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Werner RN, Pennitz A, Eisert L, Schmidle P, Zink A, Abraham S, Schäkel K, Wolff I, Goebeler M, Plange J, Sollfrank L, Zielbauer S, Koll P, Amschler K, Müller V, Nast A. The impact of off-label use regulations on patient care in dermatology - A prospective study of cost-coverage applications filed by tertiary dermatology clinics throughout Germany. J Eur Acad Dermatol Venereol 2022; 36:2241-2249. [PMID: 35737866 DOI: 10.1111/jdv.18357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND In dermatology, a medical specialty with a relatively high number of rare diseases, physicians often have to resort to off-label treatment options. To avoid claims, physicians in Germany can file a cost coverage-request (off label-application, OL-A). OBJECTIVES Our aim was to investigate the extent to which the current regulations affect patient care. MATERIAL AND METHODS Prospective cohort study among tertiary dermatology clinics throughout Germany, consecutively including OL-As (05/2019-09/2020) and assessing the follow-up correspondence. We modelled regressions to assess factors associated with cost coverage decisions and the time needed by health insurers to process the OL-As. RESULTS Thirteen clinics provided data on 121 OL-As, two of which applied for on-label treatments. Of the remaining 119 OL-As, 70 (58.8%) were immediately approved and 44 (37.0%) rejected. Including cases with one or more appeals, 87 of 119 OL-As (73.1%) were finally approved and 26 (21.9%) rejected. There was an association of the final approval rate with (1) the class of medication/treatment, with approval rates being significantly lower for JAK inhibitors than for biologics (OR 0.16, 95%-CI: 0.03-0.82); (2) German state, with approval rates being lower in eastern than in western states (OR 0.30, 95%-CI 0.12-0.76); and (3) cost of the intervention (no linear trend). However, none of these predictors was significant in our multiple logistic regression models. The median health insurer's processing time (first response) was 29 days (IQR 22-38). Our analyses showed no evidence of an association with the predictors we assessed. In cases approved, the median time from the decision to file an OL-A to the actual initiation of the treatment was 65.5 days (IQR 51-92). CONCLUSIONS Our study points to substantial delays and inequalities in the provision of timely health care for dermatological patients with rare diseases, often involving treatments for which there is no adequate approved therapy.
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Affiliation(s)
- Ricardo Niklas Werner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venereology and Allergology, Division of Evidence-based Medicine (dEBM), Charitéplatz 1, 10117, Berlin, Germany
| | - Antonia Pennitz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venereology and Allergology, Division of Evidence-based Medicine (dEBM), Charitéplatz 1, 10117, Berlin, Germany
| | - Lisa Eisert
- Vivantes Klinikum Neukölln, Department of Dermatology and Venereology, Rudower Straße 48, 12351, Berlin, Germany
| | - Paul Schmidle
- Technical University Munich, School of Medicine, Department of Dermatology and Allergy Biederstein, Biedersteiner Str. 29, 80802, Munich, Germany
| | - Alexander Zink
- Technical University Munich, School of Medicine, Department of Dermatology and Allergy Biederstein, Biedersteiner Str. 29, 80802, Munich, Germany
| | - Susanne Abraham
- Technische Universität Dresden, Carl Gustav Carus Faculty of Medicine, Department of Dermatology, Fetscherstr. 74, 01307, Dresden, Germany
| | - Knut Schäkel
- University Hospital Heidelberg, Department of Dermatology, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Isabel Wolff
- Universitätsklinikum Tübingen, Department of Dermatology, Liebermeisterstraße 25, 72076, Tübingen, Germany
| | - Matthias Goebeler
- Universitätsklinikum Würzburg, Department of Dermatology, Venereology and Allergology, Josef-Schneider Str. 2, Gebäude D8, 97080, Würzburg, Germany
| | - Johanna Plange
