Impact of a global leader on pharmaceutical practice and policy around the world

This commentary describes the contributions of a Dutch pharmacist who contributed in a unique manner to the development of community pharmacy practice in Europe, to the evolution of practice-based research and to its publication. With an interest in pharmaceutical care and in clinical pharmacy, Dr. van Mil changed practice and policy in Europe over the last decades in a very visible way, here documented through a summary of some of his main written contributions. We write this to honour his memory and contribute to the preservation of his legacy.

Intensive monitoring of adverse drug events associated with the use of new glucose-lowering drugs: results from an inception cohort study in Portugal

AIMS

To determine the frequency and the time-course profile of adverse drug events associated with new glucose-lowering drugs in daily practice and to explore factors potentially associated to these events.

METHODS

An inception cohort study was implemented. Adults with type 2 diabetes mellitus initiating a dipeptidyl peptidase-4 inhibitor, a glucagon-like peptide-1 receptor agonist or a sodium-glucose co-transporter-2 inhibitor were eligible for inclusion. Data were collected through baseline and follow-up telephone questionnaires, administered at 2 weeks, 3 months and 6 months. Kaplan-Meier curves and log-rank were computed to compare the time to adverse drug event onset. Cox models were used to explore potential factors associated with adverse drug events.

RESULTS

A total of 1328 participants were recruited to the study. In all, 1118 adverse drug events were reported (of which 36% were not listed in the summary of product characteristics) by 41% of participants. The median latency time of adverse drug events reported in ≥1% of participants ranged from 0 to 2 days. Glucagon-like peptide-1 receptor agonist and sodium-glucose co-transporter-2 inhibitor subgroups were associated with an increased likelihood of adverse drug event reporting when compared with the dipeptidyl peptidase-4 inhibitor subgroup. A total of 328 glucose-lowering drugs were withdrawn, more than half as a result of an adverse drug event.

CONCLUSIONS

More than two-fifths of participants reported an adverse drug event; dipeptidyl peptidase-4 inhibitors led to the highest proportion of unlabelled adverse drug events. Adverse drug event latency time data show that counselling and adverse drug event management should be proactively addressed from treatment initiation. There should be greater focus on prevalent new users of glucose-lowering drugs, who were more complex participants in this study in terms of type 2 diabetes disease, as they were more likely to report an adverse drug event than the incident new users.

"Threshold-crossing": A Useful Way to Establish the Counterfactual in Clinical Trials?

A central question in the assessment of benefit/harm of new treatments is: how does the average outcome on the new treatment (the factual) compare to the average outcome had patients received no treatment or a different treatment known to be effective (the counterfactual)? Randomized controlled trials (RCTs) are the standard for comparing the factual with the counterfactual. Recent developments necessitate and enable a new way of determining the counterfactual for some new medicines. For select situations, we propose a new framework for evidence generation, which we call "threshold-crossing." This framework leverages the wealth of information that is becoming available from completed RCTs and from real world data sources. Relying on formalized procedures, information gleaned from these data is used to estimate the counterfactual, enabling efficacy assessment of new drugs. We propose future (research) activities to enable "threshold-crossing" for carefully selected products and indications in which RCTs are not feasible.

From adaptive licensing to adaptive pathways: delivering a flexible life-span approach to bring new drugs to patients

The concept of adaptive licensing (AL) has met with considerable interest. Yet some remain skeptical about its feasibility. Others argue that the focus and name of AL should be broadened. Against this background of ongoing debate, we examine the environmental changes that will likely make adaptive pathways the preferred approach in the future. The key drivers include: growing patient demand for timely access to promising therapies, emerging science leading to fragmentation of treatment populations, rising payer influence on product accessibility, and pressure on pharma/investors to ensure sustainability of drug development. We also discuss a number of environmental changes that will enable an adaptive paradigm. A life‐span approach to bringing innovation to patients is expected to help address the perceived access vs. evidence trade‐off, help de‐risk drug development, and lead to better outcomes for patients.

Assessment of biotechnology drugs: what are the issues?

Biotechnology is increasingly regarded as an important reservoir for the development of new and innovative, but generally expensive, pharmaceuticals. At the same time, concerns about cost containment have triggered a keen interest in evaluating and comparing the values of diverse health care interventions. In this paper we studied the process of assessment and diffusion of biotechnology drugs by studying three cases, i.e. nebacumab, colony stimulating factors and recombinant human growth hormone. These cases are evaluated in a standardised format, concerning safety, efficacy, cost-effectiveness and ethical, legal and social issues. Many factors that determine the fate of a biotechnology drug seemed to be similar to those of 'classical' drugs. The definition and measurement of clinically relevant outcomes has been identified as a key factor in the assessment process. Another important issue is the relatively small population for the primary indications of biotechnology drugs and the subsequent process of broadening of indications. Paradoxically, the current trend towards evidence-based medicine means that we will increasingly have to make decisions based on 'incomplete' knowledge'.

Postmarketing surveillance of the safety of cyclic etidronate

To evaluate the safety of cyclic etidronate in routine clinical practice, we obtained information from 550 general practices in the United Kingdom that provide the medical records to the General Practice Research Database. A group of 7977 patients taking cyclic etidronate and two age-, gender-, and practice-matched control groups, one with osteoporosis and one without, were analyzed. For the group taking cyclic etidronate, the average age was 71.6 years and follow-up was 10,328 person-years. Conditions that do not induce osteoporosis generally occurred in these patients at a rate comparable to that in the control groups. The incidence of osteomalacia was low and comparable between patients taking cyclic etidronate and controls with osteoporosis. No medically significant increases in frequency were observed among patients taking cyclic etidronate for a broad group of diseases that may potentially be induced by exposure to the drug. These data support the favorable risk:benefit ratio of cyclic etidronate.

