1
|
Villamañán E, Sobrino C, Carpio C, Moreno M, Arancón A, Lara C, Pérez E, Jiménez C, Zamarrón E, Jiménez-Nácher I, Herrero A, Álvarez-Sala R. Inhaled bronchodilators use and clinical course of adult inpatients with Covid-19 pneumonia in Spain: A retrospective cohort study. Pulm Pharmacol Ther 2021; 69:102007. [PMID: 34129946 PMCID: PMC8196225 DOI: 10.1016/j.pupt.2021.102007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/20/2021] [Accepted: 03/06/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND In the current coronavirus health crisis, inhaled bronchodilators(IB) have been suggested as a possible treatment for patients hospitalized. Patients with evidence of Covid-19 pneumonia worldwide have been prescribed these medications as part of therapy for the disease, an indication for which this medications could be ineffective taken on account the pathophysiology and mechanisms of disease progression. OBJECTIVE The main objective was to evaluate whether there is an association between IB use and length of stay. Primary end points were the number of days that a patient stayed in the hospital and death as a final event in a time to event analysis. Pneumonia severity, oxygen requirement, involved drugs, comorbidity, historical or current respiratory diagnoses and other drugs prescribed to treat coronavirus pneumonia were also evaluated. METHODS A descriptive, observational, cross-sectional study was performed in this tertiary hospital in Madrid (Spain). Data were obtained regarding patients hospitalized with Covid-19, excluding those who were intubated. The primary and secondary outcomes such as duration of hospitalization and death were compared in patients who received IB with those in patients who did not. RESULTS 327 patients were evaluated, mean age was 64.4 ± 15.8 years. Median length of hospitalization stay was 10 days. Of them 292 (89.3%) overcame the disease, the remaining 35 died. Patients who had received IB did not have less mortality rate (odds ratio 0.839; 95% CI: 0.401 to 1.752) and less hospitalization period when compared with patients who did not received IB (odds ratio 1.280; 95% CI: 0.813 to 2.027). There was no significant association between IB use and recovery or death. Hypertension and diabetes were the most common comorbidities. The prevalence of chronic respiratory disease in our cohort was low (21.1%). Anticholinergics were the IB more frequently prescribed for Covid-19 pneumonia. Better response in patients treated with inhaled corticosteroids was not observed. CONCLUSION Off-label indication of inhaled-bronchodilators for Covid-19 patients are common in admitted patients. Taken on account our results, the use of IB for coronavirus pneumonia apparently is not associated with a significantly patient's improvement. Our study confirms the hypothesis that inhaled bronchodilators do not improve clinical outcomes or reduce the risk of Covid-19 mortality. This could be due to the fact that the virus mainly affects the lung parenchyma and the pulmonary vasculature and probably not the airway. More researches are necessary in order to fill the gap in evidence for this new indication.
Collapse
Affiliation(s)
- Elena Villamañán
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain.
