Tools for Identifying Potentially Inappropriate Prescriptions for Children and Their Applicability in Clinical Practices: A Systematic Review

Background: Drug use safety in children is a global public health problem. The potentially inappropriate prescription screening tools are expected to reduce adverse drug reactions and promote rational drug use.

Objectives: To systematically evaluate children’s potentially inappropriate prescription screening tools and validation studies on these tools.

Methods: We systematically searched six databases PubMed, Embase, Cochrane Library, CNKI, VIP and Wanfang Data. Two reviewers independently selected articles by the eligible criteria and extracted data. Then we evaluated the coverage of diseases or drugs in these tools and the consistency of items between tools.

Results: Five children’s potentially inappropriate prescription screening tools were identified, most tools were formed by Delphi expert consensus and focused on respiratory system drugs, anti-infective drugs, and gastrointestinal drugs. The coincidence rates of items between the POPI and the POPI Int, the POPI and the POPI United Kingdom, the POPI United Kingdom and the POPI int, and the POPI United Kingdom and the PIPc were 82.0, 55.1, 51.0 and 2.2% respectively, and the KIDs List did not overlap other four tools. Only the POPI tool developed by French experts was comprehensively validated by studies and most tools have not been validated.

Conclusion: The development of screening tools for potentially inappropriate prescribing in children is a neglected field and most tools lack studies to validate clinical applicability. More researchers need to form their national potentially inappropriate prescription screening tools for children based on the best available clinical evidence and the actual clinical situation in their countries.

Prevention of risks associated with inappropriate use/unnecessary consumption of medicines

In the code of public health, misuse is defined as intentional and inappropriate use of a medicine or product, which is not in accordance with the terms of the marketing authorisation or the registration as well as with good practice recommendations. Very often this involves an individual or the interaction of several individuals including the patient, his/her carers, prescriber(s) and/or dispensers. Misuse is common; it is the source of medicinal adverse effects for which a significant part is avoidable. Medicines initially prescribed or dispensed in the context of their marketing authorization (MA) can also be the subject of primary dependency and misappropriation. Companies which develop medicines nationally make declarations to the ANSM (French National Agency for the Safety of Medicines and Health Products) and implement measures to limit non-compliant use of their products. Recently, the coronavirus disease-2019 (COVID-19) pandemic has highlighted the influence and societal impact of drug misuse. The finding of the existence of systemic misuse, the impossibility of proposing simple solutions leads us to propose two main areas for improved information and the training of users and health professionals in medicines in the context of multi-faceted interventions: prevention of misuse on the one hand and its identification and treatment on the other hand.

Prévention des risques liés à un usage inapproprié/consommation inutile des médicaments☆

Le mésusage est défini dans le Code de santé publique comme une utilisation intentionnelle et inappropriée d’un médicament ou d’un produit, non conforme à l’autorisation de mise sur le marché ou à l’enregistrement ainsi qu’aux recommandations de bonnes pratiques. On retrouve un acteur ou plus souvent l’interaction de plusieurs acteurs parmi lesquels le patient, ses aidants, le ou les prescripteurs et le ou les dispensateurs. Le mésusage est fréquent, il est source d’effets indésirables médicamenteux dont une partie importante est évitable. Des médicaments initialement prescrits ou dispensés dans le cadre de leur autorisation de mise sur le marché (AMM) peuvent également faire l’objet de dépendance primaire et de détournement. Les entreprises qui exploitent un médicament sur le territoire national déclarent auprès de l’ANSM et mettent en place des mesures pour limiter l’usage non conforme de leurs produits. Récemment, le contexte de la pandémie coronavirus-19 (COVID-19) a mis en lumière l’influence et l’impact sociétal du mésusage médicamenteux. Le constat de l’existence d’un mésusage systémique, de l’impossibilité de proposer des solutions simplistes nous amène à proposer deux principaux axes d’amélioration de l’information et de la formation des usagers et des professionnels de santé sur les médicaments dans le cadre d’interventions multi-facettes : la prévention du mésusage, d’une part, son identification et sa prise en charge, d’autre part.

