[Usefulness of the summary of product characteristics as a tool to improve prescription in elderly patients]

BACKGROUND AND OBJECTIVE

The Drug Technical Data Sheet should contribute to a safe and effective use of medications in the elderly, providing accurate information on the prescription, on the possible benefits or risks of the medications, or failing that, communicating the lack of information on their use in this group. The aim of this article was to quantify the specific information for people over 65 years of age included in the data sheets of the drugs available in Spain, and enables an adequate prescription in this population.

MATERIALS AND METHODS

A multidisciplinary group reviewed all the Technical Data Sheets of drugs approved by the Spanish Agency for Medicines and Health Devices (AEMPS). The quality of the information was classified into 4 categories: information specifically referring to the population over 65 years old; information specifically referring to the population over 80 years old; recommendations not specific to the elderly; and specific information for the elderly.

RESULTS

A total of 1,462 Technical Sheets were reviewed, of which 48% had information regarding prescription in the elderly. Information on the use in patients over 80 years old was present in 1.23% of the sheets. Only 6.83% of all the sheets reviewed included specific recommendations for the elderly.

CONCLUSIONS

There is little specific information regarding prescription in the elderly in the technical data sheets of drugs prescribed/sold in Spain. To improve knowledge in this field, data must be provided in the sheets that are based on the scientific literature, clinical trials for the elderly, or pharmacovigilance studies focused on this population.

Assessment of self-reporting reading of medicine's labels and the resources of information about medicines in general public in Malaysia

This study was undertaken to assess the people's self-reported reading of medicine labels and its associated factors and to assess the sources of information about medicines among general public. A cross-sectional study was carried out among general public in the State of Penang, Malaysia. A total of 888 participants were conveniently selected and completed the survey. A self-administered questionnaire was used to obtain the data from all the participants. Most of the participants (74.2%) reported that they have adequate information about medicines provided on their medicine labels. In addition, 86.9% of them reported that they read their medicine's label for the directions of usage and 84.3% for the dosage instruction. However, 42.1% of the participants do not read their medicine's label for the active ingredients, and 33% of them do not read their medicine's label for the safety information. In addition, 36.5% of the respondents did not read the label of medicine for the symptoms which can be used for. However, females, Malay respondents, and higher education level (college/university) were more likely to self-reported the reading medicine's label. Females were more likely to read the labels of medicines compared with males (OR = 1.6, 95% CI 1.20-2.13, P = .001). The reading of medicine labels was predicted by females, Malay respondents, and higher educated people. Health educational programs are needed to clarify label's information that can help in concept of patient safety.

People's Understanding of Verbal Risk Descriptors in Patient Information Leaflets: A Cross-Sectional National Survey of 18- to 65-Year-Olds in England

Introduction

Evidence suggests the current verbal risk descriptors used to communicate side effect risk in patient information leaflets (PILs) are overestimated.

Objectives

The aim was to establish how people understand the verbal risk descriptors recommended for use in PILs by the European Commission (EC), and alternative verbal risk descriptors, in the context of mild and severe side effects.

Methods

A cross-sectional online survey was carried out by a market research company recruiting participants aged between 18 and 65 years living in England. Data were collected between 18 March and 1 April 2016. Participants were given a hypothetical scenario regarding the risk of mild or severe medication side effects and asked to estimate how many out of 10,000 people would be affected for each of the verbal risk descriptors being tested.

Results

A total of 1003 participants were included in the final sample. The risks conveyed by the EC recommended verbal risk descriptors were greatly overestimated by participants. Two distinct distributions were apparent for participant estimates of side effect risks: those for ‘high risk’ verbal descriptors (e.g. ‘common’, ‘likely’, ‘high chance’) and those for ‘low risk’ verbal descriptors (e.g. ‘uncommon’, ‘unlikely’, ‘low chance’). Within these two groups, the distributions were near to identical regardless of what adverb (e.g. very, high, fair) or adjective (e.g. common, likely, chance) was used. The EC recommended verbal risk descriptors were more likely to be understood in accordance with their intended meanings when describing severe side effects. Very few demographic or psychological factors were consistently associated with how well participants understood the EC recommended verbal risk descriptors.

Discussion

The current verbal risk descriptors used in PILs are ineffective at best and misleading at worst. Discontinuing the use of verbal risk descriptors would limit the likelihood of people overestimating the risk of side effects.

Electronic supplementary material

The online version of this article (doi:10.1007/s40264-017-0542-1) contains supplementary material, which is available to authorized users.

How does the side-effect information in patient information leaflets influence peoples' side-effect expectations? A cross-sectional national survey of 18- to 65-year-olds in England

OBJECTIVES

To establish how the terms recommended by the European Commission to describe side-effect risk in patient information leaflets (PILs) influences expectations of side-effects and to identify factors associated with these side-effect expectations.

DESIGN

A cross-sectional online survey was carried out by a market research company.

SETTING

Data were collected in England between 18th March and 1st April 2016.

PARTICIPANTS

A total of 1003 adults aged between 18 and 65.

MAIN OUTCOME MEASURES

Self-reported expectation that the described side-effects would affect participants if they took the medicine, measured on a likelihood scale from 1 (very unlikely) to 5 (very likely).

RESULTS

Participants formed high expectations of side-effects for "very common" and "common" side-effects, with 51.9% and 45.0% of participants rating these as "very likely" or "likely" to happen to them, respectively. This fell to 8.1% for "uncommon," 5.8% for "rare" and 4.1% for "very rare." For each descriptor, higher expectations of side-effects were more associated with women or being from an ethnic minority, or having less education, a household illness, high perceived sensitivity to medicines or negative beliefs about medicines.

