Drug utilisation and off-label use of medications in anaesthesia in surgical wards of a teaching hospital

Academic Clinical Trials Submitted to an Institutional Ethics Committee at a Tertiary Care Center: A Retrospective Analysis

Background The role of academia in clinical research has given rise to the concept of academic clinical trials (ACTs), which are vital in generating evidence. Through the implementation of the New Drugs and Clinical Trials Rules-2019 (NDCTR-2019) rules, the Institutional Ethics Committee (IEC) has obtained a quasi-regulatory role. The study aims to assess the challenges the IEC faced when processing, approving, and monitoring ACTs. The other objectives included the number of ACTs submitted to the IEC, as well as administrative, scientific, and ethical issues stated by the IEC and the Drug Controller General of India (DCGI) authorities. We also aimed to provide some insight into the type of decision made by IEC and DCGI - the delay or inconsistency between the queries. Methods This retrospective study was conducted in the IEC of a tertiary care hospital, Mumbai, Maharashtra, India. A comprehensive search of the IEC database was carried out by the study team, and only those protocols of ACTs submitted to IEC between January 2015 and December 2021 were included. The studies submitted between January 2015 and February 2019, i.e., before the release of NDCTR-2019, were classified as the "Before" category. All subsequently submitted protocols were grouped together as the "After" group. Descriptive statistics were used to represent the data, while comparison between the two timeframes were made using the Mann-Whitney U test with a level of significance at 5%. Results This six-year study showed that merely 1.4% (34/2400) trials fulfilled the criteria of an ACT. An increase in the ACT protocol submission was noted in the "After" group (20 vs. 14). Most ACTs were drug trials, with 67.6% (23/34) trials conducted majorly in the Department of Anesthesiology. There was a statistical increase in time query reply by the principal investigator to IEC and the time between submission and approval in the "After" group (p<0.05). IEC sent out 94 administrative, 565 scientific, and 216 ethical queries. On IEC monitoring, protocol deviations were noted; nonetheless, no ACTs reported protocol deviations or serious adverse events. Conclusions Since the implementation of NDCTR-2019, IEC has taken on a quasi-regulatory function, and there has been an increase in the caliber of IEC monitoring and adherence to ethical norms.

Off-label drugs use in neurology outpatient department: A prospective study at a tertiary care teaching hospital

Background:

Off-label drug use refers to any use of an approved or cleared drug that is not included in that product's approved labeling or cleared indications for use. It may be in terms of indication, age group, dosage, or route of administration. Off-label drug prescriptions are common neurology practice.

Aim:

The aim of the study is to evaluate the prevalence pattern of off-label drug use in neurology.

Subjects and Methods:

A prospective, observational, cross-sectional study was carried out in the neurology outpatient department of tertiary care teaching hospital. Data of patients above 18 years were recorded after obtaining their informed consent. The National Formulary of India (NFI) and British National Formulary (BNF) guidelines were used as tools for evaluation of the prevalence of off-label drug use.

Results:

A total of 709 drugs were recorded from the prescription data of 205 patients collected in the duration of 2 months. The results reported 145 (20.45%) and 317 (44.71%) drugs as off-label as per the NFI and BNF, respectively. Prescriptions with minimum 1 off-label drug use were 78.05% – BNF and 46.83% – NFI. The indication was one of the most common causes of drugs being off-label. Out of the total 317 off-label drug uses reported, 84 were unlicensed drug use as per the BNF. There is strong and positive correlation established between the age of the patients, number of drugs prescribed, and total off-label drugs prescribed per patient in the given study. The most common off-label drug use noted was with clonazepam and amitriptyline.

Conclusion:

Off-label prescriptions practice is common in the field of neurology.

Off-label use of pentazocine and the associated adverse events among pediatric surgical patients in a tertiary hospital in Northern Nigeria: a retrospective chart review

Background and aims: Pentazocine remains a widely used opioid pre-anesthetic medication and post-operative analgesic in low- and middle-income countries despite concerns. We assessed the adverse events (AEs) associated with off-label use of pentazocine in pediatric surgical patients and determined the possible risk factors associated with slow respiratory AEs.Method: Children ≤18 years old were administered pentazocine IM/IV as a pre-anesthetic medication or post-operative analgesic. Pertinent data including total daily dose and duration of use of pentazocine and its associated AEs were obtained from patients' case files. Risk factors associated with slow respiratory AEs were determined using logistic regression analyses.Results: One hundred and fifty-nine patients were included with a median age of 2 years; they were mainly males (52.8%). Pentazocine was administered off-label to all patients for post-operative pain management (96.2%) or pre-anesthetic medication (3.8%). All patients experienced at least one AE with most experiencing 2-7 AEs. Rapid breathing (120; 18.7%), followed by fast pulse (101; 15.7%) and sleepiness/sedation/drowsiness (81; 12.6%) were the most common AEs. None of the demographics and clinical variables significantly predicted the risk of slow respiratory AEs.Conclusion: Off-label use of pentazocine is common and associated with multiple AEs. Care is needed as no predictors of slow respiratory AEs were observed.

Physician-pharmacist agreement about off-label use of medications in private clinical settings in Baghdad, Iraq

Objective:

1) To evaluate the relationship between physician-pharmacist agreement about the off-label drug use and 2) and to identify the most common off-label medication category/indications and prescriber clinical disciplines in private settings in Baghdad area, Iraq

Methods:

This study evaluated 980 off-label use requests in the private clinical settings within Baghdad area, Iraq from October 2013 to September 2015. The efficacy, safety, and convenience of each drug request and its alternative options were evaluated according to the patient health and demographic characteristics and standard guidelines.

Results:

Of the 980 physician off-label requests, only 22.7% were approved by the pharmacists. Rheumatology and Nephrology accounted for the highest ratio of off-label use requests for adults (30.3% and 26.3%). The pharmacist rejection ratio of off-label use was comparable between the two groups (p>0.05). Most of the issued requests were attributed either to unapproved indication or to combination of more than one drug (38% and 35.3%). A low acceptance rate was reported in the requests issued for treatment in different clinical lines to the authorized one (11.9%). The lowest rate of acceptance was reported in the requests that had very low evidence level (9.1%). The mostly prescribed medications were musculoskeletal agents (28.9%). Finally, 78.2% of the requests came from clinical branches for adults. Although the agreement rate for requests in adults was higher than that in pediatrics, the two rates were not significantly different.

Conclusion:

Community pharmacists should effectively take responsibility for assessing off-label drug requests in Iraqi private settings. The quality of evidence does not represent the major factor influencing the approval rate of off-label drug use. The availability of safer and/or affordable alternatives and prescribing for a different patient age category highly impacted the pharmacists’ approval rate.