IcelandReykjavikIceland
| | - Natasha Nassar
- The Children’s Hospital at Westmead Clinical SchoolThe University of SydneySydneyNew South WalesAustralia,Menzies Centre for Health PolicyThe University of SydneySydneyNew South WalesAustralia
| | - Sallie‐Anne Pearson
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia,Menzies Centre for Health PolicyThe University of SydneySydneyNew South WalesAustralia
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Gaps in Accessibility of Pediatric Formulations: A Cross-Sectional Observational Study of a Teaching Hospital in Northern Thailand. CHILDREN 2022; 9:children9030301. [PMID: 35327673 PMCID: PMC8947278 DOI: 10.3390/children9030301] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/13/2022] [Accepted: 02/18/2022] [Indexed: 11/17/2022]
Abstract
The lack of appropriate medicines for children has a significant impact on health care practices in various countries around the world, including Thailand. The unavailability of pediatric medicines in hospital formularies causes issues regarding off-label use and extemporaneous preparation, resulting in safety and quality risks relating to the use of medicines among children. This research aimed to identify missing pediatric formulations based on the experience of healthcare professionals in a teaching hospital in northern Thailand. A cross-sectional survey was conducted to collect data on missing pediatric formulations, the reasons for their inaccessibility, their off-label uses, their reactions to the situation, and suggestions to improve access to these identified medications. The survey was distributed to all physicians, nurses, and pharmacists involved in prescribing, preparing, dispensing, and administering pediatric medicines. A total of 218 subjects responded to the survey. Omeprazole, sildenafil, and spironolactone suspension were most often identified as missing formulations for children by physicians and pharmacists. They are unavailable on the Thai market or in any hospital formulary. For nurses, sodium bicarbonate, potassium chloride, and chloral hydrate were the most problematic formulations in terms of preparation, acceptability, and administration. These medicines were difficult to swallow because of their taste or texture.
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Johannesson J, Hansson P, Bergström CAS, Paulsson M. Manipulations and age-appropriateness of oral medications in pediatric oncology patients in Sweden: Need for personalized dosage forms. Biomed Pharmacother 2022; 146:112576. [PMID: 35062056 DOI: 10.1016/j.biopha.2021.112576] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022] Open
Abstract
Due to the lack of age-appropriate formulations for children, healthcare professionals and caregivers frequently manipulate dosage forms to facilitate oral administration and obtain the required dose. In this study, we investigated drug manipulation and age-appropriateness of oral medications for pediatric oncology patients with the aim of identifying the therapeutic needs for personalized dosage forms. An observational study at a pediatric oncology ward, combined with analysis of the age-appropriateness of the oral medications, was performed. Nurses frequently manipulated solid dosage forms to administer them via enteral feeding tubes. Of the active pharmaceutical ingredients (APIs) assessed for age-appropriateness, 74% (29 of 39) were identified to need personalization, either because of lack of child-friendly dosage form, suitable dosage strength, or both. Most APIs, due to limited solubility, were sensitive to formulation changes, such as drug manipulation. This study demonstrates problems and therapeutic needs regarding oral dosage forms in treatment of children with cancer. Expertise in formulation design, new manufacturing technologies, and patient-centered information are needed to address age-appropriate formulations for children.
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Affiliation(s)
- Jenny Johannesson
- Department of Pharmacy, Uppsala University, Uppsala Biomedical Center, P.O Box 580, SE-751 23 Uppsala, Sweden
| | - Paula Hansson
- Department of Women's and Children's Health, Uppsala University, Akademiska sjukhuset, SE-751 85 Uppsala, Sweden
| | - Christel A S Bergström
- Department of Pharmacy, Uppsala University, Uppsala Biomedical Center, P.O Box 580, SE-751 23 Uppsala, Sweden
| | - Mattias Paulsson
- Department of Women's and Children's Health, Uppsala University, Akademiska sjukhuset, SE-751 85 Uppsala, Sweden.