DISCUSSION

The current use of verbal descriptors to communicate side-effect risk in PILs leads to high side-effect expectations. These expectations could contribute to nocebo-induced medication side-effects experienced by patients. Additional work is required to identify ways to improve the way risk information is conveyed in PILs.

Knowledge of appropriate acetaminophen use: A survey of college-age women

OBJECTIVES

To evaluate college-age women's knowledge of appropriate doses and potential toxicities of acetaminophen, competency in interpreting Drug Facts label dosing information, and ability to recognize products containing acetaminophen.

METHODS

In this cross-sectional prospective study, a 20-item written survey was provided to female college students at a University of Michigan fundraising event in March 2015.

RESULTS

A total of 203 female college students, 18-24 years of age, participated in the study. Pain was experienced on a daily or weekly basis by 22% of the subjects over the previous 6 months, and 83% reported taking acetaminophen. The maximum 3-gram daily dose of extra-strength acetaminophen was correctly identified by 64 participants; an additional 51 subjects indicated the generally accepted 4 grams daily as the maximum dose. When provided with the Tylenol Drug Facts label, 68.5% correctly identified the maximum amount of regular-strength acetaminophen recommended for a healthy adult. Hepatotoxicity was associated with high acetaminophen doses by 63.6% of participants, significantly more than those who selected distracter responses (P < 0.001). Knowledge of liver damage as a potential toxicity was correlated with age 20 years and older (P < 0.001) but was independent from race and ethnicity and level of alcohol consumption. Although more than one-half of the subjects (58.6%) recognized that Tylenol contained acetaminophen, fewer than one-fourth correctly identified other acetaminophen-containing products.

CONCLUSION

Despite ongoing educational campaigns, a large proportion of the college-age women who participated in our study did not know and could not interpret the maximum recommended daily dose from Drug Facts labeling, did not know that liver damage was a potential toxicity of acetaminophen, and could not recognize acetaminophen-containing products. These data suggest a continued role for pharmacists in educational efforts targeted to college-age women.

Global shortage of neonatal and paediatric antibiotic trials: rapid review

OBJECTIVES

There have been few clinical trials (CTs) on antibiotics that inform neonatal and paediatric drug labelling. The rate of unlicensed and off-label prescribing in paediatrics remains high. It is unclear whether the current neonatal and paediatric antibiotic research pipeline is adequate to inform optimal drug dosing. Using the ClinicalTrials.gov registry, this review aims to establish the current global status of antibiotic CTs in children up to 18 years of age.

METHODS

Studies were identified using key word searches of the ClinicalTrials.gov registry and were manually filtered using prespecified inclusion/exclusion criteria.

RESULTS

76 registered open CTs of antibiotics in children were identified globally; 23 (30%) were recruiting newborns (only 8 (11%) included preterm neonates), 52 (68%) infants and toddlers, 58 (76%) children and 54 (71%) adolescents. The majority of registered trials were late phase (10 (15%) phase 3 and 23 (35%) phase 4/pharmacovigilance). Two-thirds were sponsored by non-profit organisations, compared with pharmaceutical companies (50 (66%) vs 26 (34%), respectively). A greater proportion of non-profit funded trials were efficacy-based strategic trials (n=34, 68%), in comparison with industry-led trials, which were most often focused on safety or pharmacokinetic data (n=17, 65%). Only 2 of the 37 antibiotics listed on the May 2016 Pew Charitable Trusts antibiotic development pipeline, currently being studied in adults, appear to be currently recruiting in open paediatric CTs.

CONCLUSIONS

This review highlights that very few paediatric antibiotic CTs are being conducted globally, especially in neonates. There is a striking disparity noted between antibiotic drug development programmes in adults and children.

Comparative analysis of package inserts of local and imported antihypertensive medications in Palestine

BACKGROUND

Package inserts (PIs) as a reliable reference for patients and health care providers should provide accurate, complete and up-to-date information. The purpose of the current study is to assess and compare the PIs of antihypertensive agents locally produced in Palestine and their imported counterparts.

METHODS

Thirty-five PIs were assessed for the presence of 31 information statements using a scoring method. Word counting of 20 headings and subheadings was used to evaluate and compare local and imported PIs for information quantity.

RESULTS

None of the analysed PIs fulfilled the criteria. All of them included the brand name, active ingredients, indications, directions for use, adverse drug reactions, drug-drug interactions, pregnancy and lactation considerations, and storage. Whereas none of them, either local or imported PIs, included the shelf life and instructions to convert tablets or capsules into liquid forms. Additionally, only one (5%) imported and no (0%) local PIs mentioned the duration of therapy. Moreover, 93.4% of local PIs were deficient in areas regarding the inactive ingredients and date of last revision, and 86.7% did not mention the drug dose and possibility of tablet splitting. Furthermore, the maximum dose was not indicated in 90% of imported and 86.7% of local PIs. In general, imported PIs contained more detailed information than their local counterparts, where the range of differences in medians between the local and imported PIs was from 1.5-fold for pregnancy considerations to >42.00-fold for the effect on the ability to drive and use machines.

CONCLUSIONS

The findings of this study revealed the superiority of imported over local PIs in both quality and quantity of information provided. This emphasises the need for appropriate measures to be taken by the Ministry of Health and local manufacturers to ensure efficiency of local PIs in providing accurate, complete and up-to-date information.

