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Neumann J, Dhein S, Kirchhefer U, Hofmann B, Gergs U. Effects of congeners of amphetamine on the human heart. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:4615-4642. [PMID: 38340182 PMCID: PMC11166837 DOI: 10.1007/s00210-024-02983-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/28/2024] [Indexed: 02/12/2024]
Abstract
Central stimulatory and hallucinogenic drugs of abuse like amphetamine and most congeners of amphetamine can have cardiac harmful effects. These cardiac side effects can lead to morbidities and death. In this paper, we review current knowledge on the direct and indirect effects of these amphetamine congeners on the mammalian heart-more specifically, the isolated human heart muscle preparation. In detail, we address the question of whether and how these drugs affect cardiac contractility and their mechanisms of action. Based on this information, further research areas are defined, and further research efforts are proposed.
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Affiliation(s)
- Joachim Neumann
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Magdeburger Str. 4, 06112, D-06097, Halle, Germany.
| | - Stefan Dhein
- Rudolf-Boehm Institut für Pharmakologie und Toxikologie, Universität Leipzig, Härtelstraße 16-18, D-04107, Leipzig, Germany
| | | | - Britt Hofmann
- Cardiac Surgery, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany
| | - Ulrich Gergs
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Magdeburger Str. 4, 06112, D-06097, Halle, Germany
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2
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Vogelberg C, Cuevas Schacht F, Watling CP, Upstone L, Seifert G. Therapeutic principles and unmet needs in the treatment of cough in pediatric patients: review and expert survey. BMC Pediatr 2023; 23:34. [PMID: 36670372 PMCID: PMC9860236 DOI: 10.1186/s12887-022-03814-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 12/20/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND There are evidence gaps in the management of pediatric cough, particularly for acute pediatric cough. This study had two aims: to identify therapeutic principles and unmet needs in the treatment of cough in pediatric patients (internationally), and to consider the evidence required to address these unmet needs. METHODS A MEDLINE/PubMed database search was performed to identify articles describing therapeutic principles in the treatment of pediatric cough. An online survey of international pediatric cough experts was conducted, with questions on the definitions, diagnosis, treatment, and unmet needs in pediatric cough management. RESULTS Cough guidelines have differing definitions of pediatric patients (≤12-18 years), acute pediatric cough (< 2-3 weeks), and chronic pediatric cough (> 4-8 weeks). Similarly, among 18 experts surveyed, definitions varied for pediatric patients (≤10-21 years), acute pediatric cough (< 3-5 days to < 6 weeks), and chronic pediatric cough (> 2-8 weeks). Guidelines generally do not recommend over-the-counter or prescription cough medicines in acute pediatric cough, due to lack of evidence. In the expert survey, participants had differing opinions on which medicines were most suitable for treating acute pediatric cough, and noted that effective treatments are lacking for cough-related pain and sleep disruption. Overall, guidelines and experts agreed that chronic pediatric cough requires diagnostic investigations to identify the underlying cough-causing disease and thereby to guide treatment. There are unmet needs for new effective and safe treatments for acute pediatric cough, and for randomized controlled trials of existing treatments. Safety is a particular concern in this vulnerable patient population. There is also a need for better understanding of the causes, phenotypes, and prevalence of pediatric cough, and how this relates to its diagnosis and treatment. CONCLUSIONS Whereas pediatric cough guidelines largely align with regard to the diagnosis and treatment of chronic cough, there is limited evidence-based guidance for the management of acute cough. There is a need for harmonization of pediatric cough management, and the development of standard guidelines suitable for all regions and patient circumstances.
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Affiliation(s)
- Christian Vogelberg
- grid.412282.f0000 0001 1091 2917Paediatric Department, University Hospital Carl Gustav Carus Dresden, Technical University Dresden, Dresden, Germany
| | - Francisco Cuevas Schacht
- grid.419216.90000 0004 1773 4473Department of Pulmonology and Thoracic Surgery, National Institute of Paediatrics, Mexico City, Mexico
| | | | | | - Georg Seifert
- grid.6363.00000 0001 2218 4662Department of Paediatric Oncology/Haematology, Otto-Heubner Centre for Paediatric and Adolescent Medicine (OHC), Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Kim I, Goulding M, Tian F, Karami S, Pham T, Cheng C, Biehl A, Muñoz M. Benzonatate Exposure Trends and Adverse Events. Pediatrics 2022; 150:189946. [PMID: 36377394 PMCID: PMC9732921 DOI: 10.1542/peds.2022-057779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Adverse events (AE), including death, occur in children with benzonatate use. This study aims to understand recent trends in benzonatate exposure and clinical consequences in pediatric patients. METHODS This retrospective analysis of data from IQVIA pharmacy drug dispensing, National Poison Data System, National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project, FDA Adverse Event Reporting System, and the medical literature evaluated exposure trends and medication-related AEs with benzonatate. Trends for comparator narcotic and nonnarcotic antitussive medications were analyzed where possible for context. RESULTS During the study period, pediatric benzonatate prescription utilization increased but remained low compared with pediatric utilization of dextromethorphan-containing prescription antitussive medications. Among the 4689 pediatric benzonatate exposure cases reported to US poison control centers from 2010 to 2018, 3727 cases (80%) were for single-substance exposures. Of these, 3590 cases (77%) were unintentional exposures and most involved children 0 to 5 years old (2718 cases, 83%). Cases involving intentional benzonatate exposure increased among children 10 to 16 years old with a more pronounced increase for multiple-substance exposures. Most benzonatate cases involving misuse or abuse were for children 10 to 16 years old (59 cases, 61%). The proportion of cases with serious adverse effects was low. There were few cases annually of serious AEs with benzonatate in children. CONCLUSIONS There were rising patterns of unintentional ingestion of benzonatate in children 0 to 5 years old and intentional benzonatate ingestion in children 10 to 16 years old. Rational prescribing and improved provider and caregiver awareness of benzonatate toxic effects may reduce risks associated with benzonatate exposure.
