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Gazarian M, Horton DB, Carleton B, Kinlaw AC, Bushnell GA, Czaja AS, Durrieu G, Gorman EF, Titievsky L, Zito J, Slaughter JL, dosReis S. Optimizing therapeutic decision-making for off-label medicines use: A scoping review and consensus recommendations for improving practice and research . Pharmacoepidemiol Drug Saf 2023; 32:1200-1222. [PMID: 37208845 PMCID: PMC10543391 DOI: 10.1002/pds.5640] [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: 08/10/2022] [Revised: 05/02/2023] [Accepted: 05/11/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE Off-label medicines use is a common and sometimes necessary practice in many populations, with important clinical, ethical and financial consequences, including potential unintended harm or lack of effectiveness. No internationally recognized guidelines exist to aid decision-makers in applying research evidence to inform off-label medicines use. We aimed to critically evaluate current evidence informing decision-making for off-label use and to develop consensus recommendations to improve future practice and research. METHODS We conducted a scoping review to summarize the literature on available off-label use guidance, including types, extent and scientific rigor of evidence incorporated. Findings informed the development of consensus recommendations by an international multidisciplinary Expert Panel using a modified Delphi process. Our target audience includes clinicians, patients and caregivers, researchers, regulators, sponsors, health technology assessment bodies, payers and policy makers. RESULTS We found 31 published guidance documents on therapeutic decision-making for off-label use. Of 20 guidances with general recommendations, only 35% detailed the types and quality of evidence needed and the processes for its evaluation to reach sound, ethical decisions about appropriate use. There was no globally recognized guidance. To optimize future therapeutic decision-making, we recommend: (1) seeking rigorous scientific evidence; (2) utilizing diverse expertise in evidence evaluation and synthesis; (3) using rigorous processes to formulate recommendations for appropriate use; (4) linking off-label use with timely conduct of clinically meaningful research (including real-world evidence) to address knowledge gaps quickly; and (5) fostering partnerships between clinical decision-makers, researchers, regulators, policy makers, and sponsors to facilitate cohesive implementation and evaluation of these recommendations. CONCLUSIONS We provide comprehensive consensus recommendations to optimize therapeutic decision-making for off-label medicines use and concurrently drive clinically relevant research. Successful implementation requires appropriate funding and infrastructure support to engage necessary stakeholders and foster relevant partnerships, representing significant challenges that policy makers must urgently address.
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Affiliation(s)
- Madlen Gazarian
- School of Biomedical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, AUSTRALIA
| | - Daniel B. Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA; Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Bruce Carleton
- Division of Translational Therapeutics, Department of Paediatrics, Faculty of Medicine, University of British Columbia, Vancouver, CANADA
- Pharmaceutical Outcomes Programme, BC Children’s Hospital, Vancouver, CANADA
- BC Children’s Hospital Research Institute, Vancouver, CANADA
| | - Alan C. Kinlaw
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina School of Pharmacy, Chapel Hill, NC USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Greta A Bushnell
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Angela S. Czaja
- Department of Pediatrics, Critical Care section, University of Colorado School of Medicine, Aurora, CO, USA
| | - Geneviève Durrieu
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Faculty of Medicine, Toulouse University Hospital (CHU), Toulouse, FRANCE
| | - Emily F. Gorman
- Health Sciences and Human Services Library, University of Maryland, Baltimore, Baltimore, MD, USA
| | | | - Julie Zito
- Professor Emerita, Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Jonathan L. Slaughter
- Center for Perinatal Research, Nationwide Children’s Hospital
- Department of Pediatrics, College of Medicine, and Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Susan dosReis
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Systems Challenges in Accessing Medicines among Children under Thailand’s Universal Health Coverage: A Qualitative Study of a Provincial Public Hospital Network. CHILDREN 2022; 9:children9040552. [PMID: 35455597 PMCID: PMC9029722 DOI: 10.3390/children9040552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/25/2022] [Accepted: 04/11/2022] [Indexed: 11/18/2022]
Abstract
Lack of access to child-appropriate medicines results in off-label use. This study aimed to explore medicine management for paediatric patients and to highlight the challenges of the healthcare system under the universal health coverage of Thailand. Semi-structured interviews were conducted with 35 healthcare practitioners working in the public hospital network of Chiang Mai province from February to September 2020. Participants were asked about their experiences in managing the medicine supply for children. Findings revealed that paediatric patients had limited access to age-appropriate medicines. Children’s medicines are rarely selected for inclusion into hospital formularies because of constraining regulations and limited budgets. Additionally, child-appropriate formulations are unavailable on the market. Pharmaceutical compounding is unavoidable. Prepared products are provided weekly or monthly because of product stability concerns. Often, tablets are dispensed, and caregivers are instructed to cut up a tablet and disperse it in syrup in order to obtain a smaller dose in a dosage form appropriate for children to use at home. Without systematic support, access to safe and quality medicines for children is limited.