Unintended Consequences of Adjusting Citalopram Prescriptions Following the 2011 FDA Warning

OBJECTIVES

In 2011, the U.S. Food and Drug Administration (FDA) issued a safety announcement cautioning providers against prescribing citalopram above 40 mg per day given concerns for QT prolongation. We assessed the impact of a health system quality improvement initiative to identify patients taking higher than the recommended dose of citalopram.

DESIGN

Retrospective cohort study.

SETTING

Nine primary care clinics within the University of Michigan from March 2012 to February 2013.

PARTICIPANTS

Adult patients taking a higher-than-recommended dose of citalopram following the FDA warning in 2011 (N = 199).

MEASUREMENTS

Frequency of EKG monitoring, clinical factors associated with patients whose citalopram dose or use was adjusted, and potential impact of these changes on overall health care utilization was assessed.

RESULTS

In patients prescribed higher-than-recommended doses of citalopram and who received a note from a pharmacist regarding the FDA warnings, only 8.5% received electrocardiogram (EKG) monitoring. Patients who were converted to an alternative antidepressant from citalopram were more likely to receive subsequent new prescriptions for benzodiazepines and sedative hypnotics (χ² = 7.9, p = 0.048). Patients who had any adjustments to their antidepressant medication had greater overall health care utilization (OR: 25.0; 95% CI: 5.7-109.6; p < 0.001) than patients remaining on the same dose of citalopram.

CONCLUSIONS

Despite a targeted quality intervention to address the FDA warning regarding citalopram, the warning was associated with low levels of EKG monitoring, increased anxiolytic and sedative medication use, and higher healthcare utilization. This finding may represent destabilization of patients on previously therapeutic doses of their antidepressant and an unintended consequence of the FDA warning.

A Review of Patient-Reported Outcome Labeling in the United States (2011-2015)

BACKGROUND

A review of new drug approvals (NDAs) by the Food and Drug Administration (FDA) for 2006 to 2010 showed that 24.1% of new drugs had patient-reported outcome (PRO) labeling.

OBJECTIVES

To review PRO labeling for NDAs for 2011 to 2015 and to compare key findings reported previously.

METHODS

A review of the FDA drug approval reports for NDAs was conducted using the FDA Web site to determine the number of NDAs for the period 2011 to 2015. For all identified NDAs, drug approval package and product labeling were reviewed to identify PRO end-point status and PRO labeling. NDAs for the period 2006 to 2015 were grouped by disease category as per the International Classification of Diseases, Tenth Revision. Data were summarized for all NDAs and for approvals in diseases that traditionally rely on PROs for evaluating treatment benefit (PRO-dependent). Results were compared with NDAs for the period 2006 to 2010.

RESULTS

In the period 2011 to 2015, 16.5% of the 182 NDAs had PRO labeling. For PRO-dependent NDAs, this figure was 46.9% and 46.0% for the period 2006 to 1010 and the period 2011 to 2015, respectively. Most of the PRO labeling for the period 2011 to 2015 was based on primary end points (76.7%). Almost all PRO labeling was for concepts proximal to the disease.

CONCLUSIONS

There is potential for increased PRO labeling, especially for drug approvals in diseases that traditionally rely on PROs for evaluating treatment benefit to satisfy regulatory needs. Less PRO labeling based on secondary end points may be indicative of drug manufacturers' reluctance to aid and enhance the value propositions of their products to all stakeholders, including patients.

Assessment of drug use patterns in terms of the WHO patient-care and facility indicators at four hospitals in Southern Ethiopia: a cross-sectional study

BACKGROUND

Patient-centered care is now the goal for virtually all healthcare systems. The aim of this research was to evaluate the patient care quality in regard to drug dispensing in four hospitals in southern Ethiopia namely Wolaita Sodo University teaching and referral hospital (WSUTRH), Tercha zonal hospital (TZH), Sodo Christian hospital (SCH) and Dubo St. Mary's Catholic primary hospital (DSMCPH).

METHODS

A cross sectional study was conducted by using the WHO patient care and facility indicators between September 10 and October 20, 2014. Patients who visited the outpatient departments of the four hospitals were selected by systematic random sampling method and interviewed. In total 384 patients were selected based on a rough estimate of proportion of patients visiting to the four hospitals. Facility indicators including the availability of essential drugs list (EDL), national drug formulary, standard treatment guideline (STG) and key drugs were evaluated. Descriptive statistical calculations were performed using SPSS® version 20.0 software.

RESULT

The mean number of drugs was in the range between 1.9 ± 0.9 to 2.2 ± 2.0. The mean consultation time range was found to be 4.2 ± 1.6 to 4.9 ± 5.0 min whereas the mean dispensing time was ranged from 96.1 ± 52.0 to 152.3 ± 47.6 s. The overall mean number of drug prescribed for the four hospitals was 2.0 ± 1.2 and the mean percentage of medications actually dispensed in the hospitals was thus calculated to be 86.3. The mean percentage of medications clearly labeled was 45.4. Patients who knew their dosage forms accurately were 78.8. Among the four hospitals evaluated only one hospital (25 %) had at least a copy of the Ethiopian essential drug list (EDL), standard treatment guideline for hospitals and drug formulary. The mean availability of key drugs in the hospitals was found to be 65.7 %.

CONCLUSION

The result of the present study indicates that the patient consulting time, medications labeling and availability of key drugs in the hospitals are inadequate. The medication labeling practice in the four hospitals is unacceptably low. These patient care indicators need a special attention for improvement.

Postmarket safety in Canada: are significant therapeutic advances and biologics less safe than other drugs? A cohort study

OBJECTIVES

Examine the probability of new active substances (NASs) approved in Canada between 1 January 1997 and 31 March 2012 acquiring a serious postmarket safety warning.