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Mashat GD, Hazique M, Khan KI, Ramesh P, Kanagalingam S, Ul Haq Z, Victory Srinivasan N, Khan AI, Khan S. Comparing the Effectiveness of Honey Consumption With Anti-Cough Medication in Pediatric Patients: A Systematic Review. Cureus 2022; 14:e29346. [PMID: 36284810 PMCID: PMC9583571 DOI: 10.7759/cureus.29346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/19/2022] [Indexed: 11/30/2022] Open
Abstract
Coughing is one of the most prevalent symptoms in children presenting at outpatient departments. This systematic review aimed to review previous literature in order to compare the use of honey and antitussive medications for treating coughs in children. Literature was screened across five databases using Medical Subject Heading (MeSH) strategy, keywords, and inclusion and exclusion criteria. The remaining literature was evaluated using a quality appraisal tool checklist. This review includes systematic reviews, meta-analyses, randomized controlled trials (RCTs), observational studies, cross-sectional studies, and articles without a defined methodology section. This review suggests that honey is effective in treating children above 12 months of age, while cold and cough medications (CCMs) are safe if administered at therapeutic doses. Since fatalities can occur in children under two years of age, further RCT studies on CCMs are required to establish safety across all age groups.
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Mital R, Lovegrove MC, Moro RN, Geller AI, Weidle NJ, Lind JN, Budnitz DS. US emergency department visits for acute harms from over-the-counter cough and cold medications, 2017-2019. Pharmacoepidemiol Drug Saf 2022; 31:225-234. [PMID: 34757641 PMCID: PMC10917081 DOI: 10.1002/pds.5384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/06/2021] [Accepted: 11/05/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Characterization of emergency department (ED) visits for acute harms related to use of over-the-counter cough and cold medications (CCMs) by patient demographics, intent of CCM use, concurrent substance use, and clinical manifestations can help guide prevention of medication harms. METHODS Public health surveillance data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project were used to estimate numbers and population rates of ED visits from 2017 to 2019. RESULTS Based on 1396 surveillance cases, there were an estimated 26 735 (95% CI, 21 679-31 791) US ED visits for CCM-related harms annually, accounting for 1.3% (95% CI, 1.2-1.5%) of all ED visits for medication adverse events. Three fifths (61.4%, 95% CI, 55.6-67.2%) of these visits were attributed to non-therapeutic CCM use (nonmedical use, self-harm, unsupervised pediatric exposures). Most visits by children aged <4 years (74.0%, 95% CI, 59.7-88.3%) were for unsupervised CCM exposures. Proportion hospitalized was higher for visits for self-harm (76.5%, 95% CI, 68.9-84.2%) than for visits for nonmedical use (30.3%, 95% CI, 21.1-39.6%) and therapeutic use (8.8%, 95% CI, 5.9-11.8%). Overall, estimated population rates of ED visits for CCM-related harms were higher for patients aged 12-34 years (16.5 per 100 000, 95% CI, 13.0-20.0) compared with patients aged <12 years (5.1 per 100 000, 95% CI, 3.6-6.5) and ≥ 35 years (4.3 per 100 000, 95% CI, 3.4-5.1). Concurrent use of other medications, illicit drugs, or alcohol was frequent in ED visits for nonmedical use (61.3%) and self-harm (75.9%). CONCLUSIONS Continued national surveillance of CCM-related harms can assess progress toward safer use.
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Affiliation(s)
- Rohan Mital
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Maribeth C Lovegrove
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Ruth N Moro
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Andrew I Geller
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Nina J Weidle
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
- Eagle Global Scientific, LLC (contractor to CDC), Atlanta, Georgia, USA
| | - Jennifer N Lind
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Daniel S Budnitz
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
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Wang GS, Reynolds KM, Banner W, Bond GR, Kauffman RE, Palmer RB, Paul IM, Rapp-Olsson M, Green JL, Dart RC. Adverse Events Related to Accidental Unintentional Ingestions From Cough and Cold Medications in Children. Pediatr Emerg Care 2022; 38:e100-e104. [PMID: 32576790 DOI: 10.1097/pec.0000000000002166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Previous research has demonstrated that accidental unsupervised ingestions (AUIs) were responsible for the majority of cough and cold medication (CCM) ingestions leading to significant adverse events (AEs) in children. The objective of this analysis was to characterize the role of AUIs in the morbidity associated with CCM exposure in children. METHODS This surveillance study collected data from 5 United States data sources from 2009 to 2016, in children younger than 6 years with an AE from an AUI involving at least 1 CCM over-the-counter pharmaceutical ingredient. An expert panel reviewed each case to determine causality. RESULTS From 4756 total cases reviewed, 3134 (65.9%) had an AE from an AUI determined to be at least potentially related to a CCM ingredient. The majority (61.3%) of cases occurred in children aged 2 to younger than 4 years. Most exposures occurred in the child's own residence (94.9%), and 43.8% were admitted to a health care facility (22.0% to a critical care unit). Dextromethorphan and diphenhydramine, when packaged alone or in combination products, contributed to 96.0% of AUIs. The most common specific products involved were single-ingredient pediatric liquid diphenhydramine (30.1%) and single-ingredient pediatric liquid dextromethorphan (21.4%). There were 3 deaths from solid diphenhydramine formulations. CONCLUSIONS There continues to be opportunities for the implementation of interventions to prevent AUIs of CCM in children. Additional emphasis on engineering controls, such as flow restrictors for liquid formulations targeting diphenhydramine and dextromethorphan products, represent additional opportunities to further reduce AEs from AUIs of CCM.
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Affiliation(s)
| | - Kate M Reynolds
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | - William Banner
- Oklahoma Center for Poison and Drug Information, Oklahoma University College of Pharmacy, Oklahoma City, OK
| | - G Randall Bond
- Faculté de Médecine, Hope Africa University, Bujumbura, Burundi
| | - Ralph E Kauffman
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Robert B Palmer
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | - Ian M Paul
- Pediatrics and Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Malin Rapp-Olsson
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
| | | | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO
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Yin HS, Neuspiel DR, Paul IM, Franklin W, Tieder JS, Adirim T, Alvarez F, Brown JM, Bundy DG, Ferguson LE, Gleeson SP, Leu M, Mueller BU, Connor Phillips S, Quinonez RA, Rea C, Rinke ML, Shaikh U, Shiffman RN, Vickers Saarel E, Spencer Cockerham SP, Mack Walsh K, Jones B, Adler AC, Foster JH, Green TP, Houck CS, Laughon MM, Neville K, Reigart JR, Shenoi R, Sullivan JE, Van Den Anker JN, Verhoef PA. Preventing Home Medication Administration Errors. Pediatrics 2021; 148:183379. [PMID: 34851406 DOI: 10.1542/peds.2021-054666] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.