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Kader R, Liminga G, Ljungman G, Paulsson M. Manipulations of Oral Medications in Paediatric Neurology and Oncology Care at a Swedish University Hospital: Health Professionals' Attitudes and Sources of Information. Pharmaceutics 2021; 13:pharmaceutics13101676. [PMID: 34683968 PMCID: PMC8538608 DOI: 10.3390/pharmaceutics13101676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/11/2021] [Indexed: 02/01/2023] Open
Abstract
Oral administration of medications to children requires age-appropriate dosage forms and strengths. In this study, we: (i) assessed the extent of oral dosage form manipulations, (ii) documented how it is carried out, and (iii) examined the attitudes and sources of information regarding the handling from healthcare professionals. Prospective reviews of electronic records, ward observations, and clinician surveys were performed at a paediatric neurology ward and a paediatric oncology ward in Sweden during April to May of 2018. Approximately 15% of oral medications were manipulated for the studied patient group (median age 12.9 years in oncology, 5.8 years in neurology) with approximately 30% of the patients having an enteral feeding tube. Manipulations were performed both to obtain an appropriate dose from, for example, a fraction of the original tablet or to obtain a powder that could be used to prepare a slurry for administration through enteral feeding tubes. Risks identified were related to patient safety such as cross contamination, suboptimal absorption/pharmacokinetics and inaccurate dose. When examining the working environment of nurses, we observed safe handling of hazardous substances but the nurses occasionally experienced stress and a fear of making mistakes due to absence of information. Paediatricians experienced a lack of time to search for proper information on manipulations. As a step towards improving safety in paediatric medication, we suggest the introduction of clinical pharmacists into the team and further evaluating the possibilities of using more ready-to-administer medications with necessary product information and pharmacovigilance support.
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Affiliation(s)
- Rania Kader
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
- Division of Pharmacokinetics and Drug Therapy, Department of Pharmaceutical Biosciences, Uppsala University, 751 85 Uppsala, Sweden
| | - Gunnar Liminga
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
| | - Gustaf Ljungman
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
| | - Mattias Paulsson
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (R.K.); (G.L.); (G.L.)
- Correspondence: ; Tel.: +46-18-611-3733
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Extent, reasons and consequences of off-labeled and unlicensed drug prescription in hospitalized children: a narrative review. World J Pediatr 2021; 17:341-354. [PMID: 34080130 DOI: 10.1007/s12519-021-00430-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/07/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Off-label and unlicensed prescriptions pose a severe safety concern among the pediatric population. We aimed to summarize the up-to-date evidence on the extent, reasons, and consequences of off-label and unlicensed drugs in hospitalized pediatric patients. METHODS We systematically searched PubMed, EMBASE, SCOPUS, Web of Science and Google Scholar between 1990 and 2020 in which the last search was conducted on 12 February 2021. We included studies with the following inclusion criteria: (1) observational studies in design; (2) target population was hospitalized pediatric patients whether admitted in the intensive care unit or in the general ward; (3) study reporting the prevalence of off-label, unlicensed prescriptions or both; and (4) published in English. RESULTS A total of 47 studies were eligible for inclusion. The proportion of off-label and unlicensed prescriptions ranged from 7.4% to 99.5% and 0.1% to 74.4%, respectively. The most frequent category of off-label prescriptions was prescription outside the age range, with the most commonly reported reason for off-label prescriptions being the lack of information specifically for pediatrics on the drug information leaflets. The consequences of off-label and unlicensed prescriptions ranged from minor and bearable skin reactions to debilitating renal failure, risking deaths. CONCLUSIONS Off-label and unlicensed prescriptions are extensive and require progressively meditative interventions. However, the pediatric population is currently a "therapeutic orphan". Unless adequate pediatric clinical trials and licensed drugs become available, off-label and unlicensed drug prescription should not entirely be banned but rather promoted in an organized manner.