DESIGN

Cohort study.

DATA SOURCES

Annual reports of the Therapeutic Products Directorate and the Biologic and Genetic Therapies Directorate; evaluations of therapeutic innovation from the Patented Medicine Prices Review Board and Prescrire International; MedEffect Canada website.

INTERVENTIONS

Postmarket regulatory safety warning or withdrawal from market due to safety reasons.

PRIMARY AND SECONDARY OUTCOME MEASURES

Compare the probability of acquiring a postmarket safety warning in Canada in four different groups of drugs: (1) traditional medications versus biologics; (2) medications that offer significant new therapeutic benefits versus those that do not. Determine how well the type of review that an NAS received from Health Canada predicted the product's postmarket therapeutic value.

RESULTS

The probability of a traditional NAS acquiring a serious safety warning and/or being withdrawn was 29.9% (95% CI 21.8% to 40.2%) vs 27.3% (95% CI 18.2% to 39.7%) for an NAS of biological origin (p=0.47, log-rank test). For medications that were significant therapeutic advances the probability was 40.2% (95% CI 24.5% to 60.9%) vs 33.9% (95% CI 26.4% to 42.7%) for those that were not (p=0.18, log-rank test). Health Canada was 77.4% accurate in predicting the therapeutic importance of an NAS.

CONCLUSIONS

There was no difference in postmarket regulatory safety action between traditional medications and biologics and no difference between drugs with significant therapeutic benefits and those without. Although these results draw on Canadian data, they are likely to be relevant internationally. Further research should assess whether the current level of premarket safety evaluation is acceptable.

Assessment of PRO label claims granted by the FDA as compared to the EMA (2006-2010)

BACKGROUND

The US Food and Drug Administration (FDA) provides formal guidance for the use of patient-reported outcomes (PROs) in support of labeling claims, whereas the European Medicines Agency (EMA) offers insight in a reflection paper relating to health-related quality of life in lieu of formal guidance.

OBJECTIVES

PRO label claims granted for new molecular entities and biologic license applications from 2006 through 2010 were reviewed to evaluate consistencies and discrepancies in PRO label claims granted by the FDA and the EMA and to highlight trends in the acceptance of PRO claims across agencies.

METHODS

Products approved by both the FDA and the EMA were identified. By using US Drug Approval Packages and European Public Assessment Reports packages, any PRO label claims made for the same product by the same company were compared.

RESULTS

Both agencies approved a total of 75 products. Of these, 35 (47%) had at least one EMA-granted PRO label claim compared with 14 (19%) by the FDA. Most FDA-grated claims focused on symptoms; however, EMA-granted claims were more likely to include higher order concepts. Few (~12%) were granted the same label claims. Despite this discordance between the two agencies, where PRO label claims were granted by both the FDA and the EMA, there was similarity in the type of label claim.

CONCLUSIONS

The EMA is more likely than the FDA to grant PRO claims and for higher order constructs. On a macro level, there appears to be poor concordance between claims granted by both agencies. On close examination, however, there appears to be greater concordance than previously recognized, which may be instructive in formulating future PRO strategies. Further research to create strategic alignment across agencies may be beneficial.

[Dizziness as a side effect of pharmacological therapy]

Dizziness is a well-known side effect of a wide range of drugs. However, the side effects reported in the summary of product characteristics are not exclusively based on placebo-controlled trials. Based on a systematic review of the literature including randomised placebo-controlled clinical trials, antihypertensive combination drugs, methylphenidate, high doses of tramadol and serotonin-norepinephrine reuptake inhibitors were associated with an increased risk of dizziness. Antihypertensive monotherapy and selective serotonin reuptake inhibitors were generally not associated with an increased risk of dizziness when compared with placebo.

Pattern of extemporaneous prescriptions and preparations in a tertiary health institution: a five-year assessment

Due to the increasing rate in the demand of extemporaneous formulations, it became necessary to assess the pattern of prescription and preparation in a developing institution. The purpose of this study was to assess the pattern of extemporaneous prescription and preparation in the University of Benin Teaching Hospital, Benin City, Nigeria. Records of prescription and preparation of extemporaneous formulations were assessed retrospectively between 2007 and 2011. Fifty-nine different types of drugs were prescribed with a frequency of 6,882 times during the period. These were indicated for eight classes of systemic disease. Eighteen drugs were indicated for central nervous diseases, followed by 16 drugs for cardiovascular diseases. Of the 18 drugs indicated for central nervous diseases, pyridoxine was the most common. Rifampicin for tuberculosis was the most frequently formulated, followed by spironolactone for cardiovascular disorders. Most preparations were labeled to be used for a maximum of two weeks. They were all liquid preparations packaged in amber-colored bottles. Distilled water was the most common vehicle utilized for trituration; while ascorbic acid syrup was commonly used to bulk the solution and as a sweetening agent. None of the patients reported with any form of pharmaceutical degradation or toxicity within two weeks of expected use. There were reports of spillages due to poor handling. Maximum volume prepared was 75 mL. The study suggests an adequate setup of a quality-control unit in the institution to meet the increasing demand for specific agents. This will enhance an effective healthcare delivery among patients.

Outcomes associated with concordance of oral antidiabetic drug treatments to prescribing information in patients with type 2 diabetes mellitus and chronic kidney disease

OBJECTIVES

This retrospective study aims to examine the association between prescribing information (PI)-concordant oral antidiabetic drug (OAD) treatment and clinical and economic outcomes in patients with type 2 diabetes mellitus and stages 3-5 chronic kidney disease (CKD).