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Kogawa AC, Peltonen L, Antonio SG, Salgado HRN. Submission of Rifaximin to Different Techniques: Characterization, Solubility Study, and Microbiological Evaluation. AAPS PharmSciTech 2019; 20:125. [PMID: 30805802 DOI: 10.1208/s12249-019-1329-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/03/2019] [Indexed: 12/31/2022] Open
Abstract
Rifaximin, an oral antimicrobial drug, is marketed as 200-mg tablets. The daily dose ranges from 600 mg (1 tablet 3 times a day) to 800 mg (2 tablets twice a day). It is used for a wide range of ages, from adults to children, since it is indicated for the treatment of hepatic encephalopathy, travelers' diarrhea, irritable bowel syndrome, Clostridium difficile, ulcerative colitis, and acute diarrhea. The success of pharmacotherapy will depend on correct fulfillment of drug administration; however, it becomes difficult when the tablets are large and the doses are frequent. Rifaximin belongs to class IV according to the Biopharmaceutic Classification System (BCS), meaning that it is both poorly soluble and poorly permeable. Thus, in this study, solubility of rifaximin was improved by its complexation to β-cyclodextrin by (i) phase solubility diagram, (ii) malaxation, and (iii) decreasing particle size by wet milling. Improved solubility provides lower doses and facilitates compliance with pharmacotherapy. The products formed were analyzed by spectrophotometry in the infrared region (FT-IR), differential scanning calorimetry (DSC), and X-ray diffraction (XRD). Also, their solubility and microbiological activity were determined. The products obtained in all techniques were more soluble than the free drug; they presented higher thermal stability and antimicrobial potency was approximately 100% with all the formulations. It is important to highlight that the treatment failure not only affects the quality of life of the patients, but also contributes significantly to the economic burden of the health system. Therefore, these findings are extremely interesting, both from a technological and financial point of view.
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Booth A, Maddison J, Wright K, Fraser L, Beresford B. Research prioritisation exercises related to the care of children and young people with life-limiting conditions, their parents and all those who care for them: A systematic scoping review. Palliat Med 2018; 32:1552-1566. [PMID: 30404588 PMCID: PMC6238162 DOI: 10.1177/0269216318800172] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND In planning high-quality research in any aspect of care for children and young people with life-limiting conditions, it is important to prioritise resources in the most appropriate areas. AIM To map research priorities identified from existing research prioritisation exercises relevant to infants, children and young people with life-limiting conditions, in order to inform future research. DESIGN We undertook a systematic scoping review to identify existing research prioritisation exercises; the protocol is publicly available on the project website. DATA SOURCES The bibliographic databases ASSIA, CINAHL, MEDLINE/MEDLINE In Process and Embase were searched from 2000. Relevant reference lists and websites were hand searched. Included were any consultations aimed at identifying research for the benefit of neonates, infants, children and/or young people (birth to age 25 years) with life-limiting, life-threatening or life-shortening conditions; their family, parents, carers; and/or the professional staff caring for them. RESULTS A total of 24 research prioritisation exercises met the inclusion criteria, from which 279 research questions or priority areas for health research were identified. The priorities were iteratively mapped onto an evolving framework, informed by World Health Organization classifications. This resulted in identification of 16 topic areas, 55 sub-topics and 12 sub-sub-topics. CONCLUSION There are numerous similar and overlapping research prioritisation exercises related to children and young people with life-limiting conditions. By mapping existing research priorities in the context in which they were set, we highlight areas to focus research efforts on. Further priority setting is not required at this time unless devoted to ascertaining families' perspectives.