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13
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Kearns GL, van den Anker JN. Adolescents and Drug Development: Commentary on a Dawning Paradigm Shift. J Clin Pharmacol 2021; 61:740-743. [PMID: 33797778 DOI: 10.1002/jcph.1862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/24/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Gregory L Kearns
- Departments of Medical Education and Pediatrics, Texas Christian University and UNTHSC School of Medicine, Fort Worth, Texas, USA
| | - John N van den Anker
- Departments of Pediatrics, Pharmacology and Physiology and Genomics & Precision Medicine, George Washington University School of Medicine and Health Sciences and Children's National Hospital, Washington, District of Columbia, USA.,University Children's Hospital, University of Basel, Basel, Switzerland.,Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
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14
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Brustugun J, Notaker N, Paetz LH, Tho I, Bjerknes K. Adjusting the dose in paediatric care: dispersing four different aspirin tablets and taking a proportion. Eur J Hosp Pharm 2021; 28:76-82. [PMID: 33608434 PMCID: PMC7907695 DOI: 10.1136/ejhpharm-2019-001903] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/06/2019] [Accepted: 05/08/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES When caring for children in a hospital setting, tablets are often manipulated at the ward to obtain the right dose. One example is manipulation of tablets containing the slightly water-soluble substance aspirin, used in paediatric care as an antiplatelet agent. The evidence base, however, for choosing certain tablet formulations and manipulation methods over others for extraction of proportions is lacking. The aim of this study was to investigate the effect of tablet formulation and manipulation technique on the dose accuracy and precision attained when dispersing different commercially available aspirin tablets and extracting a small proportion suitable for children. METHODS The manipulation methods investigated simulated those observed in the paediatric clinic. Four tablet formulations-one chewable, one conventional and two dispersible-were dispersed in 10 mL water in a medicine measure. On (1) passive dispersion, (2) mixing by stirring with the syringe, or (3) stirring and pumping the dispersion in and out of the syringe, respectively, proportions (1 mL or 2 mL) were extracted and the doses recovered were determined using a validated UHPLC (ultra high-pressure liquid chromatography) method. RESULTS Fractions from the four different dispersed aspirin tablet formulations varied from 99% to 3% of that intended with the lowest degree of mixing, and from 96% to 34% of that intended with the highest degree of mixing. Only the dispersible tablets gave average doses within 20% of the intended dose. CONCLUSIONS Fraction extraction from dispersed aspirin tablets only gave doses within 20% of intended for the dispersible tablets, and then only for some of the manipulation methods: 'passive dispersion' for the 75 mg dispersible tablet and 'stirring and pumping' for the 300 mg dispersible tablet. The tablets not intended for dispersion gave unsatisfactory results, outside 20%, regardless of manipulation method. The findings underline the importance of considering both tablet formulation and dose extraction technique when manipulations are required.
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Affiliation(s)
- Jørgen Brustugun
- Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South Eastern Norway, Oslo, Norway
| | - Nikolai Notaker
- Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Lasse Holtan Paetz
- Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Ingunn Tho
- School of Pharmacy, University of Oslo, Oslo, Norway
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Brustugun J, Notaker N, Paetz LH, Tho I, Bjerknes K. Adjusting the dose in paediatric care by dispersing fragments of four different aspirin tablets. Acta Paediatr 2020; 109:2394-2401. [PMID: 32034802 PMCID: PMC7687227 DOI: 10.1111/apa.15216] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 11/28/2022]
Abstract
AIM Tablets can be manipulated in several ways to obtain a fraction as the dose-a practice frequently seen in paediatric care due to lack of suitable formulations. Splitting tablets prior to fragment dispersion in a small volume of liquid is one such method. The objective of this study was to investigate the accuracy and precision of this method. METHODS Four different types of aspirin tablets (two dispersible, one conventional and one chewing) were split with a tablet splitter into half and quarter fragments. The fragments were dispersed in a medicine measure or an oral syringe. The amount recovered was determined by UHPLC analysis. RESULTS The largest quarter fragments ranged from 26.7% to 31.5% of the full tablet weight. Dispersing the fragment in an oral syringe, the amount recovered was greater than 90.8% of the fragment manipulated for all four tablet types, when rinsing was performed. Dispersing the fragment in a medicine measure, the amounts recovered spanned from 32.9% for the conventional tablets to 98.7% for one of the dispersible tablets. CONCLUSION Dispersion of half or quarter tablets directly in an oral syringe, but not a medicine measure, could give satisfactory recovery from fragments of all the investigated aspirin tablets.