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Affiliation(s)
- H Shonna Yin
- Departments of Pediatrics and Population Health, Grossman School of Medicine, New York University, New York, New York
| | | | - Ian M Paul
- Departments of Pediatrics and Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
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Halmo LS, Wang GS, Reynolds KM, Delva-Clark H, Rapp-Olsson M, Banner W, Bond GR, Kauffman RE, Palmer RB, Paul IM, Green JL, Dart RC. Pediatric Fatalities Associated With Over-the-Counter Cough and Cold Medications. Pediatrics 2021; 148:peds.2020-049536. [PMID: 34607934 DOI: 10.1542/peds.2020-049536] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In 2008, over-the-counter cough and cold medications (CCMs) underwent labeling changes in response to safety concerns, including fatalities, reported in children exposed to CCMs. The objective of this study is to describe fatalities associated with exposures to CCMs in children <12 years old that were detected by a safety surveillance system from 2008 to 2016. METHODS Fatalities in children <12 years old that occurred between 2008 and 2016 associated with oral exposure to one or more CCMs were identified by the Pediatric Cough and Cold Safety Surveillance System. An expert panel reviewed all cases to determine the causal relationship between the exposure and death, if the intent of exposure was therapeutic, and if the dose was supratherapeutic. Other contributing factors related to the child's death were also identified as part of a root cause analysis. RESULTS Of the 180 eligible fatalities captured during the study period, 40 were judged by the expert panel to be either related or potentially related to the CCM. Of these, the majority (n = 24; 60.0%) occurred in children <2 years old and involved nontherapeutic intent (n = 22; 55.0%). The most frequently involved index ingredient was diphenhydramine (n = 28; 70.0%). In 6 cases (n = 6; 15.0%), the CCM was administered to murder the child. In another 7 cases (n = 7; 17.5%), death followed the intentional use of the CCM to sedate the child. CONCLUSIONS Pediatric fatalities associated with CCMs occurred primarily in young children after deliberate medication administration with nontherapeutic intent by a caregiver.
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Affiliation(s)
- Laurie Seidel Halmo
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - George Sam Wang
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - Kate M Reynolds
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado;
| | - Heather Delva-Clark
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado.,CPC Clinical Research, Aurora, Colorado
| | - Malin Rapp-Olsson
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - William Banner
- Oklahoma Center for Poison and Drug Information and College of Pharmacy, The University of Oklahoma Health Sciences Center, The University of Oklahoma, Oklahoma City, Oklahoma
| | - G Randall Bond
- Faculté de Médecine, Hope Africa University, Bujumbura, Burundi
| | - Ralph E Kauffman
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Robert B Palmer
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
| | - Ian M Paul
- Departments of Pediatrics and Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania; and
| | - Jody L Green
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado.,Inflexxion, Costa Mesa, California
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado
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Leceta A, García A, Sologuren A, Campo C. Bilastine 10 and 20 mg in paediatric and adult patients: an updated practical approach to treatment decisions. Drugs Context 2021; 10:dic-2021-5-1. [PMID: 34457015 PMCID: PMC8366504 DOI: 10.7573/dic.2021-5-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/02/2021] [Indexed: 01/03/2023] Open
Abstract
Background Bilastine, a non-sedating H1-antihistamine, is indicated to treat the symptoms of allergic disorders (e.g. rhinoconjunctivitis and urticaria) in adults and adolescents and, more recently, in children. Following its marketing approval, many questions regarding the ideal use of bilastine in various clinical practice situations have been received by the Medical Information Department (MID) of Faes Farma Spain. This article is an update of a previous review, with a focus on recent clinical information on the use of bilastine in paediatric and other populations. Methods Results of recent clinical studies in paediatric and other populations as well as questions received and responses provided by the Faes Farma MID. Results The information regarding the use of bilastine in paediatric patients is the most relevant aspect of this updated review. The stepwise approval of the paediatric formulations in various countries started with the European Medicines Agency approval in 2017 in accordance with a 2009 Paediatric Investigation Plan, followed by approval in other countries. The queries that are most commonly received by the Faes Farma MID include the potential for drug interactions involving bilastine and other frequently used drugs, and the use of bilastine in special populations or to treat specific symptoms related to allergic conditions. As the concomitant use of many medications is not permitted during clinical trials, the advice provided regarding the concomitant use of other medications with bilastine considers the pharmacological properties of both the drug in question and bilastine, as well as expert opinion. Likewise, advice regarding the use of bilastine in special populations (e.g. patients with renal impairment, obesity, lactose intolerance, and elderly or pregnant individuals) or to treat specific symptoms (e.g. treatment-resistant urticaria, pruritus or BASCULE syndrome) considers the best evidence from a variety of sources, including clinical studies, real-world experience, guideline recommendations and expert opinion. Conclusion This updated review provides current data regarding the best use of bilastine in specific situations and patients and identifies areas in which further knowledge is required. Although decisions regarding the use of bilastine may be aided by expert opinion that relies on knowledge of the underlying science, additional research and evidence are required to answer certain queries regarding the use of bilastine.
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Affiliation(s)
- Amalia Leceta
- Medical Affairs Department, Faes Farma SA, Bizkaia, Spain
| | | | | | - Cristina Campo
- Head of Clinical Research Medical Affairs Department, Faes Farma SA, Bizkaia, Spain
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Lam SHF, Homme J, Avarello J, Heins A, Pauze D, Mace S, Dietrich A, Stoner M, Chumpitazi CE, Saidinejad M. Use of antitussive medications in acute cough in young children. J Am Coll Emerg Physicians Open 2021; 2:e12467. [PMID: 34179887 PMCID: PMC8212563 DOI: 10.1002/emp2.12467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 11/06/2022] Open
Abstract
Acute cough, a common complaint in young children, is often the result of a viral upper respiratory infection. Cough and cold remedies generate billions of dollars in annual sales in the United States, despite a lack of evidence of their efficacy and multiple warnings by the US Food and Drug Administration. The current article begins with the best available evidence for common over-the-counter (OTC) and prescription antitussive remedies in children. The article concludes with a discussion of the pros and cons for the use of antitussives in children with cough. In general, OTC antitussive medications should not be routinely used in children under 2 years of age. In certain cases, antitussives with minimal adverse profile and some evidence of benefit may be recommended after informed counseling.