Severe cutaneous adverse reactions due to inappropriate medication use

BACKGROUND

The proportion of severe cutaneous adverse reactions (SCARs) that could be avoided if medication use was consistent with good medical practice is unknown.

OBJECTIVES

To estimate the proportion of SCARs related to inappropriate medication use.

METHODS

We carried out a retrospective study of all validated SCARs collected in a French registry between 2003 and 2016. For each case, all plausible drugs suspected of inducing SCARs (i.e. not just the drug regarded as 'the most probable') were considered with regard to (i) prescription for an inappropriate indication, (ii) unintentional rechallenge despite a previous allergy to the drug or (iii) self-medication with prescription medicines.

RESULTS

In total, 602 cases were included in the analyses. Antibiotics, anticonvulsants and allopurinol were the drugs most frequently involved, accounting for more than 50% of all cases. All suspected medications were considered to have been appropriately used for 417 of the 602 individuals included in the study population [69·3%, 95% confidence interval (CI) 65·6-73·0] and inappropriately used for 144 individuals (23·9%, 95% CI 20·5-27·3). These inappropriate uses were due mainly to prescriptions for an inappropriate indication (65·8%, 95% CI 58·4-73·2) or unintentional rechallenge (20·9%, 95% CI 14·6-27·2). Allopurinol and co-trimoxazole were the drugs most frequently involved in inappropriate indications. Antibiotics were the largest group involved in unintentional rechallenge. Nonsteroidal anti-inflammatory drugs, available on prescription, were most frequently involved in inappropriate self-medication.

CONCLUSIONS

Our results underline the need for respecting the appropriate indication for drugs in order to reduce the incidence of SCARs. Reducing unintentional rechallenge also seems to be a necessary preventive measure.

Opinions of Maltese doctors and pharmacists on medication errors

BACKGROUND

Pharmacovigilance directive 2010/84/EU focused attention on medication errors and encouraged regulators to identify causing and contributing factors.

OBJECTIVES

(1) To study opinions of doctors/pharmacists on factors bearing a causal link to MEs as well as ways to minimise MEs (2) to test whether differences in opinion exist between subgroups of doctors and pharmacists working in community, hospital or office settings.

METHODS

Different questionnaires were circulated to doctors and pharmacists. Respondents were subdivided according to their primary practice.

RESULTS

320 responses were received (204 doctors/116 pharmacists). Differences in opinion reaching statistical significance were observed on distractions from staff, overwork and fatigue, availability of technical resources and having more than 1 doctor on duty. For pharmacists', differences on issues of generic medicine availability and interruptions were found.

CONCLUSION

Distractions and interruptions while executing tasks was flagged as an area requiring attention. Issues of overwork and fatigue affect especially doctors in hospital the majority of which are of the opinion that regulatory control on patient numbers could minimize errors. Increasing technical resources and keeping knowledge up-to-date, addressing overwork and high patient workloads have been identified as important areas when looking to reduce MEs.

Hospital re-admission associated with adverse drug reactions in patients over the age of 65 years

CONTEXT

Adverse drug reactions (ADRs) are responsible for 5 % of hospital admissions, but hospital re-admission induced by ADRs remains poorly documented.

OBJECTIVE

The aim of this study was to estimate the rate of hospital re-admission and the factors associated with re-admission in the patients over the age of 65 years. Secondary, we described the characteristics of cases of ADRs leading to re-admission for drugs other than chemotherapy agents.

METHODS

Data were extracted from hospital discharge summaries provided by the Department of Medical Information of Toulouse University Hospital. All patients over the age of 65 years admitted to the hospital in 2010 for an ADR, identified from ICD-10 codes, were selected. All subsequent admissions of members of this cohort within 1 year of discharge following the index admission were reviewed retrospectively. The risk factors associated with hospital re-admission for ADRs were analyzed. Medical records were used for descriptive analysis of re-admission due to drugs other than chemotherapy agents.