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Affiliation(s)
| | - Nikolai Notaker
- Department of Pharmacy Faculty of Mathematics and Natural Sciences University of Oslo Oslo Norway
| | - Lasse Holtan Paetz
- Department of Pharmacy Faculty of Mathematics and Natural Sciences University of Oslo Oslo Norway
| | - Ingunn Tho
- Department of Pharmacy Faculty of Mathematics and Natural Sciences University of Oslo Oslo Norway
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16
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Drug Utilisation and Off-Label Use on a German Neonatal Intensive Care Unit: A Retrospective Cohort Study and 10-Year Comparison. PHARMACY 2020; 8:pharmacy8030173. [PMID: 32957455 PMCID: PMC7559028 DOI: 10.3390/pharmacy8030173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/17/2022] Open
Abstract
Pharmacotherapy of neonates is complex and marked to a large extent of off-label use. The implementation of the Paediatric Regulation (2007) gave hope for a change in the safety and efficacy for drugs used in neonatal intensive care units (NICU). This study investigates drug utilisation patterns and off-label use in a German neonatal intensive care unit (NICU) in 2014. A 12-months retrospective, observational cohort study was performed at the NICU of the University Children's Hospital Erlangen, Germany. Licensing status was determined using the Summary of Product Characteristics (SmPC). Results are compared with a similar study conducted 10 years earlier. The study included 204 patients (57.8% male) (2004: 183) and 2274 drug prescriptions were recorded (2004: 1978). The drugs that were mostly prescribed were drugs for the nervous system (2004: 22.6%; 2014: 26.9%) and anti-infectives for systemic use (2004: 26.0%; 2014: 24.9%);34.3% (2004) and 39.2% (2014) of all prescriptions were off-label;62.7% of all patients received at least one off-label or unlicensed drug (2004: 70%). For 13 drugs, the licensing status changed either from off-label to label (n = 9) or vice versa (n = 4). Overall, there was no significant change neither in terms of the drugs used nor regarding their licensing status. Further studies are needed to validate these findings in a European context.
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Brustugun J, Birkedal Aas E, Tho I, Bjerknes K. Comparing Two Methods of Tablet Manipulation to Adjust the Warfarin Dose in Paediatric Care. Pharmaceutics 2020; 12:E375. [PMID: 32325777 PMCID: PMC7238213 DOI: 10.3390/pharmaceutics12040375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 11/24/2022] Open
Abstract
Tablets containing prescribed doses are not always available, and this is of particular importance in paediatric care where suitable age-appropriate formulations are generally lacking. To obtain a child-adjusted dose, tablets are manipulated in several ways; e.g., they may be dispersed in water before a fraction is extracted, or they may be split before the resulting fragment is dispersed. In this study, the accuracy attained through these manipulation methods was investigated for two generic tablets containing the anticoagulant warfarin. Tablets were dispersed in water (10 mL) before a fraction (10%) was withdrawn, alternatively tablets were split in half or quarter fragments before the fragments were dispersed in water. To investigate the contribution of variability from the different steps in the manipulation processes, the amount of warfarin recovered from the various dispersions was determined, as was the accuracy of the splitting. A validated UHPLC-method was used for quantitative determination of warfarin. Splitting of the tablets could result in deviation >30% from the ideal, theoretical weight. The amount of drug substance extracted as a fraction from the dispersed tablets deviated no more than 10% from the intended amount. To obtain the most accurate child-adjusted fraction dose of warfarin, the tablets investigated in this study should be dispersed and the desired proportion extracted. Practices that involve splitting tablets are likely to increase the variation, and should be avoided.
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Affiliation(s)
- Jørgen Brustugun
- Hospital Pharmacy Enterprise, South Eastern Norway, 0050 Oslo, Norway; (E.B.A); (K.B.)
| | - Elisabeth Birkedal Aas
- Hospital Pharmacy Enterprise, South Eastern Norway, 0050 Oslo, Norway; (E.B.A); (K.B.)
- Department of Pharmacy, University of Oslo, 0316 Oslo, Norway
| | - Ingunn Tho
- Department of Pharmacy, University of Oslo, 0316 Oslo, Norway
| | - Kathrin Bjerknes
- Hospital Pharmacy Enterprise, South Eastern Norway, 0050 Oslo, Norway; (E.B.A); (K.B.)