- RWTH Aachen University, Department of Dermatology, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Lukas Sollfrank
- Friedrich Alexander University Erlangen-Nürnberg (FAU), Universitätsklinikum Erlangen, Department of Dermatology, German Center for Immunotherapy, Deutsches Zentrum Immuntherapie, Ulmenweg 20, 91054, Erlangen, Germany
| | - Sebastian Zielbauer
- Goethe Universität Frankfurt am Main, Universitätsklinikum Frankfurt, Department of Dermatology, Venereology and Allergology, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Goethe Universität Frankfurt am Main, Universitätsklinikum Frankfurt, Institute for General Practice, Evidence-based Medicine Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Philipp Koll
- Universität zu Köln, Department of Dermatology, Kerpenerstr. 62, 50937, Köln, Germany
| | - Katharina Amschler
- University Medical Center Göttingen, Department of Dermatology, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Verena Müller
- German Cancer Research Center (DKFZ), Skin Cancer Unit, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Ruprecht-Karl University of Heidelberg, Mannheim, University Medical Center Mannheim, Department of Dermatology, Venereology and Allergology, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Alexander Nast
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Dermatology, Venereology and Allergology, Division of Evidence-based Medicine (dEBM), Charitéplatz 1, 10117, Berlin, Germany
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2
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Mangoni AA, Jarmuzewska EA. Patient-Centricity: A Much-Needed Strategy to Enhance the Quality Use of Medicines in Older Patients. Curr Rev Clin Exp Pharmacol 2022; 17:1-2. [DOI: 10.2174/277243281701211223100004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Elzbieta A. Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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Han N, Oh JM, Kim IW. Adverse Events Related to Off-Label Drugs Using Spontaneous Adverse Event Reporting Systems. Ther Clin Risk Manag 2021; 17:877-887. [PMID: 34456568 PMCID: PMC8387311 DOI: 10.2147/tcrm.s321789] [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: 05/26/2021] [Accepted: 08/10/2021] [Indexed: 12/16/2022] Open
Abstract
Purpose The purpose of this study was to investigate the adverse events (AEs) related to the use of off-label drugs. Materials and Methods A cross-sectional study was carried out using available data pertaining to off-label drug were sourced from U.S. FDA spontaneous adverse drug reaction reporting database (FAERS) and Korea Adverse Event Reporting System database (KIDS-KD) for the years 2014 to 2018. The number and frequencies of AE cases were calculated. Disproportionality was analyzed using the proportional reporting ratio (PRR), the reporting odds ratio (ROR), the information component (IC), and the empirical Bayes geometric mean (EBGM) methods. Results The reported AEs associated with off-label drug use were more common among older patients compared with younger patients. Gastric nonspecific symptoms and therapeutic procedure (4.16–4.57%) and haemorrage term (4.16–5.29%) were the most common AE symptoms and antithrombotic agents and immunosuppressants were the drugs most commonly reported to cause AEs in FAERS. Secondary term events (43.45–48.62%) including inappropriate schedule of drug administration and medication error were the most common AEs, and immunosuppressants and antipsychotics were the most common AE-related drugs from KIDS-KD. The numbers of reported AEs in new drug categories such as other antineoplastic agents trended to increase from 2014 to 2018 in both datasets. Conclusion The numbers of reported AEs with off-label drug increased annually. AEs associated with off-label drugs may have a significant impact on older patients. Healthcare experts should be concerned about prescriptions of off-label drugs, especially anticoagulants and newly developed drugs such as immunosuppressants and antineoplastic agents.