| | - Carmen Sobrino
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Carlos Carpio
- Pneumology Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Marta Moreno
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Ana Arancón
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Catalina Lara
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Ester Pérez
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Carlos Jiménez
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | - Ester Zamarrón
- Pneumology Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | | | - Alicia Herrero
- Pharmacy Department, La Paz University Hospital, IdiPAZ, Madrid, Spain
| | | |
Collapse
|
2
|
Villamañán E, Sobrino C, Bilbao C, Fernández J, Herrero A, Calle M, Alvaro D, Segura M, Picazo G, Rodríguez JM, Baldominos G, Ramirez MT, Larrubia Y, Llorente J, Martinez A, Alvarez-Sala R. Off-label use of inhaled bronchodilators in hospitalised patients in Spain: a multicentre observational study. Eur J Hosp Pharm 2020; 28:e23-e28. [PMID: 32332071 DOI: 10.1136/ejhpharm-2019-002171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Off-label prescription of inhaled bronchodilators (IB) is frequent, despite the fact that they can be ineffective and increase avoidable healthcare costs. OBJECTIVE To analyse the frequency of off-label prescription of IB in hospitalised patients. Indications and level of evidence, involved drugs, medical specialties prescribing off-label IB and patients' adherence to IBs were also evaluated. METHOD A descriptive, observational, cross-sectional study was performed in four tertiary hospitals in Spain. The main outcome measure was the number of patients prescribed off-label IBs. Prescriptions were checked against the European Medicines Agency-approved indications. The level of evidence supporting off-label prescription of IBs (according to MICROMEDEX 2.0) was also analysed. Patients were interviewed to test differences (off-label vs on-label) in adherence and knowledge about their inhaled therapy. RESULTS 217 patients were prescribed IBs, 92 of whom were givend off-label IBs (54.7% men, mean age 73.9±12.9 years). The most common off-label prescriptions for IBs were: unspecified dyspnoea (not related to COPD or asthma) (27.2%), respiratory infections (23.9%) and heart failure (22.8%). 76.8% of patients did not have evidence supporting them. Beta2-agonist+corticosteroids and anticholinergics were most commonly prescribed off-label. Internal Medicine was the main medical specialty involved. There were no differences between off-label and on-label users in terms of patients' knowledge about treatment and adherence. CONCLUSION Off-label indications for IBs are common in hospitalised patients and are generally indicated without scientific support. Dyspnoea not related to COPD or asthma, respiratory infections and heart failure were the main off-label indications, most frequently treated with anticholinergics and beta2-agonists+corticosteroids, for which their efficacy and safety has not been proved. Our results show that prescribing needs to be improved to follow the evidence that exists. Moreover, further research focused on off-label indications is needed to clarify whether they are effective, safe and cost-effective.
Collapse
Affiliation(s)
| | | | - Cristina Bilbao
- Pharmacy, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | | | | | - Myriam Calle
- Pharmacy, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Dolores Alvaro
- Pneumology, Mostoles University Hospital, Mostoles, Spain
| | - Maria Segura
- Pharmacy, Mostoles University Hospital, Mostoles, Spain
| | - Gracia Picazo
- Pharmacy, Mostoles University Hospital, Mostoles, Spain
| | | | - Gema Baldominos
- Pharmacy, Hospital Universitario Principe de Asturias, Alcala de Henares, Spain
| | - Maria Teresa Ramirez
- Pneumology, Infanta Sofia University Hospital, San Sebastian de los Reyes, Spain
| | - Yolanda Larrubia
- Pharmacy, Infanta Sofia University Hospital, San Sebastian de los Reyes, Spain
| | - Jesús Llorente
- Pharmacy, Infanta Sofia University Hospital, San Sebastian de los Reyes, Spain
| | - Alicia Martinez
- Infanta Sofia University Hospital, San Sebastian de los Reyes, Spain
| | | |
Collapse
|
3
|
Rodwin MA. Rooting out institutional corruption to manage inappropriate off-label drug use. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2013; 41:654-664. [PMID: 24088156 DOI: 10.1111/jlme.12075] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Prescribing drugs for uses that the FDA has not approved - off-label drug use - can sometimes be justified but is typically not supported by substantial evidence of effectiveness. At the root of inappropriate off-label drug use lie perverse incentives for pharmaceutical firms and flawed oversight of prescribing physicians. Typical reform proposals such as increased sanctions for manufacturers might reduce the incidence of unjustified off-label use, but they do not remove the source of the problem. Public policy should address the cause and control the practice. To manage inappropriate off-label drug use, off-label prescriptions must be tracked in order to monitor the risks and benefits and the manufacturers' conduct. Even more important, reimbursement rules should be changed so that manufacturers cannot profit from off-label sales. When off-label sales pass a critical threshold, manufacturers should also be required to pay for independent testing of the safety and effectiveness of off-label drug uses and for the FDA to review the evidence. Manufacturers should also finance, under FDA supervision, programs designed to warn physicians and the public about the risks of off-label drug use.