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Affiliation(s)
- Samuel H. F. Lam
- Department of Emergency MedicineSutter Medical Center SacramentoSacramentoCaliforniaUSA
| | - James Homme
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Pediatrics and Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | | | - Alan Heins
- Department of Emergency MedicineUniversity of South Alabama College of MedicineMobileAlabamaUSA
| | - Denis Pauze
- Department of Emergency Medicine, Emergency Medicine & PediatricsAlbany Medical CenterAlbanyNew YorkUSA
| | - Sharon Mace
- Department of Emergency MedicineMetro Health Medical CenterCleveland Clinic Emergency Medicine ResidencyCleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland ClinicClevelandOhioUSA
| | - Ann Dietrich
- Department of PediatricsOhio University Heritage College of MedicineDublinOhioUSA
| | - Michael Stoner
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's HospitalThe Ohio State University College of MedicineColumbusOhioUSA
| | - Corrie E. Chumpitazi
- Department of Pediatrics, Section of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
| | - Mohsen Saidinejad
- Department of Emergency Medicine, Harbor UCLA Medical Center, David Geffen School of Medicine at UCLAThe Lundquist Institute for Biomedical Innovation at Harbor UCLATorranceCaliforniaUSA
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Petkova V, Hadzhieva BR. Pilot study of over-the-counter drugs applied among the pediatric population in Bulgaria. PHARMACIA 2021. [DOI: 10.3897/pharmacia.68.e63805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Herbal medicines have evolved through their traditional use in a specific or cultural context. The pharmacological effects of herbal medicines are not due to their “natural” origin, but to the complex character of biologically active substances. Pediatricians have begun to integrate the use of complementary / alternative medical therapies with conventional health care.
The first aim of the study was to make an analysis of over-the-counter (OTC) drugs (OTCDs) with a plant component. The secondary aim was to investigate OTCDs in terms of composition and nosology for use by the pediatric population in Bulgaria.
Registered OTC drugs with a herbal component for children are prescribed for the treatment of colds, pain, gastrointestinal diseases, mild sleep disorders, neurovegetative dystonias and kinetosis, urinary tract inflammation, liver disease, and are also applied topically to inflammation, trauma, urticaria and scars.
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12
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Yehya A, Numan M, Matalqah L. No Time for Lullabies Tracing down Pharmacological Effects & Uses of H1-Antihistamines in Children Younger than 6 Years. Glob Pediatr Health 2021; 8:2333794X21992170. [PMID: 33748342 PMCID: PMC7903821 DOI: 10.1177/2333794x21992170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives. To provide a qualitative and a quantitative analysis of H1-antihistamines pharmacological uses pattern among children (<6 years old) and to evaluate the parental-related awareness. Methods. A cross-sectional study was carried out at 5 retail pharmacies in Jordan over 5 months (October/2019-February/2020). Parents who requested any of H1-antihistmine agent for a child (<6 years) were invited to participate. Results. A total of 516 children, most of them were toddlers (1-3) years, received at least 1 H1-antihistamine. More than half of the cases received H1-antihistamine as self-medication (56.3%). Sedating antihistamine agents were the most frequently used among children (<6 years old) (77.9%) among which Chlorpheniramine maleate was the most commonly used agent (62.9%). About half of the children (47.0%) received H1-antihistamine to induce sleep. Whereas, 21.7% and 12.9% received them to manage flu, and allergic rhinitis (AR), respectively. Around 66.6% of the cases were classified as off-label use. Most of the parents (80.5%) were aware of the sedative adverse effects of H1-antihistamines, whereas a fewer number (31.9%) were aware of their cognitive effects. Finally, more than two thirds of parents (79.7%) were unfamiliar with off-label drug use in children. Conclusion. Despite the availability of less-sedating H1-antihistamines with a wide safety and efficacy record, the use of sedating H1-antihistamines remains popular in children.
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Affiliation(s)
| | - Mohammad Numan
- Jordan University of Science and Technology (JUST), Irbid, Jordan
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13
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Gober HJ, Li KH, Yan K, Bailey AJ, Carleton BC. Hydroxyzine Use in Preschool Children and Its Effect on Neurodevelopment: A Population-Based Longitudinal Study. Front Psychiatry 2021; 12:721875. [PMID: 35153845 PMCID: PMC8832122 DOI: 10.3389/fpsyt.2021.721875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
We identified the first-generation antihistamine hydroxyzine as the earliest and most frequently prescribed drug affecting the central nervous system in children under the age of 5 years in the province of British Columbia, Canada (1. 1% prevalence). Whereas, the antagonism of H1-receptors exerts anti-pruritic effects in atopic dermatitis and diaper rash, animal studies suggest an adverse association between reduced neurotransmission of histamine and psychomotor behavior. In order to investigate hydroxyzine safety, we characterized the longitudinal patterns of hydroxyzine use in children under the age of 5 years and determined mental- and psychomotor disorders up to the age of 10 years. We found significantly higher rates of ICD-9 and ICD-10 codes for disorders such as tics (307), anxiety (300) and disturbance of conduct (312) in frequent users of hydroxyzine. Specifically, repeat prescriptions of hydroxyzine compared to a single prescription show an increase in tic disorder, anxiety and disturbance of conduct by odds ratios of: 1.55 (95%CI: 1.23-1.96); 1.34 (95%CI: 1.05-1.70); and 1.34 (95%CI: 1.08-1.66) respectively in children up to the age of 10 years. Furthermore, a non-significant increased trend was found for ADHD (314) and disturbance of emotions (313). This is the first study reporting an association between long-term neurodevelopmental adverse effects and early use of hydroxyzine. Controlled studies are required in order to prove a causal relationship and to confirm the safety of hydroxyzine in the pediatric population. For the time being, we suggest the shortest possible duration for hydroxyzine use in preschool-age children.