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Affiliation(s)
- Nayoung Han
- Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea.,College of Pharmacy, Jeju National University, Jejusi, Jeju Special Self-Governing Province, Republic of Korea
| | - Jung Mi Oh
- Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea.,College of Pharmacy, Seoul National University, Seoul, Republic of Korea
| | - In-Wha Kim
- Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
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4
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Laroche ML, Van Ngo TH, Sirois C, Daveluy A, Guillaumin M, Valnet-Rabier MB, Grau M, Roux B, Merle L. Mapping of drug-related problems among older adults conciliating medical and pharmaceutical approaches. Eur Geriatr Med 2021; 12:485-497. [PMID: 33745106 DOI: 10.1007/s41999-021-00482-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/06/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To lay the fundamentals of drug-related problems (DRPs) in older adults, and to organize them according to a logical process conciliating medical and pharmaceutical approaches, to better identify the causes and consequences of DRPs. MATERIALS AND METHODS A narrative overview. RESULTS The causes of DRPs may be intentional or unintentional. They lie in poor prescription, poor adherence, medication errors (MEs) and substance use disorders (SUD). Poor prescription encompasses sub-optimal or off-label drug choice; this choice is either intentional or unintentional, often within a polypharmacy context and not taking sufficiently into account the patient's clinical condition. Poor adherence is often the consequence of a complicated administration schedule. This review shows that MEs are not the most frequent causes of DRPs. SUD are little studied in older adults and needs to be more investigated because the use of psychoactive substances among older people is frequent. Prescribers, pharmacists, nurses, patients, and caregivers all play a role in different causes of DRPs. The potential deleterious outcomes of DRPs result from adverse drug reactions and therapeutic failures. These can lead to a negative benefit-risk ratio for a given treatment regimen. DISCUSSION/CONCLUSION Interdisciplinary pharmacotherapy programs show significant clinical impacts in preventing or resolving adverse drug events and, suboptimal responses. New technologies also seem to be interesting solutions to prevent MEs. Better communication between healthcare professionals, patients and their caregivers would ensure greater safety and effectiveness of treatments.
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Affiliation(s)
- Marie-Laure Laroche
- Centre de Pharmacovigilance, de Pharmacoépidémiologie et D'information sur les Médicaments, Centre de Biologie et de Recherche en Santé, Service de Pharmacologie, Toxicologie et Pharmacovigilance, CHU de Limoges, 87 042, Limoges Cedex, France. .,Université de Limoges, INSERM 1248, Faculté de Médecine, Limoges, France. .,Université de Limoges, Unité Vie-Santé, Faculté de Médecine, Limoges, France.
| | - Thi Hong Van Ngo
- Centre de Pharmacovigilance, de Pharmacoépidémiologie et D'information sur les Médicaments, Centre de Biologie et de Recherche en Santé, Service de Pharmacologie, Toxicologie et Pharmacovigilance, CHU de Limoges, 87 042, Limoges Cedex, France.,Université de Limoges, INSERM 1248, Faculté de Médecine, Limoges, France
| | - Caroline Sirois
- Université Laval, Faculté de Pharmacie, Québec, Canada.,Centre de Recherche VITAM en Santé Durable, Centre D'excellence sur le Vieillissement de Québec, Québec, Canada
| | - Amélie Daveluy
- Centre d'addictovigilance, Service de pharmacologie médicale, CHU Bordeaux, Bordeaux, France.,Université de Bordeaux, Inserm, Bordeaux Population Health Research Center, U1219, Bordeaux, France
| | - Michel Guillaumin
- Centre de Pharmacovigilance de Pharmacoépidémiologie et d'information sur les Médicaments de-Franche Comté, CHU Besançon, Besançon, France.,Département de Gériatrie, CHU de Besançon, Besançon, France
| | - Marie-Blanche Valnet-Rabier
- Centre de Pharmacovigilance de Pharmacoépidémiologie et d'information sur les Médicaments de-Franche Comté, CHU Besançon, Besançon, France
| | - Muriel Grau
- Centre de Pharmacovigilance, de Pharmacoépidémiologie et D'information sur les Médicaments, Centre de Biologie et de Recherche en Santé, Service de Pharmacologie, Toxicologie et Pharmacovigilance, CHU de Limoges, 87 042, Limoges Cedex, France.,Université de Limoges, Unité Vie-Santé, Faculté de Médecine, Limoges, France
| | - Barbara Roux
- Centre de Pharmacovigilance, de Pharmacoépidémiologie et D'information sur les Médicaments, Centre de Biologie et de Recherche en Santé, Service de Pharmacologie, Toxicologie et Pharmacovigilance, CHU de Limoges, 87 042, Limoges Cedex, France.,Université de Limoges, INSERM 1248, Faculté de Médecine, Limoges, France
| | - Louis Merle
- Centre de Pharmacovigilance, de Pharmacoépidémiologie et D'information sur les Médicaments, Centre de Biologie et de Recherche en Santé, Service de Pharmacologie, Toxicologie et Pharmacovigilance, CHU de Limoges, 87 042, Limoges Cedex, France.,Université de Limoges, Unité Vie-Santé, Faculté de Médecine, Limoges, France