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Affiliation(s)
- Alison Booth
- Martin House Research Centre, Department of Health Sciences, Faculty of Sciences, University of York, York, UK
| | - Jane Maddison
- Social Policy Research Unit, University of York, York, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Lorna Fraser
- Martin House Research Centre, Department of Health Sciences, Faculty of Sciences, University of York, York, UK
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Affiliation(s)
- Quique Bassat
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain, Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
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Stacey SR, Turner SC, Coulthard KP, Miller H. Paediatric Pharmacy in Australia: Where Have We Come From and Where Do We Need To Go? JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2013.tb00215.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Sonya R Stacey
- Royal Children's Hospital, The Queensland Children's Medical Research Institute, School of Pharmacy; The University of Queensland
| | | | | | - Hugh Miller
- Royal Children's Hospital, Children's Health Queensland Hospital and Health Service; Brisbane Queensland
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Mellis C. Evidence-based medicine: what has happened in the past 50 years? J Paediatr Child Health 2015; 51:65-8. [PMID: 25536873 DOI: 10.1111/jpc.12800] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2014] [Indexed: 12/27/2022]
Abstract
Although the phrase 'evidence-based medicine' (EBM) was used for the first time in the medical literature less than 25 years ago, the history of EBM goes back for centuries. What is remarkable is how popular and how globally accepted the EBM movement has become in such a short time. Many famous, past clinicians have played major roles in the disciplines that preceded EBM, particularly 'clinical epidemiology'. It soon became clear to the early EBM champions that 'evidence' was only part of the clinical decision-making process. Consequently, both clinical expertise and the patient's values and preferences were rapidly incorporated into the concept we now know as 'EBM'. The current need for high-quality, easily accessible 'evidence-based summaries' for busy clinicians is now apparent, as traditional EBM requires both considerable time and skill. Consequently, there is a progressive move away from the primary literature (such as randomised controlled trials) to systematic reviews and other 'evidence-based summaries'. The future of EBM will almost certainly involve widespread utilisation of 'clinical (computer)-based decision support systems'.
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Affiliation(s)
- Craig Mellis
- Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Sage DP, Kulczar C, Roth W, Liu W, Knipp GT. Persistent pharmacokinetic challenges to pediatric drug development. Front Genet 2014; 5:281. [PMID: 25221567 PMCID: PMC4145254 DOI: 10.3389/fgene.2014.00281] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 07/31/2014] [Indexed: 12/11/2022] Open
Abstract
The development of new therapeutic agents for the mitigation of pediatric disorders is largely hindered by the inability for investigators to assess pediatric pharmacokinetics (PK) in healthy patients due to substantial safety concerns. Pediatric patients are a clinical moving target for drug delivery due to changes in absorption, distribution, metabolism and excretion (ADME) and the potential for PK related toxicological (T) events to occur throughout development. These changes in ADMET can have profound effects on drug delivery, and may lead to toxic or sub-therapeutic outcomes. Ethical, economical, logistical, and technical barriers have resulted in insufficient investigation of these changes by industrial, regulatory, and academic bodies, leading to the classification of pediatric patients as therapeutic orphans. In response to these concerns, regulatory agencies have incentivized investigation into these ontogenic changes and their effects on drug delivery in pediatric populations. The intent of this review is to briefly present a synopsis of the development changes that occur in pediatric patients, discuss the effects of these changes on ADME and drug delivery strategies, highlight the hurdles that are still being faced, and present some opportunities to overcome these challenges.
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Affiliation(s)
- Daniel P Sage
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University West Lafayette, IN, USA
| | - Christopher Kulczar
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University West Lafayette, IN, USA
| | - Wyatt Roth
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University West Lafayette, IN, USA
| | - Wanqing Liu
- Department of Medicinal Chemistry and Molecular Pharmacology, College of Pharmacy, Purdue University West Lafayette, IN, USA
| | - Gregory T Knipp
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University West Lafayette, IN, USA
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Pediatric health care quality measures: considerations for pharmacotherapy. Paediatr Drugs 2013; 15:441-7. [PMID: 23918049 DOI: 10.1007/s40272-013-0042-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Measuring the quality use of medicines can be conceptualized as a mechanism for understanding appropriate use, underuse, overuse, or misuse. For pediatric pharmacotherapy, measuring the quality use of medicines requires awareness of the differences in health care between children and adults and the differences in the quality and quantity of science that supports evidence-based practice in pediatric health care compared with adult health care. Here we use the Pediatric Quality Measures Program that arose from the Children's Health Insurance Program Reauthorization Act in the United States to illustrate the challenges in developing quality measures of pediatric pharmacotherapy. The challenges are primarily twofold: (i) weak evidence base for the specific pharmacotherapy in children and (ii) limited data to calculate the measure. A weak evidence base must often be weighed against the importance of the topic if the quality measure is intended to address a known quality of care or public health problem. Limited data because of insufficient amount or inappropriate type will affect implementation of the measure and its eventual usefulness. Methods to meet these challenges often depend on the priorities of and the tools available to end users. Health information technology is emerging as a tool to improve quality measurement but presents additional challenges.