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Affiliation(s)
- Hans J Gober
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Pharmacy, Kepler University Hospital, Linz, Austria
| | - Kathy H Li
- Therapeutic Evaluation Unit, Provincial Health Services Authority, Vancouver, BC, Canada.,Pharmaceutical Outcomes Programme, BC Children's Hospital, Vancouver, BC, Canada
| | - Kevin Yan
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anthony J Bailey
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bruce C Carleton
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Therapeutic Evaluation Unit, Provincial Health Services Authority, Vancouver, BC, Canada.,Pharmaceutical Outcomes Programme, BC Children's Hospital, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
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14
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Alghamdi F, Roth C, Jatana KR, Elmaraghy CA, Rice J, Tobias JD, Thung AK. Opioid-Sparing Anesthetic Technique for Pediatric Patients Undergoing Adenoidectomy: A Pilot Study. J Pain Res 2020; 13:2997-3004. [PMID: 33239908 PMCID: PMC7682613 DOI: 10.2147/jpr.s281275] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/11/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION An opioid-sparing anesthetic involves a multi-modal technique with non-opioid medications targeting different analgesic pathways. Such techniques may decrease adverse effects related to opioids. These techniques may be considered in patients at higher risk for opioid-related adverse effects including obstructive sleep apnea or sleep disordered breathing. METHODS A prospective, pilot study was performed in 10 patients (3-8 years of age), presenting for adenoidectomy. The perioperative regimen included oral dextromethorphan (1 mg/kg) and acetaminophen (15 mg/kg) plus single boluses of intraoperative dexmedetomidine (0.5 μg/kg) and ketamine (0.5 mg/kg). Pain scores were assessed in the post anesthesia care unit (PACU) using the FLACC (Face, Legs, Activity, Cry, Consolability) scale. Patients with a pain score >4 received fentanyl as needed. PACU time, pain scores, and parent satisfaction were recorded. Postoperatively, patients were instructed to use oral acetaminophen or ibuprofen every 6 hours as needed for pain. RESULTS The study cohort included 10 patients, 3-8 years of age. All patients had opioid-free anesthetic care. PACU time ranged from 24 to 102 minutes (median: 56 minutes). FLACC pain scores were 0 for all PACU assessments. Nine patients were discharged home and 1 patient had a planned overnight admission. Following hospital discharge, the pain scores were satisfactory during the 72-hour study period and 90% of the patients' guardians were satisfied or highly satisfied with their child's pain control. CONCLUSION This opioid-sparing approach provided safe and effective pain control as well as parental satisfaction following adenoidectomy in children. Additional prospective studies are needed to determine whether this regimen is effective in a larger cohort of patients with and for other otolaryngology procedures.
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Affiliation(s)
- Faris Alghamdi
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Catherine Roth
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Kris R Jatana
- Department of Otolaryngology and Head & Neck Surgery, Nationwide Children’s Hospital and the Ohio State University, Columbus, OH, USA
| | - Charles A Elmaraghy
- Department of Otolaryngology and Head & Neck Surgery, Nationwide Children’s Hospital and the Ohio State University, Columbus, OH, USA
| | - Julie Rice
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Arlyne K Thung
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
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15
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Wang GS, Green JL, Reynolds KM, Banner W, Bond GR, Kauffman RE, Palmer RB, Paul IM, Rapp-Olsson M, Dart RC. Trends in adverse events and related health-care facility utilization from cough and cold medication exposures in children. Clin Toxicol (Phila) 2020; 59:351-354. [PMID: 32914676 DOI: 10.1080/15563650.2020.1815761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Initial research following regulatory changes addressing the pediatric safety of cough and cold medications (CCMs) demonstrated decreases in adverse events (AEs). Using a national multi-source surveillance system, we studied subsequent CCM-related AE case rate trends and associated health-care facility (HCF) evaluation in children. METHODS Data were collected from 2009 to 2016. Case eligibility included: age <12 years; exposure to an over-the-counter product containing ≥1 CCM pharmaceutical ingredient; ≥1 significant AE that occurred in the United States. RESULTS About 4756 (72.6%) cases were determined at least potentially related to an index ingredient. Accidental unsupervised ingestions (AUIs; 3134; 65.9%) were the most common case type. Nearly half of AE cases involved children 2 to <4 years old (2,159; 45.4%). The AE case rate did not change significantly over time (p = 0.22). The proportion of AE cases resulting in HCF admission increased from 32.4% (207) in 2009 to 43.4% (238) in 2016 (p < 0.01). Exposures to diphenhydramine (1,305; 67.3%) and/or dextromethorphan (591; 30.5%) were involved in the majority of HCF admissions. CONCLUSIONS The proportion of AE cases resulting in HCF admission increased from 2009 to 2016. Efforts to prevent AUIs such as packaging innovation and engineering controls, particularly for diphenhydramine and dextromethorphan-containing products, should be pursued.
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Affiliation(s)
- George Sam Wang
- Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA.,Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Jody L Green
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Kate M Reynolds
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - William Banner
- Oklahoma Center for Poison and Drug Information, Oklahoma University College of Pharmacy, Oklahoma City, OK, USA
| | - G Randall Bond
- Faculté de Médecine, Hope Africa University, Bujumbura, Burundi
| | - Ralph E Kauffman
- Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Robert B Palmer
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Ian M Paul
- Pediatrics & Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Malin Rapp-Olsson
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, CO, USA
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16
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Meyers RS, Thackray J, Matson KL, McPherson C, Lubsch L, Hellinga RC, Hoff DS. Key Potentially Inappropriate Drugs in Pediatrics: The KIDs List. J Pediatr Pharmacol Ther 2020; 25:175-191. [PMID: 32265601 DOI: 10.5863/1551-6776-25.3.175] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The safe use of medications in pediatric patients requires practitioners to consider the unique pharmacokinetics and pharmacodynamics of drugs prescribed in this age group. In an effort to create a standard of care for the safe use of medications in this population, a list of drugs that are potentially inappropriate for use in pediatric patients has been developed and titled the "KIDs List." METHODS A panel of 7 pediatric pharmacists from the Pediatric Pharmacy Association were recruited to evaluate primary, secondary, and tertiary literature; FDA Pediatric Safety Communications; the Lexicomp electronic database; and product information for drugs that should be considered potentially inappropriate for use in pediatric patients. Information was rated using predefined criteria. A PubMed search was conducted using the following terms: adverse drug events OR adverse drug reactions. The search was limited to humans; age <18 years; case reports, observational studies, or clinical trials; and English language. No date range was used. Results were used to create an evidence-based list of candidate drugs that was then peer-reviewed and subjected to a 30-day public comment period prior to being finalized. RESULTS A PubMed search yielded 4049 unique titles, of which 210 were deemed relevant for full review. Practitioner recommendations highlighted an additional 77 drugs. FDA Pediatric Safety Communications and the Lexicomp database yielded 22 and 619 drugs, respectively. After critical analysis, peer review, and public review the final KIDs List contains 67 drugs and/or drug classes and 10 excipients. CONCLUSIONS This extensive effort led to compilation of the first list of drugs that are potentially inappropriate for prescribing in all or in a select subgroup of pediatric patients. If avoidance is not clinically possible, the drug should be used with caution and accompanied by appropriate monitoring.