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5
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Mangoni AA, Erre GL. Translating evidence into practice during the COVID-19 pandemic: pitfalls and mileages. Ther Adv Drug Saf 2021; 12:2042098621998876. [PMID: 33796258 PMCID: PMC7968020 DOI: 10.1177/2042098621998876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Arduino A. Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Bedford Park, SA 5042, Australia
| | - Gian Luca Erre
- Dipartimento di Scienze Mediche, Università degli Studi di Sassari, Sassari, Italy, and Dipartimento di Specialità Mediche, Azienda Ospedaliero-Universitaria di Sassari, Sassari, Italy
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Mangoni AA, Jarmuzewska EA. Incorporating pharmacokinetic data into personalised prescribing for older people: challenges and opportunities. Eur Geriatr Med 2021; 12:435-442. [PMID: 33417165 DOI: 10.1007/s41999-020-00437-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 12/09/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE We discuss the known age-associated changes in drug metabolism and elimination, the potential use of this information when selecting specific therapeutic strategies in older patients, and the steps required to fill the knowledge gap in this field. METHODS We conducted a narrative review that encapsulates the current knowledge regarding the main age-associated changes in drug metabolism and elimination and discusses their possible inclusion in current and future personalised prescribing tools for the older patient population. RESULTS Despite some progress in this field, the lack of specific information regarding the impact of frailty, pharmacogenomics, and drug-drug, drug-disease, and organ-organ interactions, particularly in subjects > 80 years, currently prevents the routine incorporation of pharmacokinetic data, barring measures of renal function, into personalised prescribing tools. CONCLUSIONS The incorporation of pharmacokinetic data into personalised prescribing, an approach based on the consideration of a number of patient's characteristics when selecting the right drug(s) and dose regimen(s) to maximize effectiveness and limit toxicity, remains a hypothetical construct in geriatric care. Pending the inclusion of frail and complex older patients in pre- and post-marketing studies, a better understanding of the key pharmacokinetic alterations of common medications in "real-life" patients, together with the implementation of effective strategies tackling inappropriate prescribing, is likely to improve clinical outcomes and reduce healthcare utilization in the older population.
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Affiliation(s)
- Arduino A Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Bedford Park, SA, 5042, Australia. .,Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Elzbieta A Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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7
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Exposure to Antidepressant Medication and the Risk of Incident Dementia. Am J Geriatr Psychiatry 2019; 27:1177-1188. [PMID: 31235427 DOI: 10.1016/j.jagp.2019.05.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/27/2019] [Accepted: 05/27/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To test competing hypotheses that monotherapeutic antidepressant exposure is associated with an increased versus a decreased risk of dementia. METHODS A prospective national matched cohort study from Israel (N = 71,515) without dementia (2002-2012) aged 60 and over were followed up for incident dementia from May 2013 to October 2017. Exposure to antidepressant monotherapy was classified with Anatomical Therapeutic Chemical Codes (N06A) from January 1, 2013 to December 31, 2016. The association between antidepressant monotherapy and the risk of incident dementia was quantified with hazard ratios (HR) and their 95% confidence intervals (CI) obtained from Cox regression models unadjusted and adjusted for 42 covariates. The robustness of the results was tested with 24 sensitivity analyses: 19 analyses restricted to subsamples with plausible differential dementia risks (e.g., anxiety and depression), and 5 analyses across and within antidepressant drug classes. RESULTS In the primary analysis, the risk of incident dementia for the group exposed to antidepressant monotherapy compared to the group unexposed to antidepressants was estimated with an unadjusted HR = 4.09 (df = 1, 95% Wald CI = 3.64, 4.60) and an adjusted HR = 3.43 (df = 1, 95% Wald CI = 3.04, 3.88). Across the 24 sensitivity analyses the estimated adjusted HR values ranged from 1.99 to 5.47. CONCLUSION In this study, monotherapeutic antidepressant exposure in old age was associated with increased incident dementia. Clinicians, caregivers, and patients may wish to consider this potentially negative consequence of antidepressant exposure and aim to balance the costs and benefits of treatment.