METHODS

The study used a large, national administrative claims database with laboratory findings to identify patients with a diagnosis of diabetes and indication of stages 3-5 CKD (first observed indication as the index date) between 1/1/2005 and 30/06/2009. OADs prescribed during 6 months following the index date (baseline period) were evaluated and patients were considered non-PI-concordant if any did not meet the recommendations regarding patients with renal impairment. Glycemic control and measures of healthcare costs (standardized to 2010 US dollars using the Consumer Price Index) and resource utilization were assessed during the 12 months following the baseline period. Severe hypoglycemic events were assessed after the baseline period until lost to follow-up. Regression analyses were performed after adjusting for demographic and clinical characteristics.

RESULTS

Among the 3300 patients included in the study, 2454 (74.4%) were non-PI-concordant. The non-PI-concordant patients had higher risk of severe hypoglycemic events identified in all settings (HR = 1.35, 95% CI: 1.10-1.67) and events identified in inpatient hospital setting (HR = 2.51, 95% CI: 1.49-4.22), were more likely to have inpatient hospital admissions (OR = 1.27, 95% CI: 1.02-1.57), and were less likely to have glycemic control (OR = 0.56, 95% CI: 0.44-0.71). Annual diabetes-related cost was $1638 higher in the non-PI-concordant cohort (p = 0.0048).

LIMITATION

The retrospective cohort design does not allow for conclusions to be drawn on the causal effect of PI-concordant use based on the associations observed.

CONCLUSION

Our findings suggest PI-concordant treatment to be associated with better clinical and diabetes-associated economic outcomes. Future research is warranted to confirm the associations found in this study.

2011 drug packaging review: too many dangers and too many patients overlooked

Every year, Prescrire's analysis of drug packaging confirms the importance of taking packaging into account in assessing a drug's harm-benefit balance. Safe, tried and true options are available, yet the quality of most of the drug packaging Prescrire examined in 2011 left much to be desired. Few of the packaging items examined help prevent medication errors and many actually increase the risks: misleading and confusing labelling, dosing devices that create a risk of overdose, bottles without a child-proof cap, and inadequate or dangerous patient information leaflets. Umbrella brands continue to expand and are a potential source of medication errors. Some patients are at greater risk: the patient leaflets for NSAIDs endanger pregnant women and their unborn babies; children are insufficiently protected by paediatric packaging and are at risk due to the lack of child-proof caps on too many bottles. The raft of regulatory measures taken by the French drug regulatory agency (Afssaps) in the aftermath of the Mediator disaster overlooked the importance of packaging. Until drug regulatory agencies tackle the vast issue of drug packaging, it is up to healthcare professionals to protect patients from harm.

Overuse of psychotropic medications among children and adolescents with autism spectrum disorders: perspective from a developing country

Psychopharmacotherapy can be an effective part of the treatment for individuals with autism spectrum disorders (ASDs). However debate continues over the potential benefits and costs of these treatments; additionally little is known about the pattern of psychotropic medication use in developing countries. We aimed to survey the use of psychotropic medication, their subcategories and its associations among a representative local sample of 345 Iranian pupils with ASDs. All required information about demographics as well as clinical and medication history of children was collected through interviews with the families. Overall, 80% of participants were currently using at least one psychotropic medication while, and up to 97% of the sample had at least one psychotropic medication claim during the last year. Antipsychotics were the most frequent medications (57.4%) while antidepressants were used by only a small proportion of participants (8.7%). Further analysis revealed no significant association between any psychotropic medication use on one hand and clinical and demographic characteristics on the other hand. Time differences, cross cultural variations, and also cost and availability of treatment options in developing countries are discussed as possible explanations for different patterns and more than expected rate of psychotropic medication use in pupils with ASD.

[Analysis of similar drug labeling: potential medication errors]

OBJECTIVE

This study aimed to examine drug packaging and labeling, identifying similarities among them that may lead to medication errors, which may occur by unintentional substitution, in different sectors of the pharmacy of a university hospital in northeastern Brazil.

METHODS

Cross-sectional observational study, which included 300 pharmaceutical presentations (150 pairs) that were photographed from May to December 2010. Concordance analysis of data related to the pictures of possibly similar packaging and labels was validated using the Kappa index.

RESULTS

Of all drugs evaluated (n = 150), about 43% of "possibly similar drugs" were in the central pharmacy (n = 65) and were related to small-volume parenteral solutions. The strength of interobserver agreement in the category "very similar to each other" was considered "satisfactory" (Kappa = 0584) in 90.66% of the drugs evaluated (n = 136). The overall Kappa analysis of the study was 0.488. Variables with statistical significance were: "same color label or packaging", with the respective percentages for both primary and secondary packaging (52%-44%), p = 0.028; the variable "same color of drug presentation" obtained similar values and statistical significance to the previous variable; for the variable "same arrangement of words", the values found for both packages were close to 50%, p = 0.001; and for the variable "same color of the words", the percentages were: (50.7% - 44%) (p = 0.008).

CONCLUSION

Our results indicate similarities related to the labeling of drugs with potential for errors, especially in dispensing, storage, and administration if preventive measures are not adopted.

Buyer beware? Does the information provided with herbal products available over the counter enable safe use?

BACKGROUND

Herbal products obtained over the counter are commonly used in Europe, North America and Australia. Although there is concern about a lack of information provided to consumers to allow the safe use of these products, there has been no published research to confirm these fears. In this study, we evaluated written information provided with commonly used herbal products in the UK in advance of a European Union Directive issued in April 2011 that tightened regulations for some herbal products, including requirements to provide safety information.