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18
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Dittrich ATM, Draaisma JMT, van Puijenbroek EP, Loo DMWMT. Analysis of Reporting Adverse Drug Reactions in Paediatric Patients in a University Hospital in the Netherlands. Paediatr Drugs 2020; 22:425-432. [PMID: 32557243 PMCID: PMC7383033 DOI: 10.1007/s40272-020-00405-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS The risk to develop adverse drug reactions (ADRs) is high for paediatric patients. This is, amongst other reasons, due to the inevitable use of off-label and unlicensed medicines. Moreover, there is limited knowledge on ADRs in children. Thus, adequate recognition may be challenging. The lack of dedicated studies and the voluntary nature of pharmacovigilance systems used to gain insight into the characteristics of ADRs contribute to this problem. The goal of this study is to identify whether ADRs in paediatric patients are adequately documented by the medical team and whether they are subsequently reported to the national pharmacovigilance system. METHODS All patients admitted to the paediatric medium care of the Radboudumc Amalia Children's hospital during 1 month, and using one or more drugs, were included. Two researchers analysed retrospectively and independently the number of possible ADRs in the medical records. The ADRs were listed per paediatric subspecialty, to evaluate any differences in documentation and reporting of the ADRs. Subsequently, the causality, severity, and seriousness of the ADRs were assessed. The ADRs were categorised by system organ class and drug class. The national pharmacovigilance centre was consulted to check if there were any reports coming from our hospital and to collect the total number of reports. RESULTS The medical records of 301 patients were analysed, 81 patients were suffering from one or more ADRs. In total 132 suspected ADRs were found, divided among 19 different paediatric subspecialties. Numbers were too small to investigate the differences in ADR documentation. Of these found ADRs, 55% were not explicitly noted as such in the medical records by the treating physician. None of the ADRs were reported to the national pharmacovigilance centre. Most ADRs scored 'possible' in the causality assessment, were mild or moderate, and a small number were serious. The ADRs occurred in 25 different organ systems. In total 25 different drug classes were involved. CONCLUSIONS The results of the present study show that a large number of ADRs are not registered in the medical records and are not reported to the national pharmacovigilance system. Furthermore, it is shown that the number of ADRs occurring at our centre is much higher than the number reported to the national pharmacovigilance centre. Only an average of 513 ADRs in paediatric patients are reported per year nationwide, suggesting that there is extensive underreporting.
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Affiliation(s)
- Anne T. M. Dittrich
- grid.461578.9Department of Paediatrics, Radboud University Medical Centre, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Huispost 804, Postbus 9101, 6500 HB Nijmegen, the Netherlands ,grid.5590.90000000122931605Department of Pharmacology and Toxicology, Radboud University, Nijmegen, the Netherlands
| | - Jos M. T. Draaisma
- grid.461578.9Department of Paediatrics, Radboud University Medical Centre, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Huispost 804, Postbus 9101, 6500 HB Nijmegen, the Netherlands
| | - Eugène P. van Puijenbroek
- grid.419940.10000 0004 0631 9549Netherlands Pharmacovigilance Centre Lareb, ’s-Hertogenbosch, the Netherlands ,grid.4830.f0000 0004 0407 1981Unit of Pharmacotherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - D. Maroeska W. M. te Loo
- grid.5590.90000000122931605Department of Pharmacology and Toxicology, Radboud University, Nijmegen, the Netherlands ,grid.461578.9Department of Paediatric Haematology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Amalia Children’s Hospital, Nijmegen, the Netherlands
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Mukattash TL, Jarab AS, Daradkeh A, Abufarha R, AbuHammad SH, AlRabadi NN. Parental views and attitudes towards use of unlicensed and off‐label medicines in children and paediatric clinical trials: an online cross‐sectional study in the Arab world. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2019. [DOI: 10.1111/jphs.12293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Tareq L. Mukattash
- Department of Clinical Pharmacy Faculty of Pharmacy Jordan University of Science and Technology Irbid Jordan
| | - Anan S. Jarab
- Department of Clinical Pharmacy Faculty of Pharmacy Jordan University of Science and Technology Irbid Jordan
| | - Aseel Daradkeh
- Department of Clinical Pharmacy Faculty of Pharmacy Jordan University of Science and Technology Irbid Jordan
| | - Rana Abufarha
- Department of Therapeutics and Clinical Pharmacy Faculty of Pharmacy Private Applied Science University Amman Jordan
| | - Sawsan H. AbuHammad
- Department of Maternal and Child Nursing Faculty of Nursing Jordan University of Science and Technology Irbid Jordan
| | - Nasr N. AlRabadi
- Department of Pharmacology Faculty of Medicine Jordan University of Science and Technology Irbid Jordan
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20
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Kouti L, Aletayeb M, Aletayeb SMH, Hardani AK, Eslami K. Pattern and extent of off-label and unlicensed drug use in neonatal intensive care units in Iran. BMC Pediatr 2019; 19:3. [PMID: 30609923 PMCID: PMC6320573 DOI: 10.1186/s12887-018-1370-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 12/13/2018] [Indexed: 12/15/2022] Open
Abstract
Background Many newborns may need to be hospitalized and receive drugs during the first days of their lives. These drugs are fundamentally prescribed as off-label and unlicensed. This study aimed to investigate the amount of these kinds of drugs administered in the Neonatal Intensive Care Units (NICUs) of Abuzar and Imam Khomeini Teaching Hospitals in Ahvaz, Iran. Methods This was a 3-month descriptive, cross-sectional study with retrospective nature in which 193 hospitalized newborns were studied. Demographic data were extracted from the patients’ files. The drugs were classified as off-label, unlicensed or licensed according to the Pediatric & Neonatal Dosage Handbook (Lexicomp®, 22nd Edition). Results In total, 1049 prescriptions were registered for the 193 hospitalized newborns (term and preterm). For each newborn, the mean numbers of prescriptions and drugs received were 5.4 and 4.5, respectively. The mean numbers of prescriptions and drugs were greater for preterm newborns. Of the total 1049 prescriptions, 38.1% were off-label and 1.9% were unlicensed. Of the 193 newborns, 85% received at least one off-label or unlicensed prescription. Off-label prescriptions were mostly related to dose (44.8%) and dosing interval (36.5%). Most off-label drugs were antibiotics (mainly Gentamicin). Albuterol was used off-label in 100% of the cases. Conclusions The results of the present study show that the prescription of off-label and unlicensed drugs in NICUs is as high in Iran as in other countries. This suggests that it is necessary to provide information to neonatologists to decrease the prescription of off-label and unlicensed drugs.