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Mangoni AA, Bryant K, Jarmuzewska EA. Medication Management Issues in Old Age: A Call for Submissions to Current Clinical Pharmacology. ACTA ACUST UNITED AC 2019; 14:2-4. [PMID: 30968764 DOI: 10.2174/157488471401190301120237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Arduino A Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders, University and Flinders Medical Centre, Adelaide, Australia
| | - Kimberley Bryant
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders, University and Flinders Medical Centre, Adelaide, Australia.,Department of Orthopaedic and Trauma Surgery, College of Medicine and Public Health, Flinders University and Flinders, Medical Centre, Adelaide, Australia
| | - Elzbieta A Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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Ruiter R, Burggraaf J, Rissmann R. Under-representation of elderly in clinical trials: An analysis of the initial approval documents in the Food and Drug Administration database. Br J Clin Pharmacol 2019; 85:838-844. [PMID: 30681181 PMCID: PMC6422639 DOI: 10.1111/bcp.13876] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/04/2019] [Accepted: 01/18/2019] [Indexed: 01/02/2023] Open
Abstract
Aims To evaluate the availability of pharmacokinetic, safety and efficacy analyses specifically targeted at elderly, prior to the authorization of drugs. Methods A cross‐sectional, structured review of publicly available initial approval documents of Food and Drug Administration‐approved drugs was performed. The 10 most frequently on‐label prescribed drug classes, drugs with known pharmacokinetic differences in the elderly or drugs that are relatively contraindicated in elderly (e.g. anticholinergics or benzodiazepines) were included in the analyses. Results In total, 1129 unique active pharmaceutical ingredients were found eligible for the analyses, of these, 506 were found in the Food and Drug Administration database (45%). The initial approval documents were available for 182 drugs. For the majority of the drugs, the initial approval documents in the database showed information on pharmacokinetics in elderly (n = 113; 62%). Furthermore, over time, the availability of information with regard to elderly increased statistically significantly from 0% in the period 1970–1979 to 76% for the period 2010–2018. Information on safety and efficacy was less frequently present, i.e. 42% and 45%, respectively and, moreover, the availability of information did not improve over time. Conclusion The under‐representation of elderly in clinical trials thereby challenging the external validity of benefit/risk assessments of launched drugs was confirmed. Priority should be given to a study population that is representative for the target population.
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Affiliation(s)
- Rikje Ruiter
- Centre for Human Drug Research, Leiden, the Netherlands.,Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
| | - Jacobus Burggraaf
- Centre for Human Drug Research, Leiden, the Netherlands.,Leiden University Medical Centre, Leiden, the Netherlands.,Leiden Academic Center for Drug Research, Leiden, the Netherlands
| | - Robert Rissmann
- Centre for Human Drug Research, Leiden, the Netherlands.,Leiden University Medical Centre, Leiden, the Netherlands.,Leiden Academic Center for Drug Research, Leiden, the Netherlands
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10
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Abstract
PURPOSE The authors investigated whether the use of psychotropics and environmental temperature on admission influence hospital length of stay (LOS) and mortality in older medical patients. METHODS Clinical and demographic characteristics, Charlson Comorbidity Index, use of psychotropic and nonpsychotropic drugs, hospital LOS, and mortality were retrospectively collected in medical patients 65 years and older (n = 382) admitted to a metropolitan teaching hospital during 5 consecutive heat waves (HWs) between 2007 and 2009. Patients admitted either before or after each HW, matched for HW period, age, and admission day of the week, served as controls (non-HW, n = 1339). RESULTS Total number of psychotropic and nonpsychotropic drugs, Charlson Comorbidity Index, comorbidities, number of daily admissions, LOS, and mortality were similar in the HW and non-HW groups. After adjusting for clinical and demographic confounders, competing risks regression showed that psychotropic use, particularly antipsychotics, predicted increased LOS during non-HW (subdistribution hazard ratio: 95% CI, 0.82, 0.72-0.94; P = 0.003) but not HW (subdistribution hazard ratio: 95% CI, 0.89, 0.69-1.14; P = 0.36) periods. The effect of psychotropics on LOS during normal weather conditions was particularly evident in the old-old subgroup (difference [SE] in coefficients between non-HW and HW periods: -0.52 [0.25], P = 0.036 in patients >80 years; 0.11 [0.19], P = 0.54, in patients 65-80 years). By contrast, psychotropics did not predict hospital mortality during non-HW or HW periods. CONCLUSIONS Psychotropic use on admission, particularly antipsychotics, predicted hospital LOS, but not mortality, in older medical patients, particularly those older than 80 years, during normal environmental temperature. However, there was no effect of psychotropics on LOS during extreme heat.