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Wang GS, Reynolds KM, Banner W, Bond GR, Kauffman RE, Palmer RB, Paul IM, Rapp-Olsson M, Green JL, Dart RC. Medication Errors From Over-the-Counter Cough and Cold Medications in Children. Acad Pediatr 2020; 20:327-332. [PMID: 31562931 DOI: 10.1016/j.acap.2019.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/14/2019] [Accepted: 09/22/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Out of hospital medication-related adverse events (AEs) from cough and cold medications (CCMs) can have significant public health impact. The objective of this study was to characterize pediatric medication error AEs involving over-the-counter (OTC) CCMs to identify preventable factors. METHODS Multisource national data surveillance system study using an expert panel evaluating CCM AEs related to medication errors. INCLUSION CRITERIA age <12 years, and at least 1 significant AE from at least 1 index ingredient from a CCM OTC product. RESULTS From 2009 through 2016, 4756 cases were determined to have a significant AE related to an OTC CCM ingredient and 513 (10.8%) cases were due to a medication error. Nearly half of medication errors involved children 2 to <6 years old (n = 235; 45.8%). Many involved administration by a parent (n = 231; 45.0%) or alternative caregiver (n = 148; 28.8%). In nearly all cases (93.2%), the medication error involved the wrong dose of the medication. Health care facility evaluation occurred in 381 (74.3%) cases. Diphenhydramine and dextromethorphan were responsible for most medication errors and medication errors involving health care facility evaluation. There were no deaths from medication errors. CONCLUSION In this multiyear surveillance study, medication errors most commonly occurred in children <6 years old who received the wrong volume of a liquid product. Diphenhydramine and dextromethorphan dosing errors were the most common cause of medication errors resulting from CCM use. Continued standardization of measuring devices, concentrations, and units of measure along with consumer education are needed to further decrease medication errors from CCMs.
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Affiliation(s)
- George Sam Wang
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus (GS Wang), Aurora, Colo; Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo
| | - Kate M Reynolds
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo.
| | - William Banner
- Oklahoma Center for Poison and Drug Information, Oklahoma University College of Pharmacy (W Banner), Oklahoma City, Okla
| | - G Randall Bond
- Faculté de Médecine, Hope Africa University (GR Bond), Bujumbura, Burundi
| | - Ralph E Kauffman
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine (RE Kauffman), Kansas City, Mo
| | - Robert B Palmer
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo
| | - Ian M Paul
- Pediatrics & Public Health Sciences, Penn State College of Medicine (IM Paul), Hershey, Pa
| | - Malin Rapp-Olsson
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo
| | - Jody L Green
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo; Inflexion, an IBH Company (JL Green), Costa Mesa, Calif
| | - Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority (GS Wang, KM Reynolds, RB Palmer, M Rapp-Olsson, JL Green, and RC Dart), Denver, Colo
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18
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Dorney K, Dodington JM, Rees CA, Farrell CA, Hanson HR, Lyons TW, Lee LK. Preventing injuries must be a priority to prevent disease in the twenty-first century. Pediatr Res 2020; 87:282-292. [PMID: 31466080 DOI: 10.1038/s41390-019-0549-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 08/03/2019] [Accepted: 08/13/2019] [Indexed: 02/08/2023]
Abstract
Injuries continue to be the leading cause of morbidity and mortality for children, adolescents, and young adults aged 1-24 years in industrialized countries in the twenty-first century. In this age group, injuries cause more fatalities than all other causes combined in the United States (U.S.). Importantly, many of these injuries are preventable. Annually in the U.S. there are >9 million emergency department visits for injuries and >16,000 deaths in children and adolescents aged 0-19 years. Among injury mechanisms, motor vehicle crashes, firearm suicide, and firearm homicide remain the leading mechanisms of injury-related death. More recently, poisoning has become a rapidly rising cause of both intentional and unintentional death in teenagers and young adults aged 15-24 years. For young children aged 1-5 years, water submersion injuries are the leading cause of death. Sports and home-related injuries are important mechanisms of nonfatal injuries. Preventing injuries, which potentially cause lifelong morbidity, as well as preventing injury deaths, must be a priority. A multi-pronged approach using legislation, advancing safety technology, improving the built environment, anticipatory guidance by clinical providers, and education of caregivers will be necessary to decrease and prevent injuries in the twenty-first century.
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Affiliation(s)
- Kate Dorney
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - James M Dodington
- Department of Pediatrics, Yale-New Haven Hospital, New Haven, CT, USA
| | - Chris A Rees
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Caitlin A Farrell
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Holly R Hanson
- Division of Pediatric Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA.
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Palmer RB, Reynolds KM, Banner W, Bond GR, Kauffman RE, Paul IM, Green JL, Dart RC. Adverse events associated with diphenhydramine in children, 2008-2015. Clin Toxicol (Phila) 2019; 58:99-106. [PMID: 31062642 DOI: 10.1080/15563650.2019.1609683] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Diphenhydramine (DPH) exposures in children may be the result of accidental unsupervised ingestions, caregiver error, and intentional misuse of DPH-containing cough and cold medications (CCM). We sought to understand the nature of pediatric ingestions of DPH, particularly the toxicity and outcome of a single product, single ingredient DPH (DPH-only) exposures, in order to derive ingredient-specific information about the clinical effects and course of such cases.Methods: As part of a U.S. multi-year safety surveillance program to assess the safety of over-the-counter (OTC) medications used in cough and cold preparations in children <12 years of age, an expert panel reviewed cases involving symptomatic adverse events potentially related to oral exposures to these medications. After individual review, the cases were categorized by causal relationship of the reported ingredients to the adverse event, exposure intent (therapeutic, non-therapeutic, unknown intent), and dose (therapeutic, supratherapeutic, or unknown). Following panel review, any disagreement on classification was discussed until a consensus was reached. The data were then analyzed with respect to descriptive findings.Results: The panel reviewed 6618 eligible cases and determined 2802 were at least potentially related to oral exposure to DPH. Of these, 2028 were DPH-only cases (39.1% of all cases judged at least potentially related to a cough and cold medication). The majority (79.5%) of DPH-only cases occurred in children 2 to <4 years of age and involved accidental unsupervised ingestions (74.7%). Liquid pediatric formulations were the most common (51.7%) products reported followed by solid pediatric formulations (24.0%). The most common adverse events were tachycardia (53.4%), hallucinations (46.5%), somnolence (34.7%), agitation (33.9%), and mydriasis (26.3%). Seizures occurred in only 5.5% of cases. Five (0.2%) deaths were reported; in the death cases, the DPH dose was judged supratherapeutic in one and unknown in the other four. Child abuse was reported in four of the five death cases and three of the five deaths were homicides.Conclusions: Exposures to DPH-only products were the most common type of exposure detected in our study of adverse events associated with CCM in children. The majority of the DPH-only cases were the result of accidental unsupervised ingestions. Most adverse events were relatively mild self-limited anticholinergic effects and few deaths occurred. Deaths involving DPH were often associated with child abuse or homicide. Interventions targeting the prevention of accidental unsupervised are likely to be impactful in preventing morbidity associated with DPH-only exposure.