RESULTS

We found that 553 of the 1000 patients admitted for ADRs in 2010 were re-admitted to hospital within 1 year. Among them, 87 cases were re-admitted for ADRs (estimated rate of 87/1000 re-admission for an ADR within 1 year). A comparison of the patients re-admitted for ADRs (n = 87) with those of patients re-admitted for other causes (n = 410) suggested that only cancer increased the risk of re-admission for ADRs (OR = 7.69 [4.59-12.88] 95 % CI). ADRs due to the same drug combination were the suspected cause of repeat admission in half the cases (other than chemotherapy). Hospital re-admission was considered avoidable in four cases (22 %).

CONCLUSION

This study shows an estimated rate of re-admission for an ADR around 87/1000 within 1 year, and the same drug combination were the suspected cause of repeat admission in half the cases. At least, 11 % of cases were avoidable.

No evidence for a causal link between uric acid and type 2 diabetes: a Mendelian randomisation approach

AIMS/HYPOTHESIS

Epidemiological and experimental evidence suggests that uric acid has a role in the aetiology of type 2 diabetes. Using a Mendelian randomisation approach, we investigated whether there is evidence for a causal role of serum uric acid for development of type 2 diabetes.

METHODS

We examined the associations of serum-uric-acid-raising alleles of eight common variants recently identified in genome-wide association studies and summarised this in a genetic score with type 2 diabetes in case-control studies including 7,504 diabetes patients and 8,560 non-diabetic controls. We compared the observed effect size to that expected based on: (1) the association between the genetic score and uric acid levels in non-diabetic controls; and (2) the meta-analysed uric acid level to diabetes association.

RESULTS

The genetic score showed a linear association with uric acid levels, with a difference of 12.2 μmol/l (95% CI 9.3, 15.1) by score tertile. No significant associations were observed between the genetic score and potential confounders. No association was observed between the genetic score and type 2 diabetes with an OR of 0.99 (95% CI 0.94, 1.04) per score tertile, significantly different (p = 0.046) from that expected (1.04 [95% CI 1.03, 1.05]) based on the observed uric acid difference by score tertile and the uric acid to diabetes association of 1.21 (95% CI 1.14, 1.29) per 60 μmol/l.

CONCLUSIONS/INTERPRETATION

Our results do not support a causal role of serum uric acid for the development of type 2 diabetes and limit the expectation that uric-acid-lowering drugs will be effective in the prevention of type 2 diabetes.

[Quantification of the part allocated to the preventability of vitamin K antagonists therapy bleeding events]

A prospective cohort of patients with a high INR (>or=5) and being treated by vitamin K antagonists (VKA) was assessed in the Amiens University Hospital. One of the purposes of the study was to assess the preventability of the haemorrhages due to VKA. The preventability concept is not very used in France. Identifying the preventability part of a side effect of a drug needs an adapted and reliable tool. Although different methods of assessment of preventability have been developed, none of them is unquestionable. For the needs of our study, we built a scale of measure adapted from a scale of preventability already published by defining more accurately some items and by reducing the subjective part of the interpretation. We were able to confirm the relevance of our revised scale by testing it by two experts. After consensus on the conflicting data, two thirds of the severe bleedings were considered as "potentially or totally preventable". These data are in agreement with published data. Indeed the data found in the literature are concordant to consider that an important part of VKA bleedings events can be prevented by a better management of the treatment.

Progress in the pharmacotherapy of gout

PURPOSE OF REVIEW

To summarize new knowledge on approved and emerging drugs used to treat hyperuricemia or the clinical manifestations of gout.

RECENT FINDINGS

Results of several clinical trials provide new data on the efficacy and safety of the approved urate-lowering drugs, allopurinol and febuxostat. New recommendations have been presented on appropriate dosing of colchicine for acute gout flares and potential toxicities of combining colchicine with medications such as clarithromycin. Emerging therapies, including pegloticase, the uricosuric agent RDEA596, and the interleukin-1 inhibitors, rilonacept and canakinumab, have shown promise in early and late phase clinical trials.

SUMMARY

Recent publications demonstrate an opportunity to use existing gout therapies more effectively in order to improve both efficacy and safety. Emerging therapies for gout show promise for unmet needs in selected gout populations.