Collapse
Affiliation(s)
- Marc A Rodwin
- Professor at Suffolk University Law School and Lab Fellow at the Edmond J. Safra Center for Ethics at Harvard University
| |
Collapse
|
4
|
Islam MS. Off-label promotion of drugs in Bangladesh: evidence from promotional brochures circulated among general practioners by pharmaceutical companies. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2010. [DOI: 10.1211/ijpp.16.6.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Abstract
Aims and objectives
To gauge the incidences and nature of off-label promotion of drugs in the promotional brochures circulated among general practioners (GPs) in Bangladesh.
Setting
A single district town of Bangladesh.
Methods
Pharmaceutical promotional brochures were obtained from the ten GPs seeing the most patients using convenience sampling. Data sheets for both proprietary and generic products were used to identify off-label promotion in the brochures. This was done because drug formulations as well as other scientific information are copied from the original brands in Bangladesh. Data management and statistical analysis were performed using Microsoft Excel.
Key findings
Of the total promotional claims, 32% were found to be off-label while the rest were as per the approved indications. Brochures for drugs used in cases of diabetes contained the highest rates (66.7%) of off-label claims followed by centrally acting drugs (56.3%). Among the centrally acting drugs, clonazepam was found to have the highest (44%) level of off-label claims. Brochures on vitamin and mineral preparations were reported to promote off-label use with mecobalamin alone having 50% off-label claims. Brochures on flucloxacillin were reported to have the highest (19%) level of off-label claims among the antibiotics. Significant levels (35%) of off-label claims were found in brochures for anti-ulcerant drugs, with ranitidine having about 58%. Promotional brochures on cardiovascular drugs and non-steroidal anti-inflammatory drugs (NSAIDs) showed 29.7% and 19.4% off-label claims respectively.
Conclusion
In this study, a high level of off-label promotional claims was reported in the pharmaceutical promotional brochures distributed among GPs in Bangladesh.
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Reimer P, Vosshenrich R. Off-label use of contrast agents. Eur Radiol 2008; 18:1096-101. [PMID: 18274752 DOI: 10.1007/s00330-008-0886-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 01/10/2008] [Accepted: 01/22/2008] [Indexed: 01/28/2023]
Abstract
When contrast agents are approved, the label describes the approved indications and particular circumstances of use such as age, organ function or pregnancy. The use of contrast agents outside their labelled indications is increasing, namely with contrast agents used for MRI. The aim of this paper is to improve the knowledge about this topic. The basis for off-label use is the physician's prerogative, which finds its basis in the "Declaration of Helsinki". Off-label use is allowed under special conditions and might be even the medical state of the art. The necessity for off-label use will continue to increase for MR-contrast agents, as the regulatory requirements for approval of new indications continuously increase, and clinical trials for registration purposes are quite costly and time consuming. As a consequence, manufacturers will concentrate on clinical studies for the essential indications.
Collapse
Affiliation(s)
- P Reimer
- Radiology, Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Moltkestrasse 90, 76133 Karlsruhe, Germany.
| | | |
Collapse
|
7
|
Reiter D. Sailing the straits of approval: the nature of FDA approval and its implications for surgeons. Facial Plast Surg Clin North Am 2007; 15:247-50, vii-viii. [PMID: 17544941 DOI: 10.1016/j.fsc.2007.01.009] [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: 10/23/2022]
Abstract
Use of Food and Drug Administration-approved medications and products for other than the approved indications is common in facial plastic surgery and violates no laws. Addressing practical concerns about such use strengthens the doctor-patient relationship and can minimize the risk of successful allegations of negligence in the event of untoward outcomes. The facial plastic surgeon can find support and assistance with off-label use in two general areas. Abundant scientific literature focuses on off-label use and addresses its practical, scientific, legal, moral, and ethical issues. The Food and Drug Administration also addresses off-label use in its own publications. It offers guidelines for physicians that, if followed, facilitate incorporation of off-label use into practice with minimal risk and maximum potential for therapeutic success.
Collapse
Affiliation(s)
- David Reiter
- Department of Otolaryngology-Head & Neck Surgery, Jefferson Medical College, 925 Chestnut Street, 6th Floor, Philadelphia, PA 19107, USA.
| |
Collapse
|