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Affiliation(s)
- Robert B Palmer
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Kate M Reynolds
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - William Banner
- Oklahoma Center for Poison and Drug Information, Oklahoma University College of Pharmacy, Oklahoma City, OK, USA
| | - G Randall Bond
- Faculté de Médecine, Hope Africa University, Bujumbura, Burundi
| | - Ralph E Kauffman
- Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Ian M Paul
- Pediatrics & Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Jody L Green
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA.,Inflexxion, an IBH Company, Costa Mesa, CA, USA
| | - Richard C Dart
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Lovegrove MC, Weidle NJ, Budnitz DS. Ingestion of Over-the-Counter Liquid Medications: Emergency Department Visits by Children Aged Less Than 6 Years, 2012-2015. Am J Prev Med 2019; 56:288-292. [PMID: 30573336 PMCID: PMC6714556 DOI: 10.1016/j.amepre.2018.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/30/2018] [Accepted: 10/01/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Unintentional medication ingestions by young children lead to nearly 60,000 emergency department visits annually; 15% involve oral liquid medications. Safety packaging improvements have been shown to limit liquid medication ingestions. Estimated rates of emergency department visits for pediatric ingestions by product were calculated to help target interventions. METHODS Frequencies and rates of emergency department visits for unintentional pediatric ingestions were estimated using adverse event data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project and retail sales/pharmacy dispensing data from Information Resources, Inc. and QuintilesIMS (collected 2012-2015; analyzed 2017). Rates of emergency department visits for ingestions of over-the-counter liquid medications were compared with those for prescription solid medications. RESULTS From the results of 568 cases, an estimated 6,427 emergency department visits (95% CI=4,907, 7,948) were made annually after a child aged <6 years accessed one of the four most commonly implicated over-the-counter liquid medications without caregiver oversight. Nearly two thirds (63.8%) of these visits were made by children aged ≤2 years and 9.0% resulted in hospitalization. Acetaminophen was the most commonly implicated over-the-counter liquid medication (2,515 estimated emergency department visits annually). Rates of emergency department visits for liquid diphenhydramine and acetaminophen ingestions (8.1 and 7.4 emergency department visits per 100,000 bottles sold) were higher than rates for other common over-the-counter liquids and comparable to high-rate prescription solid medications (clonidine and buprenorphine/naloxone: 11.1 and 10.5 emergency department visits per 100,000 dispensed prescriptions, respectively). CONCLUSIONS Product-specific rates of emergency department visits for unintentional ingestions can help prioritize preventive interventions, such as enhancing safety packaging with flow restrictors.
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Affiliation(s)
- Maribeth C Lovegrove
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nina J Weidle
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; Eagle Medical Services, LLC, Atlanta, Georgia
| | - Daniel S Budnitz
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
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Green JL, Reynolds KM, Banner W, Bond GR, Kauffman RE, Palmer RB, Paul IM, Dart RC. Evaluation of the quality and value of data sources for postmarket surveillance of the safety of cough and cold medications in children. BMC Med Res Methodol 2018; 18:175. [PMID: 30577764 PMCID: PMC6303866 DOI: 10.1186/s12874-018-0626-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 11/21/2018] [Indexed: 11/18/2022] Open
Abstract
Background The purpose of this report is to evaluate the quality of data sources used to study cough and cold medication (CCM) safety in children via the Pediatric Cough and Cold Safety Surveillance System. Methods The System utilized the National Poison Data System (NPDS), FDA Adverse Event Reporting System (FAERS), English-language medical literature, manufacturer postmarket safety databases, and news/media reports to identify cases from January 2008 through September 2016. Each data source was evaluated by the proportion of detected cases determined to be eligible (met case criteria) and the proportion determined to be evaluable (able to determine causal relationship between adverse event and exposure). Results A total of 7184 unique cases were identified from 27,597 detected reports. Of these, 6447 (89.7%) were evaluable. The data source with the highest volume of detected cases was news/media; however, only 0.3% of those cases were eligible for panel review and only 0.2% (24 out of 13,450 cases) were evaluable. The data source with the highest proportion of eligible and evaluable cases was NPDS with 7691 detected cases, 6113 (79.5%) eligible cases, and 5587 (72.6%) evaluable cases. Conclusions The data sources utilized to evaluate the safety profile of pediatric CCMs yielded variable detection and evaluation rates, but overall provided a comprehensive look at exposures that otherwise cannot be studied in clinical trials. While this study suggests that each source made a valuable contribution and that evaluable cases are generalizable, improvements are needed in case completeness and accuracy to enhance the quality of postmarket safety evaluations. Electronic supplementary material The online version of this article (10.1186/s12874-018-0626-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jody L Green
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd, 777 Bannock St. MC 0180, Denver, CO, 80204, USA.,Inflexxion Inc, 890 Winter St, Suite 235, Waltham, MA, 02451, USA
| | - Kate M Reynolds
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd, 777 Bannock St. MC 0180, Denver, CO, 80204, USA.