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van Riet-Nales DA, Hussain N, Sundberg KA, Eggenschwyler D, Ferris C, Robert JL, Cerreta F. Regulatory incentives to ensure better medicines for older people: From ICH E7 to the EMA reflection paper on quality aspects. Int J Pharm 2016; 512:343-351. [DOI: 10.1016/j.ijpharm.2016.05.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 04/29/2016] [Accepted: 05/01/2016] [Indexed: 10/21/2022]
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Alafris A. The Ongoing Dilemma on the Use of Antipsychotics to Manage the Behavioral Symptoms of Dementia. J Clin Pharmacol 2016; 56:1058-9. [DOI: 10.1002/jcph.763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/04/2016] [Indexed: 11/07/2022]
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13
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Mangoni AA, Pilotto A. New drugs and patient-centred end-points in old age: setting the wheels in motion. Expert Rev Clin Pharmacol 2015; 9:81-9. [PMID: 26455964 DOI: 10.1586/17512433.2016.1100074] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Older patients with various degrees of frailty and disability, a key population target of pharmacological interventions in acute and chronic disease states, are virtually neglected in pre-marketing studies assessing the efficacy and safety of investigational drugs. Moreover, aggressively pursuing established therapeutic targets in old age, e.g. blood pressure, serum glucose or cholesterol concentrations, is not necessarily associated with the beneficial effects, and the acceptable safety, reported in younger patient cohorts. Measures of self-reported health and functional status might represent additional, more meaningful, therapeutic end-points in the older population, particularly in patients with significant frailty and relatively short life expectancy, e.g. in the presence of cancer and/or neurodegenerative disease conditions. Strategies enhancing early knowledge about key pharmacological characteristics of investigational drugs targeting older adults are discussed, together with the rationale for incorporating non-traditional, patient-centred, end-points in this ever-increasing group.
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Affiliation(s)
- Arduino A Mangoni
- a Discipline of Clinical Pharmacology, School of Medicine , Flinders University and Flinders Medical Centre , Bedford Park , Australia
| | - Alberto Pilotto
- b Department of Orthogeriatrics, Rehabilitation and Stabilization, Frailty Area , E.O. Galliera Hospital, National Relevance and High Specialization Hospital , Genova , Italy
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14
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Iaboni A, Seitz DP, Fischer HD, Diong CC, Rochon PA, Flint AJ. Initiation of Antidepressant Medication After Hip Fracture in Community-Dwelling Older Adults. Am J Geriatr Psychiatry 2015; 23:1007-15. [PMID: 25488107 DOI: 10.1016/j.jagp.2014.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 09/16/2014] [Accepted: 10/13/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the incidence, characteristics, and correlates of antidepressant drug therapy initiation among community-dwelling older adults following hip fracture. DESIGN Retrospective cohort study using linked, population-based administrative data. SETTING Province of Ontario, Canada. PARTICIPANTS Older adults, aged 65 years or older, with a hip fracture and hip fracture surgery between April 1, 2003, and February 28, 2011. The study sample was restricted to individuals who returned home following surgery and who had not been dispensed an antidepressant in the year prior to their fracture (N=25,436). MEASUREMENTS We determined the incidence of new antidepressant use defined by the dispensing of antidepressant drug therapy within 90 days of discharge home. We identified independent correlates of antidepressant initiation using multivariate regression. RESULTS Overall, antidepressants were newly initiated in 8.8% of older adults with hip fracture in the 90 days following hospital discharge. There was a statistically significant, 1.3-fold increase in incidence of antidepressant prescribing from 2003 to 2010. Trazodone, frequently prescribed at a low dose, accounted for 39.0% of newly dispensed antidepressants, followed by selective serotonin reuptake inhibitors (36.9%). Rehabilitation admission, psychiatric evaluation, a diagnosis of dementia, and baseline benzodiazepine use were the strongest independent correlates of antidepressant initiation. CONCLUSION The period after a hip fracture is associated with a high rate of initiation of antidepressant therapy. The data raise the possibility that antidepressants are frequently prescribed off-label in these patients. Further research is needed to investigate the safety and efficacy of antidepressant use in this vulnerable population.