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Roth WJ, Kissinger CB, McCain RR, Cooper BR, Marchant-Forde JN, Vreeman RC, Hannou S, Knipp GT. Assessment of juvenile pigs to serve as human pediatric surrogates for preclinical formulation pharmacokinetic testing. AAPS JOURNAL 2013; 15:763-74. [PMID: 23595360 DOI: 10.1208/s12248-013-9482-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 03/25/2013] [Indexed: 11/30/2022]
Abstract
Pediatric drug development is hampered by biological, clinical, and formulation challenges associated with age-based populations. A primary cause for this lack of development is the inability to accurately predict ontogenic changes that affect pharmacokinetics (PK) in children using traditional preclinical animal models. In response to this issue, our laboratory has conducted a proof-of-concept study to investigate the potential utility of juvenile pigs to serve as surrogates for children during preclinical PK testing of selected rifampin dosage forms. Pigs were surgically modified with jugular vein catheters that were externalized in the dorsal scapular region and connected to an automated blood sampling system (PigTurn-Culex-L). Commercially available rifampin capsules were administered to both 20 and 40 kg pigs to determine relevant PK parameters. Orally disintegrating tablet formulations of rifampin were also developed and administered to 20 kg pigs. Plasma samples were prepared from whole blood by centrifugation and analyzed for rifampin content by liquid chromatography-tandem mass spectrometry. Porcine PK parameters were determined from the resultant plasma-concentration time profiles and contrasted with published rifampin PK data in human adults and children. Results indicated significant similarities in dose-normalized absorption and elimination parameters between pigs and humans. Moreover, ontogenic changes observed in porcine PK parameters were consistent with ontogenic changes reported for human PK. These results demonstrate the potential utility of the juvenile porcine model for predicting human pediatric PK for rifampin. Furthermore, utilization of juvenile pigs during formulation testing may provide an alternative approach to expedite reformulation efforts during pediatric drug development.
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Affiliation(s)
- Wyatt J Roth
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA
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Adams LV, Craig SR, Mmbaga EJ, Naburi H, Lahey T, Nutt CT, Kisenge R, Noel GJ, Spielberg SP. Children's medicines in Tanzania: a national survey of administration practices and preferences. PLoS One 2013; 8:e58303. [PMID: 23484012 PMCID: PMC3590153 DOI: 10.1371/journal.pone.0058303] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 02/01/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The dearth of age-appropriate formulations of many medicines for children poses a major challenge to pediatric therapeutic practice, adherence, and health care delivery worldwide. We provide information on current administration practices of pediatric medicines and describe key stakeholder preferences for new formulation characteristics. PATIENTS AND METHODS We surveyed children aged 6-12 years, parents/caregivers over age 18 with children under age 12, and healthcare workers in 10 regions of Tanzania to determine current pediatric medicine prescription and administration practices as well as preferences for new formulations. Analyses were stratified by setting, pediatric age group, parent/caregiver education, and healthcare worker cadre. RESULTS Complete data were available for 206 children, 202 parents/caregivers, and 202 healthcare workers. Swallowing oral solid dosage forms whole or crushing/dissolving them and mixing with water were the two most frequently reported methods of administration. Children frequently reported disliking medication taste, and many had vomited doses. Healthcare workers reported medicine availability most significantly influences prescribing practices. Most parents/caregivers and children prefer sweet-tasting medicine. Parents/caregivers and healthcare workers prefer oral liquid dosage forms for young children, and had similar thresholds for the maximum number of oral solid dosage forms children at different ages can take. CONCLUSIONS There are many impediments to acceptable and accurate administration of medicines to children. Current practices are associated with poor tolerability and the potential for under- or over-dosing. Children, parents/caregivers, and healthcare workers in Tanzania have clear preferences for tastes and formulations, which should inform the development, manufacturing, and marketing of pediatric medications for resource-limited settings.