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Affiliation(s)
- Leila Kouti
- Department of Clinical Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Aletayeb
- Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Seyyed Mohammad Hassan Aletayeb
- Department of Pediatrics, Faculty of Medicine, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Amir Kamal Hardani
- Department of Pediatrics, Faculty of Medicine, Abuzar Children's Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Kaveh Eslami
- Department of Clinical Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Two decades of off-label prescribing in children: a literature review. World J Pediatr 2018; 14:528-540. [PMID: 30218415 DOI: 10.1007/s12519-018-0186-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 08/31/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND In the past two decades, many legislative and regulatory initiatives were taken globally to improve drug use in children. However, children are still found to be prescribed with off-label drugs. This study was conducted to provide an overview of the worldwide trend in off-label prescribing in children from the year 1996 to 2016. DATA SOURCES The articles published in PubMed, MEDLINE and Google Scholar were searched using text words: off-label, unlicensed, paediatric and children. Additional articles were identified by reviewing the bibliography of the retrieved articles. Full-text articles published in English which reported on the prevalence of off-label prescribing in children between January 1996 and December 2016 were included. RESULTS A total of 101 studies met the inclusion criteria. Off-label prescribing definition included four main categories: age, indication, dose and route of administration. The three most common reference sources used in the studies were summary of product characteristics, national formularies and package inserts. Overall, the off-label prescribing rates in children ranged from 1.2 to 99.7%. The most common category of off-label prescribing in children was dose and age. CONCLUSIONS This review highlighted that off-label prescribing in children was found to be highly prevalent throughout the past two decades, persistently in the neonatal intensive care units. This suggests that besides legislative and regulatory initiatives, behavioural, knowledge aspects and efforts to integrate evidence into practice related to off-label prescribing also need to be evaluated and consolidated as part of the concerted efforts to narrow the gaps in prescribing for children.
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Allen HC, Garbe MC, Lees J, Aziz N, Chaaban H, Miller JL, Johnson P, DeLeon S. Off-Label Medication use in Children, More Common than We Think: A Systematic Review of the Literature. THE JOURNAL OF THE OKLAHOMA STATE MEDICAL ASSOCIATION 2018; 111:776-783. [PMID: 31379392 PMCID: PMC6677268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CONTENT Clinician prescribing of off-label medications is common due to a lack of pediatric-specific data regarding the dosing, efficacy and safety of medications regularly prescribed to children. OBJECTIVE This systematic review summarizes the published incidence of off-label medication use in children from the past 10 years. We also performed a retrospective chart review to determine the incidence of off-label prescriptions for children seen in the OU Physicians clinics. DATA SOURCES We conducted a literature search of PubMed and OVID Medline from 2007 to 2017. Search terms included off-label use of medications and all child. For the local review, the outpatient electronic medical record (EMR) was queried. STUDY SELECTION Studies were eligible for inclusion if the study included children < 18 years of age, defined off-label use in the paper, and included the incidence of off-label drug use. DATA EXTRACTION Each review author extracted the study data from their assigned studies. For the retrospective chart review, the EMR was queried for patients <21 years of age who had a clinic visit and received a new prescription during 2017. RESULTS We identified 31 studies, with off-label prescription rates from 3.2 % to 95%. The local retrospective chart review included 1,323 prescriptions; 504 were off-label (38.1%) and 819 were approved. The frequency of off-label prescriptions does not differ significantly between the meta-analysis from the systematic review and the local retrospective chart review (30.9% vs 38.1%). CONCLUSIONS The use of off-label medications in children remains a common practice for pediatric providers.