METHODS

Five commonly used herbal products were purchased from pharmacies, health food shops and supermarkets: St John's wort, Asian ginseng, echinacea, garlic and ginkgo. Written information provided with the products (on the package or on a leaflet contained in the package) was evaluated for inclusion of each of the key safety messages included in the monographs of the US National Center for Complementary and Alternative Medicine. Specifically, we looked for information on precautions (such as Asian ginseng not being suitable for people with diabetes), interactions with conventional medicines (such as St John's wort with the contraceptive pill and warfarin) and side effects (such as ginkgo and allergic reactions).

RESULTS

Our analysis showed that, overall, 51 (75%) of 68 products contained none of the key safety messages. This included 4 of 12 St John's wort products, 12 of 12 ginkgo products, 6 of 7 Asian ginseng products, 20 of 21 garlic products and 9 of 13 echinacea products. The two products purchased that are registered under the new European Union regulations (for St John's wort) contained at least 85% of the safety messages.

CONCLUSIONS

Most of the herbal medicine products studied did not provide key safety information which consumers need for their safe use. The new European Union legislation should ensure that St John's wort and echinacea products will include the previously missing information in due course. The legislation does not apply to existing stock. Depending on therapeutic claims made by manufacturers, garlic, ginkgo and Asian ginseng products may not be covered by the legislation and can continue to be bought without the safety information. Also, consumers will still be able to buy products over the internet from locations outside European Union jurisdiction. Potential purchasers need to know, in both the short term and the long term, how to purchase herbal products which provide the information they need for the safe use of these products.

Impact of thiazolidinedione safety warnings on medication use patterns and glycemic control among veterans with diabetes mellitus

AIMS

In 2007, safety warnings were publicized regarding the association between thiazolidinediones (TZDs) and cardiovascular risks. This study investigated the impact of the publicized safety warnings on glycemic outcomes in patients with diabetes mellitus (DM).

MATERIALS AND METHODS

The Veterans Integrated Services Network 16 database included 13,293 DM patients using TZDs (n=13,037 rosiglitazone, n=246 pioglitazone, n=10 both) during a baseline period of 03/01/07 to 05/31/07. Three medication use patterns groups (09/01/07 to 11/30/07) were defined as follows: (1) continuation on TZD treatment, (2) switching to other non-TZD treatment, (3) discontinuation of TZD treatment without any antidiabetic treatment. Primary outcome (09/01/07 to 02/29/08) was change from baseline in A1c. The analysis of variance was used to test the association between use patterns and A1c change. A logistic regression model was used to identify the predictors for use patterns.

RESULTS

Patients (45.1%, n=5999) discontinued their TZD use. Both Groups 2 and 3 had significant A1c increases (both P values <.0001). Significant predictors for TZD discontinuation included black race, baseline heart disease, and diabetic complication [odds ratio (OR), 1.43; OR, 1.54; OR, 1.30, respectively]. Of the patients remaining on TZD therapy, 11.8% experienced improved A1c levels, and a lower percentage of patients (9.53%) experienced a deterioration in A1c levels (P<.0001). Patients who switched or discontinued an antidiabetic medication experienced improvements in body mass index (P<.0001) and triglycerides (P<.0036). The three use pattern groups had similar changes with regard to blood pressure and low-density lipoprotein.

CONCLUSION

Thiazolidinedione safety warnings may have negatively impacted the glycemic control in DM patients.

Medicine-taking practices in community-dwelling people aged > or =75 years in New Zealand

BACKGROUND

older people experience more chronic medical conditions than younger people, take more prescription medicines and are more likely to suffer from cognitive or memory problems. Older people are more susceptible to the adverse effects of medicines, which may reduce their quality of life or lead to hospitalisation or death.

OBJECTIVE

this study aims to identify medicine-taking practices amongst community-dwelling people aged > or =75 years in New Zealand.

METHODS

this study was carried out in an urban setting in Dunedin (population 120,000), New Zealand. Interviews of a random sample of people from the electoral roll using a structured questionnaire were conducted. Subjects were community-dwelling people aged > or =75 years taking one or more prescription medicines. From a random sample of 810 people extracted from the electoral roll intended to recruit 300 participants, 524 people met the study criteria and were invited to participate. People living in a rest home or hospital, not contactable by telephone, or now deceased, were excluded. Responses were analysed, medicines categorised by the Anatomical Therapeutic Chemical classification and adherence classed as high, medium and low using a modified four-item Morisky Medication Adherence Scale. Univariate and multivariate linear and logistic regression was applied to combinations of variables.

RESULTS

in total, 316 interviews were undertaken; a 61% response rate. Participants were 75-79 (35%), 80-84 (40%) and >85 years (25%); New Zealand European/European (84%), 'New Zealanders' (14%) or Maori (2%); and 141 (45%) lived alone. Almost half (49%) regularly saw a specialist and a third (34%) had been admitted to hospital in the past 12 months. Participants used a median of seven prescription medicines (range 1-19) and one non-prescription medicine (0-14). The majority (58%) believed medicines are effective and had systems/routines (92%) for remembering to take them. Doses tended to be missed following a change in routine, e.g. holiday. Men were more likely to report 'trouble remembering' than women (odds ratio = 1.86, 95% confidence interval 1.10-3.14; P = 0.020). Seventy-five percent of people had high or medium adherence scores and 25%, low scores. Common problems were reading and understanding labels (9 and 4%, respectively) and leaflets (12%, 6%), and difficulty swallowing solid dose forms (14%). Only 6% had problems paying for their medicines. Around 17% wanted to know more about their medicines, and some people were confused about their medicines following hospital discharge.