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Affiliation(s)
- Lisa V Adams
- Audrey and Theodor Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
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Coelho HLL, Rey LC, de Medeiros MS, Barbosa RA, da Cruz Fonseca SG, da Costa PQ. A critical comparison between the World Health Organization list of essential medicines for children and the Brazilian list of essential medicines (Rename). JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2013. [DOI: 10.1016/j.jpedp.2012.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Coelho HLL, Rey LC, Medeiros MSGD, Barbosa RA, Cruz Fonseca SGD, Costa PQD. A critical comparison between the World Health Organization list of essential medicines for children and the Brazilian list of essential medicines (Rename). J Pediatr (Rio J) 2013; 89:171-8. [PMID: 23642428 DOI: 10.1016/j.jped.2013.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 08/29/2012] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To perform a critical comparison between the Brazilian national essential medicines list (Rename, 2012) with the list of essential medicines for children (LEMC, 2011) of the World Health Organization (WHO), regarding the differences among drugs and formulations listed for children. METHODS The LEMC drugs were classified into four categories: 1) absent in Rename; 2) included in Rename but without any formulation suitable for children; 3) listed in Rename only in some formulations; 4) present in Rename in all formulations. The missing formulations were analyzed by therapeutic group. Alternatives present in Rename were searched. RESULTS From the 261 drugs of interest on the LEMC, 30.3% are absent from Rename, 11.1% are in Rename but without any pediatric formulation, and 32.2% are present in some but not all formulations listed in LEMC. Considering all formulations items listed in the LEMC (n = 577), 349 are missing from Rename, of these 19.6% due to their strength, and 18.5% due to the the dosage form. Useful formulations specific for neonatal care, respiratory tract, central nervous system, and anti-infectives, among other groups, are missing. CONCLUSION The lack of age-appropriate formulations of essential medicines for children in Brazil includes important therapeutic groups and indispensable drugs for severe clinical conditions. Some of these products exist in the Brazilian pharmaceutical market, but not in public facilities; others could be produced by national laboratories with commercial interest or stimulated by a specific governmental policy, as in other countries.
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Affiliation(s)
- Helena Lutéscia L Coelho
- Programa de Pós-graduação em Ciências Farmacêuticas, Universidade Federal do Ceará UFC, Fortaleza, CE, Brazil.
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Cohen SA, Lawson JA, Graudins LV, Pearson SA, Gazarian M. Changes in anticonvulsant prescribing for Australian children: implications for Quality Use of Medicines. J Paediatr Child Health 2012; 48:490-5. [PMID: 22050665 DOI: 10.1111/j.1440-1754.2011.02223.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS The evidence-base guiding choices between newer versus established anticonvulsants in children is limited. Inappropriate use exposes children to potentially ineffective and/or harmful medicines. Our objective is to describe recent anticonvulsant prescribing patterns in the Australian paediatric population, evaluating overall trends and extent of off-label prescribing of newer agents. METHODS Aggregated national data on 15 anticonvulsants with Pharmaceutical Benefits Scheme subsidy dispensed by community pharmacies for children aged <16 years were obtained from the Drug Utilisation Subcommittee, which is part of the Australian Government Department of Health and Ageing. We analysed trends for the five most prescribed anticonvulsants dispensed between 2002 and 2009 and off-label prescribing for agents where approved Australian product information stipulates a minimum age. RESULTS Valproate was the most frequently prescribed anticonvulsant with no marked change in prescription numbers per 1000 children aged 0-16 years (11.3-11.8 prescriptions/year). Lamotrigine was the most frequently prescribed newer anticonvulsant (7.9-9.3 prescriptions/year). Carbamazepine prescriptions decreased by 38% and topiramate prescriptions increased by 19% over the 7-year study period; 3.6% of topiramate prescriptions were off-label (by age) for children aged <2 years. Since Pharmaceutical Benefits Scheme listing in 2003, levetiracetam prescriptions increased steeply to 2.5 prescriptions/year per 1000 children in 2009; 4.2% were off-label for children aged <4 years. CONCLUSIONS The substantial reduction in carbamazepine use and corresponding increase in newer anticonvulsant prescribing, including off-label uses, raises questions about potentially suboptimal Quality Use of Medicines. Such major changes in prescribing may have important clinical and economic consequences. Further study to better understand paediatric prescribing choices and outcomes is needed.