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Affiliation(s)
- Andrea Iaboni
- Departments of Psychiatry, University Health Network, and University of Toronto, Toronto, Ontario, Canada.
| | - Dallas P Seitz
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Hadas D Fischer
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Christina C Diong
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Paula A Rochon
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; Department of Medicine and Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Alastair J Flint
- Departments of Psychiatry, University Health Network, and University of Toronto, Toronto, Ontario, Canada
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Bartoli C, Berland-Benhaim C, Sastre C, Baillif-Couniou V, Kintz P, Leonetti G, Pelissier-Alicot AL. Off-Label Prescribing by Psychiatrists: What is the Practitioner's Liability? J Forensic Sci 2015; 60:1461-6. [PMID: 26260136 DOI: 10.1111/1556-4029.12814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 09/01/2014] [Indexed: 12/13/2022]
Abstract
In psychiatry, the molecules available and the dosages recommended when a drug receives marketing authorization are not always adequate to treat patients with major behavioral disturbances. Off-label prescribing is frequent in this context, with regard to the indications and the dosages given as well as to the drug combinations used. However, if complications or death occur, the practitioner's liability may be engaged. The authors report three deaths attributed to off-label prescribing in psychiatry and which led to charges against the physicians. They review the precautions to be taken when prescribing in such conditions (no other possible treatment, existence of sound scientific evidence, consent obtained from the patient, or their legal representatives except in cases of force majeure) and the physician's liability if adverse events occur that could be attributed to off-label prescribing.
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Affiliation(s)
| | | | - Caroline Sastre
- AP-HM, Hôpital de la Timone, Institut de Médecine Légale, 13385, Marseille, France
| | | | - Pascal Kintz
- X-Pertise Consulting, 42 rue Principale, 67206, Mittelhausbergen, France
| | - Georges Leonetti
- Aix-Marseille Université, 13284, Marseille, France.,AP-HM, Hôpital de la Timone, Institut de Médecine Légale, 13385, Marseille, France
| | - Anne-Laure Pelissier-Alicot
- Aix-Marseille Université, 13284, Marseille, France.,AP-HM, Hôpital de la Timone, Institut de Médecine Légale, 13385, Marseille, France
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Ndukwe HC, Tordoff JM, Wang T, Nishtala PS. Psychotropic Medicine Utilization in Older People in New Zealand from 2005 to 2013. Drugs Aging 2014; 31:755-68. [DOI: 10.1007/s40266-014-0205-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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17
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Benzinger P, Ahmed M, Abbatecola A. And the winner is… geriatric medicine: Highlights from the 9th Congress of the EUGMS in Venice Lido, Italy. Eur Geriatr Med 2014. [DOI: 10.1016/j.eurger.2014.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Fiß T, Thyrian JR, Wucherer D, Aßmann G, Kilimann I, Teipel SJ, Hoffmann W. Medication management for people with dementia in primary care: description of implementation in the DelpHi study. BMC Geriatr 2013; 13:121. [PMID: 24225205 PMCID: PMC3840668 DOI: 10.1186/1471-2318-13-121] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 11/01/2013] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND As the population ages, the relative and absolute number of age-associated diseases such as dementia will increase. Evaluation of the suitability and intake of medication and pharmacological treatment is an important aspect of care for people with dementia, especially if they live at home. Regular medication reviews and systematic cooperation between physicians and pharmacists are not common in routine care. Medication management (MM), based on such a comprehensive home medication review could help to reduce drug-related problems and costs. The present article presents a medication management specifically for the application in the ambulatory setting and describes its implementation as part of a larger trial. METHODS/DESIGN A home medication review (HMR) and MM is implemented as part of the DelpHi study, a population based prospective, cluster-randomized controlled intervention study to test the efficacy and efficiency of the implementation of a collaborative care model in primary care. PARTICIPANTS people with dementia (PWD) and their caregivers are recruited by the patient's general practitioner. Inclusion criteria are a positive screening result for