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Affiliation(s)
- H. Christine Allen
- Department of Pediatrics: Section of Pediatric Critical
Care, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - M. Connor Garbe
- Department of Pediatrics: Section of General and Community
Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Julie Lees
- Department of Pediatrics: Section of General and Community
Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Naila Aziz
- Department of Pediatrics: Section of General and Community
Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Hala Chaaban
- Department of Pediatrics: Section of Neonatology,
University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Jamie L. Miller
- University of Oklahoma College of Pharmacy, Department of
Pharmacy: Clinical and Administrative Science, Oklahoma City, USA
| | - Peter Johnson
- University of Oklahoma College of Pharmacy, Department of
Pharmacy: Clinical and Administrative Science, Oklahoma City, USA
| | - Stephanie DeLeon
- Department of Pediatrics: Section of General and Community
Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK
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Lee JH, Byon HJ, Choi S, Jang YE, Kim EH, Kim JT, Kim HS. Safety and Efficacy of Off-label and Unlicensed Medicines in Children. J Korean Med Sci 2018; 33:e227. [PMID: 30190655 PMCID: PMC6125315 DOI: 10.3346/jkms.2018.33.e227] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/14/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim of this study was to explore the use of off-label/unlicensed drugs to confirm the safety and efficacy of their prescription in children in Korea. METHODS In this retrospective study, we analyzed data of patients who received any of the 32 drugs between January-December 2014 in tertiary hospitals in Korea, including demographics, diagnoses, reasons for the medication, administration route, and details of adverse drug reactions. Additionally, the mortality in the cohort was assessed. The primary outcomes were efficacy and safety, including mortality, of these drugs in pediatric patients. The secondary outcomes were the current statuses of the use of off-label/unlicensed drugs in two centers. RESULTS Totally, 5,130 prescriptions were found in 2,779 patients. Age (73.5%) and indication (11.7%) were the most frequent reasons for prescriptions being off-labeled/unlicensed. Approximately 88% of the prescriptions were effective, and 19% of the patients developed adverse drug reactions. The number of prescriptions was significantly higher in children with adverse drug reactions than it was in those without (2.8 vs. 1.5; P < 0.001). The number of prescribed off-label/unlicensed medicines and age at prescription were independently associated with adverse drug events (odds ratio, 1.55 and 1.1; P < 0.001 and 0.034, respectively). CONCLUSION Children are still prescribed medicines that are not authorized in terms of age, weight, indications, or routes of administration. Therefore, many old products require re-assessment of authorization. More prospective clinical studies should be performed to confirm the efficacy and safety of drugs in the pediatric population.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo-Jin Byon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seungeun Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Moulis F, Durrieu G, Lapeyre-Mestre M. Off-label and unlicensed drug use in children population. Therapie 2018; 73:135-149. [PMID: 29580614 DOI: 10.1016/j.therap.2018.02.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 11/15/2017] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Off-label (OL) and unlicensed (UL) drug use is widely developed in the pediatric population according to previous reviews published in the early 2010s. The present study is a narrative review of the literature of OL-UL drug use from 2013. METHODS We performed a literature search of research articles assessing OL-UL drug use in children (<18 years-old) published in Medline® from January 2013 until May 2017. RESULTS Twenty-seven studies were included. OL drug use was defined by inappropriate age, indication, dosage or way of administration according to the summary of product characteristics in >80% of studies. UL drug used was defined by the use of drugs not licensed in the country or modifications of licensed drugs in >70% of studies. Among in- and out-patients, the frequency of patients exposed to at least one OL-UL drug ranged from 36.3 to 97.0% and from 18.6 to 40.2%, respectively. Drug use was categorized as OL mostly due to inappropriate age, dosage or indication. OL-UL drug use was the most prevalent in newborns (mainly preterms) and pre-school children (aged 2-5years). Various drugs were involved, depending on patients' age. Polypharmacy and long hospital stays were risk factors for OL-UL drug use. Whether OL-UL drug use leads to a higher incidence of adverse drug reactions is a controversial finding. CONCLUSIONS OL-UL drug use is frequent in children. A standardized definition of OL-UL drug use is needed to better assess its frequency, risk factors and impact.