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Affiliation(s)
- Simon A Cohen
- Department of Paediatric Neurology, Sydney Children's Hospital, Randwick, Australia.
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Hoppu K, Anabwani G, Garcia-Bournissen F, Gazarian M, Kearns GL, Nakamura H, Peterson RG, Sri Ranganathan S, de Wildt SN. The status of paediatric medicines initiatives around the world--What has happened and what has not? Eur J Clin Pharmacol 2011; 68:1-10. [PMID: 21732178 DOI: 10.1007/s00228-011-1089-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 06/09/2011] [Indexed: 01/07/2023]
Abstract
PURPOSE This review was conducted to examine the current status of paediatric medicines initiatives across the globe. METHODS The authors made a non-systematic descriptive review of current world situation. RESULTS Two regions, the United States (US) and the European Union (EU), and the World Health Organization (WHO) have introduced strong paediatric initiatives to improve children's health through improving access to better paediatric medicines. The experience from the US initiative indicates that it is possible to stimulate development and study of paediatric medicines and provide important new information for improvement of paediatric therapy. The early results from the EU initiative are similarly encouraging. In Canada, Japan, Australia and other developed countries, specific paediatric medicines initiatives have been less extensive and weaker, with modest results. Disappointingly, current evidence suggests that results from clinical trials outside the US often do not benefit children in the country in which the trials were largely conducted. Pharmaceutical companies that have derived a financial benefit commensurate with the cost of doing the paediatric trials in one country do not seem to be making the results of these trials available to all countries if there is no financial incentive to the company. The WHO campaign 'make medicines child size' has produced substantive accomplishments in building improved foundations to improve mechanisms that will enhance children's access to critical medicines in resource-limited settings. However, practically all of this work has been performed using an amalgamation of short-term funding from a variety of sources as opposed to a sustained, programmatic commitment. CONCLUSIONS Although much still needs to be done, it's clear that with concerted efforts and appropriate resources, change is possible but slow. Retaining and fostering public and political interest in paediatric medicines is challenging, but pivotal for success.
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Affiliation(s)
- Kalle Hoppu
- Hospital for Children and Adolescents and Dept. of Clinical Pharmacology, University of Helsinki and Poison Information Centre, Helsinki University Central Hospital, P.O. Box 790, 00029, Helsinki, Finland.
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Jones S, James E, Prasad S. Disease registries and outcomes research in children: focus on lysosomal storage disorders. Paediatr Drugs 2011; 13:33-47. [PMID: 21162599 DOI: 10.2165/11586860-000000000-00000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Assessing medicines specifically for use in children has been neglected in the past, with the majority of formal clinical studies being conducted in adults. Clinical trials are a pivotal part of the drug approval process; however, they are not always applicable to the diverse populations - including children - that receive the drug after approval. They may not be the most informative assessment tool, especially in rare (or orphan) disorders where there are few patients, due to a lack of existing natural history data and the challenges of designing appropriately powered statistical analyses. Disease registries, which can collect clinical information in larger, more heterogeneous populations than can be included in a clinical trial, are becoming increasingly valuable. Their use is particularly beneficial for diseases affecting very small patient populations, such as lysosomal storage disorders (LSDs), and for looking at specific populations, for example, children. Such disease registries can provide natural history data as well as enable the impact of therapy to be examined. Moreover, despite potential limitations of enrollment bias and unmonitored data, patient registries can play a valuable role in assuring pediatric health, providing longitudinal data that can be used to monitor developmental outcomes in chronic lifelong diseases, and assessing the effectiveness of treatment. This review describes the role of registries in drug development and regulatory approval, the impact of global registry programs on pediatric research, with some examples from the field of LSDs, and how registries are impacting the clinical care such children receive.
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Affiliation(s)
- Simon Jones
- Willink Unit, Genetic Medicine, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, St Marys Hospital, Manchester, UK
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Lasky T, Ernst FR, Greenspan J, Wang S, Gonzalez L. Estimating pediatric inpatient medication use in the United States. Pharmacoepidemiol Drug Saf 2010; 20:76-82. [DOI: 10.1002/pds.2063] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2010] [Revised: 09/02/2010] [Accepted: 09/14/2010] [Indexed: 11/08/2022]
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Journal Watch. Pharmaceut Med 2009. [DOI: 10.1007/bf03256748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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