| | - William Banner
- Oklahoma Center for Poison and Drug Information, Oklahoma University College of Pharmacy, 940 NE 13TH. St, Oklahoma City, OK, 73104, USA
| | - G Randall Bond
- Faculty of Medicine, Hope Africa University, Avenue Buconyori, Ngagara Q2, Bujumbura, Burundi
| | - Ralph E Kauffman
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, 2301 Holmes St, Kansas City, MO, 64108, USA
| | - Robert B Palmer
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd, 777 Bannock St. MC 0180, Denver, CO, 80204, USA
| | - Ian M Paul
- Pediatrics & Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Rd, Hershey, PA, 17033, USA
| | - Richard C Dart
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, 1391 Speer Blvd, 777 Bannock St. MC 0180, Denver, CO, 80204, USA
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Yonemoto K, Okanari K, Koga H. Optimal Doses of H1 Antihistamines Do Not Increase Susceptibility to Febrile Convulsions in Children. Pediatr Neurol 2018; 87:42-47. [PMID: 30174243 DOI: 10.1016/j.pediatrneurol.2018.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/30/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this study was to elucidate whether H1 antihistamine administration increases susceptibility to febrile convulsions in children. METHODS A single-center, retrospective observational study was conducted in Japan. The study included 380 children with febrile convulsions between the ages of six months and five years transported via ambulance from 2011 through 2016. They were divided into the preseizure H1 antagonist "use group" and the "nonuse group." The former consisted of children who took H1 antagonists within 24 hours before the seizure onset. The primary outcome (seizure duration) and the secondary outcome (interval from fever to seizure onset) were compared between the two groups. RESULTS Of the 380 study patients, 70 (18%) were identified as the use group. None of the patients was taking excessive doses of H1 antagonists. The prevalence of seizures lasting 15 minutes or longer was not different between the use group and the nonuse group (11% versus 8%, prevalence ratio 1.47 [95% confidence interval, 0.63 to 3.42], P = 0.37). The prevalence of fever to seizure onset less than six hours was significantly lower in the use group (26% versus 52%, prevalence ratio 0.33 [95% confidence interval 0.19 to 0.60], P < 0.001). Similar results were obtained when analyses were conducted separately by different generations (first and second) of H1 antagonists. CONCLUSIONS Prolonged seizure duration and shortened interval from fever to seizure were not observed in children who received H1 antagonists. This study provides evidence that H1 antagonists at optimal doses could be safely used in febrile children with allergic symptoms.
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Affiliation(s)
- Kosuke Yonemoto
- Department of Pediatrics, National Hospital Organization Beppu Medical Center, Oita, Japan
| | - Kazuo Okanari
- Department of Pediatrics, Oita University Faculty of Medicine, Oita, Japan
| | - Hiroshi Koga
- Department of Pediatrics, National Hospital Organization Beppu Medical Center, Oita, Japan.
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Brass EP, Reynolds KM, Burnham RI, Green JL. Medication Errors With Pediatric Liquid Acetaminophen After Standardization of Concentration and Packaging Improvements. Acad Pediatr 2018. [PMID: 29522886 DOI: 10.1016/j.acap.2018.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the impact of the 2011 changes in pediatric single-ingredient liquid acetaminophen product packaging and standardization of the acetaminophen concentration (160 mg/5 mL) on poison control center exposures due to medication errors. METHODS National Poison Data System (NPDS) data from January 1, 2007, through December 31, 2016, were used to identify medication error exposures involving single-ingredient liquid acetaminophen in children younger than 12 years of age. Surveys were conducted through 6 regional poison control centers to obtain additional information on a subset of exposures. RESULTS The annual frequency of NPDS exposures due to medication errors with single-ingredient liquid acetaminophen products was 8260 ± 670 exposures/year during 2007-2011. Children <2 years of age accounted for 66% of exposures. The overall rate of exposures fell to 6669 ± 662 during 2012-2016 (19% decrease; P = .005). Four percent of exposures led to health care facility referrals. Caregivers involved with exposures in children <2 years of age cited health professionals as the source of dosing information in only 69% of cases despite the absence of specific dosing directions for these children on product labels. CONCLUSIONS Implementation of a single concentration for pediatric liquid acetaminophen products and packaging changes were associated with a decrease in medication errors reported to poison control centers. Medication errors are particularly problematic for children <2 years of age, for whom there are no specific labeled dosing instructions. Improved efforts to provide caregivers with dosing instructions for these children are encouraged.
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Affiliation(s)
- Eric P Brass
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, Palos Verdes, Calif
| | - Kate M Reynolds
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colo.
| | - Randy I Burnham
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colo
| | - Jody L Green
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colo
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Paul IM, Reynolds KM, Green JL. Adverse events associated with opioid-containing cough and cold medications in children. Clin Toxicol (Phila) 2018; 56:1162-1164. [PMID: 29631464 DOI: 10.1080/15563650.2018.1459665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Until recently most of the scrutiny of opioid-containing cough and cold medications (CCMs) by the US Food and Drug Administration (FDA) was focused on codeine, only recently shifting equal focus to those containing hydrocodone. We characterized adverse events (AEs) in children <12 years old associated with CCMs that include both an opioid and over-the-counter (OTC) ingredient. METHODS US cases from multiple sources collected as part of a safety surveillance program were included if AEs followed exposure to combination CCMs containing codeine or hydrocodone between January 2008 and December 2015. An expert panel reviewed cases to identify causal relationship between exposure and AEs and identify contributing factors. Each AE term was coded using the Medical Dictionary for Regulatory Activities with preferred terms reported. RESULTS One hundred and fourteen of the 7035 (2%) cases reviewed involved an opioid-containing product. Ninety-eight cases involved an AE at least potentially related to the opioid ingredient (38 (39%) codeine; 60 (61%) hydrocodone). All three fatality cases involved hydrocodone with an antihistamine. Among non-fatalities, somnolence, lethargy, and/or respiratory depression were more commonly reported among hydrocodone cases than codeine cases (86% vs. 61%; p = .005). DISCUSSION These safety surveillance data support the FDA's expanded label changes limiting opioid CCMs for children.
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Affiliation(s)
- Ian M Paul
- a Pediatrics & Public Health Sciences , Penn State College of Medicine , Hershey , PA , USA
| | - Kate M Reynolds
- b Rocky Mountain Poison and Drug Center , Denver Health and Hospital Authority , Denver , CO , USA
| | - Jody L Green
- b Rocky Mountain Poison and Drug Center , Denver Health and Hospital Authority , Denver , CO , USA
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