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Affiliation(s)
- Florence Moulis
- Department of medical and clinical pharmacology, Toulouse university hospital, faculty of medicine, 37, allées Jules-Guesde, 31000 Toulouse, France
| | - Geneviève Durrieu
- Department of medical and clinical pharmacology, Toulouse university hospital, faculty of medicine, 37, allées Jules-Guesde, 31000 Toulouse, France.
| | - Maryse Lapeyre-Mestre
- Department of medical and clinical pharmacology, Toulouse university hospital, faculty of medicine, 37, allées Jules-Guesde, 31000 Toulouse, France
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Aamir M, Khan JA, Shakeel F, Asim SM. Unlicensed and off-label use of drugs in pediatric surgical units at tertiary care hospitals of Pakistan. Int J Clin Pharm 2017; 39:860-866. [PMID: 28597174 DOI: 10.1007/s11096-017-0485-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 05/10/2017] [Indexed: 11/30/2022]
Abstract
Background Unlicensed and off-label prescribing practice is global dilemma around the world. This pioneering study was designed to determine unlicensed and off-label use of drug in surgical wards of tertiary care hospitals of Pakistan. Objective To assess unlicensed and off-label use of drugs in pediatric surgical unit at three tertiary care hospitals in Peshawar, Pakistan. Setting Two government and one private tertiary care hospitals in Pakistan. Method Drug profiles of 895 patients from three different clinical settings were evaluated for unlicensed and off-label use of drugs using Micromedex DRUGDEX. Main outcome measure Characteristics of the unlicensed and off-label drug prescriptions. Result Total of 3168 prescribed drugs were analyzed in this study. Indication (38.7%) and dose (34.8%) were the most frequent off-label categories. In comparison with the corresponding reference categories, infants and children, male patients and having less than five prescribed drugs were significant predictors of unlicensed prescriptions. In comparison with the corresponding reference categories, significant predictors of off-label drug prescribing were children younger than two year, children between 2-12 years, patient staying at hospital less than 5 days and patients having less than five prescribed drugs. Conclusion The prevalence of unlicensed and off-label drug prescriptions are high at pediatric surgical ward of tertiary care hospitals. More awareness of the efficacy and safety of drugs are required in pediatrics. In addition, new formulations with advanced dosing for children are also required to minimize the risk of adverse outcomes.
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Affiliation(s)
- Muhammad Aamir
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | | | - Faisal Shakeel
- Department of Pharmacy, Sarhad University of Science and Information Technology, Peshawar, Pakistan
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Bjerknes K, Bøyum S, Kristensen S, Brustugun J, Wang S. Manipulating tablets and capsules given to hospitalised children in Norway is common practice. Acta Paediatr 2017; 106:503-508. [PMID: 27935163 DOI: 10.1111/apa.13700] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/11/2016] [Accepted: 12/06/2016] [Indexed: 11/27/2022]
Abstract
AIM This study provided an overview of manipulating oral medicines given to hospitalised children and evaluated this practice in two hospitals. It focused on the type of manipulation and the dosage forms that were manipulated. METHOD This was a cross-sectional, prospective study, carried out on the paediatric wards at two Norwegian hospitals for four weeks in 2013. A medicine was said to have been manipulated if it was not administered as described in the Norwegian summary of product characteristics. RESULTS This study showed that 17% of the 3070 administrations of oral medicines to the hospitalised children involved manipulation. Tablets, including modified release preparations, were the most frequently manipulated medicines. In approximately half of these cases, only a segment of the unit dose was administered. No manipulation of oral liquids was seen. The bioavailability of as much as 44% of the most frequent given substances may be sensitive to such manipulations due to limited aqueous solubility. Various routines for splitting and handling the unit doses were observed. CONCLUSION Manipulation of oral medication was regularly performed on paediatric wards. There is an urgent need for age-appropriate medicines, documented and standardised processes for manipulating medicines and staff training on the consequences of manipulation.
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Affiliation(s)
| | - Silje Bøyum
- Hospital Pharmacy Enterprises; Oslo South Eastern Norway
- School of Pharmacy; University of Oslo; Oslo Norway
| | | | | | - Siri Wang
- Department of Medicinal Product Assessment; Norwegian Medicines Agency; Oslo Norway
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