CONCLUSION

overall, community-dwelling people aged > or =75 years in this study appeared to manage their medicines well and found them affordable. Nevertheless, there is a need to improve labelling, leaflets and education on medicines, particularly at hospital discharge.

Inconsistent labeling of food effect for oral agents across therapeutic areas: differences between oncology and non-oncology products

PURPOSE

Several recent oral oncology drugs were labeled for administration in fasted states despite the fact that food increases their bioavailability. Because this was inconsistent with the principles of oral drug delivery, we hypothesized that there were inconsistencies across therapeutic areas.

EXPERIMENTAL DESIGN

Oral agents approved by the U.S. Food and Drug Administration from January 2000 to May 2009 were included in our study. Comparison of the food labeling patterns between oncology and non-oncology drugs was made using Fisher's exact test.

RESULTS

Of the 99 drugs evaluated, 34 showed significant food effects on bioavailability. When food markedly enhanced bioavailability, eight out of nine non-oncology drugs were labeled "fed" to take advantage of the food-drug interaction, whereas all oncology drugs (n = 3) were labeled to be administered in "fasted" states (Fisher's exact test, P = 0.01).

CONCLUSIONS

Drug labeling patterns with respect to food-drug interactions observed with oncology drugs are in contradiction with fundamental pharmacologic principles, as exemplified in the labeling of non-oncology drugs. .

Antimalarial prescribing and dispensing practices in health centres of Khartoum state, 2003-04

This indicator-based study assessed the antimalarial drug prescribing and dispensing practices of health care providers in health centres of Khartoum state, and compared these with national guidelines for malaria treatment. A total of 720 patients and their prescriptions in 24 health centres were included. Prescribers adhered to national treatment guidelines for only 278 (38.6%) of patients. Although all were treated for malaria, only 77.6% patients had fever or history of fever and only 64.6% had fever and positive blood films. More than 90% of prescriptions prescribed antimalarial drugs by generic names but dosage forms were correctly written in only 23.5%. There was a high rate of prescribing antimalarial injections. Only half the patients had adequate knowledge of their treatment.

Analysis and interpretation of results based on patient-reported outcomes

This article is part of a series of manuscripts dealing with the incorporation of patient-reported outcomes (PROs) into clinical trials. The issues dealt with in this manuscript concern the common pitfalls to avoid in statistical analysis and interpretation of PROs. Specifically, the questions addressed by this manuscript involve the analysis pitfalls with PRO data in clinical trials and how can they be avoided (e.g.,missing data, multiplicity, null results etc.). The manuscript provides key literature for existing resources and proposes new guidelines.

Early evidence on the effects of regulators' suicidality warnings on SSRI prescriptions and suicide in children and adolescents

OBJECTIVE

In 2003 and 2004, U.S. and European regulators issued public health warnings about a possible association between antidepressants and suicidal thinking and behavior. The authors assessed whether these warnings discouraged use of antidepressants in children and adolescents and whether they led to increases in suicide rates as a result of untreated depression.

METHOD

The authors examined U.S. and Dutch data on prescription rates for selective serotonin reuptake inhibitors (SSRIs) from 2003 to 2005 in children and adolescents (patients up to age 19), as well as suicide rates for children and adolescents, using available data (through 2004 in the United States and through 2005 in the Netherlands). They used Poisson regression analyses to determine the overall association between antidepressant prescription rates and suicide rates, adjusted for sex and age, during the periods preceding and immediately following the public health warnings.

RESULTS

SSRI prescriptions for youths decreased by approximately 22% in both the United States and the Netherlands after the warnings were issued. In the Netherlands, the youth suicide rate increased by 49% between 2003 and 2005 and shows a significant inverse association with SSRI prescriptions. In the United States, youth suicide rates increased by 14% between 2003 and 2004, which is the largest year-to-year change in suicide rates in this population since the Centers for Disease Control and Prevention began systematically collecting suicide data in 1979.

CONCLUSIONS

In both the United States and the Netherlands, SSRI prescriptions for children and adolescents decreased after U.S. and European regulatory agencies issued warnings about a possible suicide risk with antidepressant use in pediatric patients, and these decreases were associated with increases in suicide rates in children and adolescents.

Spillover effects on treatment of adult depression in primary care after FDA advisory on risk of pediatric suicidality with SSRIs

OBJECTIVE

In 2003, the U.S. Food and Drug Administration (FDA) issued a public health advisory about the risk of suicidality in pediatric patients taking selective serotonin reuptake inhibitors (SSRIs) for depression, and in 2005, the agency mandated a black box warning and medication guide indicating that pediatric and adult patients may be at risk. The authors examine the effects of this pediatric policy on treatment of adult depression in the community.

METHOD

An adult cohort with newly diagnosed episodes of depression was created from a large national integrated claims database of managed care plans from October 1998 to September 2005 (N=475,838 unique episodes). Time-series analyses were used to compare the post-FDA advisory trends to the trends during the 5 years preceding the advisory.

RESULTS

The rate of diagnosed depression was significantly lower after the advisory than would have been expected on the basis of the preadvisory historical trend. The average percentage of adults with new (versus recurrent) depressive episodes was 88.6% in the preadvisory period (declining at an annual rate of 1.69%), and it decreased significantly to 77.5% (declining more rapidly, at an annual rate of 7.70%). The percentage of adults with depression who did not receive an antidepressant increased from an average of 20% (declining at 0.45% annually) before the policy action to an average of 30% (increasing at an annual rate of 20.6%). The data did not show any compensatory increases in psychotherapy or prescription of atypical antipsychotics or anxiolytics.