A prospective follow-up study of 5669 users of lansoprazole in daily practice

BACKGROUND

Immediately after the introduction of the proton pump inhibitor lansoprazole, a 2-year follow-up study was started to evaluate patterns of use, safety and effectiveness of this drug in naturally occurring groups of patients in the Netherlands. Medical data were recorded by participating physicians while medication listing were provided by pharmacists.

METHODS

The study was designed according to the Safety Assessment of Marketed Medicines guidelines. The only inclusion criterion was the use of lansoprazole prior to entry into the study.

RESULTS

A total of 5669 lansoprazole users was included by 374 general practitioners and 117 specialists. Lansoprazole was mostly prescribed in patients with reflux oesophagitis (55.1%), 'gastritis' (26.8%) and duodenal ulcers (11.4%), sometimes as part of a Helicobacter pylori eradication therapy (8.5%). For their complaints most patients (91.1%) had previously used acid-related drugs. Improvement or disappearance of complaints was achieved in 88.9% and 90.5% of patients after 4 and 8 weeks of treatment, respectively. Diarrhoea (4.1%), headache (2.9%) and nausea (2.6%) were the most frequently reported adverse events.

CONCLUSION

The patterns of use of lansoprazole in daily practice deviated from the recommendations in the information leaflet. Nevertheless, lansoprazole was found to be safe in this naturally occurring group of users. Effectiveness appeared to be comparable to results found in clinical trials of the registered indications for lansoprazole.

Scenario analysis of the future of clinical pharmacy

The role of clinical pharmacy in the health care system is changing rapidly. This change is almost universal among different countries and is related to developments in medical technology, health economics, informatics, socio-economic status, and professional relations. Transitions to new systems of clinical pharmacy are difficult to anticipate. Even with well defined targets, it remains uncertain what the future of clinical pharmacy will bring us. The construction of plausible scenarios may help us better in preparing for the 'new world' ahead. At the annual congresses of ESCP in Prague 1995 (24th) and Lisbon 1996 (25th), a number of scenario analysis workshops with respect to the future of clinical pharmacy were organized. This paper gives a report of the results of these scenario sessions and reflects on the implications for future policy making. After we identified the driving forces behind the future of clinical pharmacy, various sets of assumptions were made and from them scenarios were constructed which are plausible: they 'could' happen. This analysis provided a logical framework in which we ultimately depicted three alternating stories of the future of clinical pharmacy, named 'CLERK', 'CONTROLLER' and 'CARE MANAGER'. These scenarios are intended to help clinical pharmacists to break free of familiar mental maps and to stimulate creative thinking on the future.

Scenario analysis of the future of medicines

Planning future policy for medicines poses difficult problems. The main players in the drug business have their own views as to how the world around them functions and how the future of medicines should be shaped. In this paper we show how a scenario analysis can provide a powerful teaching device to readjust peoples' preconceptions. Scenarios are plausible, not probable or preferable, portraits of alternative futures. A series of four of alternative scenarios were constructed: "sobriety in sufficiency," "risk avoidance," "technology on demand," and "free market unfettered." Each scenario was drawn as a narrative, documented quantitatively wherever possible, that described the world as it might be if particular trends were to dominate development. The medical community and health policy markers may use scenarios to take a long term view in order to be prepared adequately for the future.

A study of the effects of exposure misclassification due to the time-window design in pharmacoepidemiologic studies

This paper considers the effects of the time-window design on the validity of risk estimates in record linkage studies. A time-window constitutes the number of exposure days assigned to each prescription, often fixed time-intervals. Prescription information was drawn from 36 Dutch pharmacies. Persons, assuming full compliance to the dosage regimen, used NSAIDs during 58% of the 30 day window time (31% with 90 day window). This proportion ranged from 51 to 81% for different NSAIDs; from 75% for elderly to 35% for younger persons. We observed with longer windows a substantive attenuation of incidence rates of peptic ulcer therapy. Simulations also showed that the assignment of equal windows to groups with different durations of drug use can bias risk comparisons, either away from the null or towards the null. We concluded that the choice of prescription time-windows can influence the estimates of exposure risks. Time-windows should cover the period with potential excess risk and be validated.

Rapid method for estimating the risk of acutely controversial side effects of prescription drugs

When controversy suddenly erupts about the risk of using a prescription drug, there is an urgent need for fast methods of risk estimation. Some unexpected side-effects of prescription drugs are indications for the prescribing of another kind of drug. If the risk of such a side-effect is high, it should be reflected in clustered prescribing of the side-effect-alleviating drug in sequence with the side-effect-causing drug. The risk of drug-attributable side-effects can be estimated by comparing average incidences of initial prescriptions for the side-effect-alleviating drug before, during, and long after the dispensing of the presumed side-effect-causing drug. We monitored computerized, complete drug dispensing records of anonymous outpatients for use of flunarizine, an anti-vertigo/anti-migraine drug that case reports had suggested causes mental depression and/or Parkinsonism. Among 1284 patients who eventually got flunarizine during a 31 month period, 1 in 7 was started on an anti-depressant before or long after flunarizine; only 1 in 82 might be said to have been started on an anti-depressant because of flunarizine. There was no evidence that anti-Parkinson drugs were started because of flunarizine, though the numbers are small. The analysis takes only a few days, and can help set bounds on risks of the subset of adverse drug reactions that are themselves indications for use of other drugs.