dementia, living at home and regular intake of drugs. PWD are asked to specify their regular pharmacy which is asked to participate in the study, too. INTERVENTION a comprehensive HMR is conducted as computer-assisted personal interview by specifically qualified Dementia Care Manager (DCM) at the people's home. It includes detailed information about drugs taken, their storage, administration, adherence and adverse events. The MM is conducted in cooperation between DCM, pharmacist and general practitioner and consists of a pharmaceutical evaluation, pharmaceutical recommendations and their application. Pharmacists are trained and provided with regularly updated information. The MM is designed to give information and recommendations concerning antidementia drugs, occurrence of drug related problems, intake of anticholinergic drugs, potentially clinically relevant drug-drug-interactions, adverse drug events and medication adherence. DISCUSSION The DelpHi-approach for medication management employs comprehensive instruments and procedures in the primary care setting under routine care conditions, and this approach should be useful in improving pharmacotherapy as part of the comprehensive treatment and care for people with dementia. TRIAL REGISTRATION The trial is registered at ClinicalTrials.gov, number NCT01401582.
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Affiliation(s)
- Thomas Fiß
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
| | - Jochen René Thyrian
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
- Institute for Community Medicine, University of Greifswald, Ellernholzstr 1-2, 17489 Greifswald, Germany
| | - Diana Wucherer
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
| | - Grit Aßmann
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
| | - Ingo Kilimann
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
- Department of Psychosomatic Medicine, University Hospital Rostock, Gehlsheimer Straße 28, 18147 Rostock, Germany
| | - Stefan J Teipel
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
- Department of Psychosomatic Medicine, University Hospital Rostock, Gehlsheimer Straße 28, 18147 Rostock, Germany
| | - Wolfgang Hoffmann
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
- Institute for Community Medicine, University of Greifswald, Ellernholzstr 1-2, 17489 Greifswald, Germany
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Mangoni AA, Jansen PAF, Jackson SHD. Under-representation of older adults in pharmacokinetic and pharmacodynamic studies: a solvable problem? Expert Rev Clin Pharmacol 2013; 6:35-9. [PMID: 23272791 DOI: 10.1586/ecp.12.75] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The impact of advancing age, with or without the presence of structural and/or functional organ impairment, on the disposition and effects of drugs, demands adequate representation of older adults in pharmacokinetic and pharmacodynamic studies. Currently, however, this group remains poorly represented both in pre- and post-marketing studies. This review discusses recent data on the participation of older adults in pharmacokinetic/pharmacodynamic studies using established databases, the potential barriers to study recruitment and retention and possible strategies to enhance participation in this group. The article also provides a critical appraisal of current regulatory documents on the conduct of such studies.
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Affiliation(s)
- Arduino A Mangoni
- Division of Applied Medicine, School of Medicine and Dentistry, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK.
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Jarchow-MacDonald AA, Mangoni AA. Prescribing patterns of proton pump inhibitors in older hospitalized patients in a Scottish health board. Geriatr Gerontol Int 2013; 13:1002-9. [DOI: 10.1111/ggi.12047] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2013] [Indexed: 12/13/2022]
Affiliation(s)
| | - Arduino A Mangoni
- Division of Applied Medicine, School of Medicine and Dentistry; University of Aberdeen; Aberdeen; UK
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O'Mahony D, Cherubini A, Petrovic M. Optimizing pharmacotherapy in older patients: a European perspective. Drugs Aging 2012; 29:423-5. [PMID: 22642776 DOI: 10.2165/11630990-000000000-00000] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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22
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Mangoni AA, Ford JC, MacLeod J. Authors’ Reply to Reeve and Wiese: “Difficulties Reducing Inappropriate Prescribing of Proton Pump Inhibitors in the Elderly”. Drugs Aging 2012. [DOI: 10.1007/s40266-012-0026-z] [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]
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