CONCLUSIONS

The FDA advisory had a significant spillover effect into community treatment for adults with depression, despite the focus of the policy on pediatric patients.

The impact of incremental innovation in biopharmaceuticals: drug utilisation in original and supplemental indications

BACKGROUND

The apparent decrease in the rate of approval of new molecular entities has provoked extensive discussion and fears that the productivity of biopharmaceutical research and development has severely declined in recent years.

OBJECTIVE

To investigate the extent to which traditional measures of innovative output neglect important innovations that occur after a drug receives initial market approval.

METHODS AND RESULTS

Data on drug utilisation by diagnosis for the period 1999-2004 were combined with data on the approval histories of three important classes of drugs: ACE inhibitors, histamine H(2)-antagonists/proton-pump inhibitors, and selective serotonin/norepinephrine reuptake inhibitors. Counts of new drug approvals by the FDA were classified as new indications, new dosages, new combinations, new formulations, and labeling for expanded populations. Large numbers of such "supplemental" approvals were obtained. The share of drug utilisation in indications other than that specified in the initially approved labeling was computed, and found to be very substantial in two out of the three drug classes considered.

CONCLUSIONS

Significant incremental innovation to existing pharmaceutical products has been occurring in the form of supplementary approvals for new dosages, formulations, and indications. These innovations account for a substantial share of drug utilisation and associated economic and medical benefits. Productivity trends for research and development based on counts of new molecular entities alone have therefore overlooked an important source of innovation in biopharmaceuticals.

[Cardiovascular pharmaceuticals: a risk while driving vehicles]

OBJECTIVE

To categorize cardiovascular pharmaceuticals according to their respective effect on one's capacity to drive a vehicle.

METHODOLOGY

an analysis of the technical file for 299 pharmaceutical products belonging to 1 lsubgroups inside the main category of therapeutic products related to the cardiovascular apparatus. Information compiled includes: the existence, or lack of, a section which warns of the possible effects of the medication on a person's capacity to drive a vehicle; in those affirmative cases, a statement specifying those effects.

CONCLUSIONS

32.1% of pharmaceutical products do not comply with the existing legislation and approximately half of those pharmaceutical products do not have a section on their effects on a person's capacity to drive a vehicle, or they state these products have an effect but do not bear an influence even though they can provoke important effects.

Off-label and unlicensed prescribing for newborns and children in different settings: a review of the literature and a consideration about drug safety

This review aims to give an updated overview of the worldwide situation of off-label and unlicensed drug use in the paediatric field, also taking into account the safety of this kind of treatment. A Medline and Embase search was performed between 1990 and 2006 and a total of 52 studies were identified and included in the systematic review. From the authors' analysis of the literature, the extent of paediatric unlicensed/off label use is higher in neonatal and paediatric intensive care units and oncology wards, compared with primary care. Moreover, among the nine studies reporting the contribution of an off-label/unlicensed drug use to the occurrence of adverse events, the percentage of unlicensed and/or off-label prescriptions involved in an adverse drug reaction ranged between 23 and 60%. To ensure that children are not exposed to unnecessary risks, controlled clinical trials are required. In addition, future research should be directed towards the identification of individual drugs that cause serious adverse drug reactions and lack product information.

Comparison of verbal claims for natural health products made by health food stores staff versus pharmacists in Ontario, Canada

BACKGROUND

This study tested the hypothesis that while there are no written medical claims existing for many NHP, such claims are made verbally, giving a false impression that these are proven medical products.

OBJECTIVE

To compare the number and type of verbal claims for NHP made by pharmacists to those made by health food stores personnel.

METHODS

Randomly selected Canadian pharmacies selling NHP and health food stores were visited and the staff was asked to recommend natural health products for the treatment of hypertension.

RESULTS

All health food stores (n=20) but only 4 out of 38 pharmacies (p< 0.001) recommended NHP for the treatment of hypertension. A majority of health food store staff (70%) stated that NHP are superior or equal to medicinal drugs in treating hypertension based on efficacy.

CONCLUSION

Unlike pharmacy practice, verbal claims are common practice in health food stores, despite the lack of either written claims and/or proof of efficacy for most of them. These may be a very effective approach given that 30-40% of North American adults are functionally illiterate. These verbal claims are often inappropriate and not evidence-based.

Analysis for Identification in Amnesty Bin Samples from Dance Venues

The analysis of unknown substances discarded in amnesty bins, first described by Ramsey et al, from a large central London club and 7 smaller clubs in Manchester, UK are described. The contents of the bins were collected between July 2003 and March 2004. Solid dosage formulations were identified using the TICTAC database, chemical tests, and GC-MS screening. Drugs that could not be readily identified were subjected to other analytical techniques. The goal was to document the current range of drugs available on the dance scene and compare the findings between the London club, which had been the subject of a previous survey, and Manchester clubs. More than 1000 tablets, capsules, and powder doses were discarded in the amnesty bins. Tablets containing only MDMA (ecstasy) were found to be >94% and >84% of the total in London and Manchester, respectively. Although the quantities of tablets and powders recovered were different between London and Manchester, the proportions of the drugs were remarkably similar. The most common drugs found in powders in London and Manchester respectively were cocaine (29%, 40%), amphetamine (25%, 26%), ketamine (19%, 20%), and MDMA (19%, 11%).

Impact of pharmacometrics on drug approval and labeling decisions: a survey of 42 new drug applications

The value of quantitative thinking in drug development and regulatory review is increasingly being appreciated. Modeling and simulation of data pertaining to pharmacokinetic, pharmacodynamic, and disease progression is often referred to as the pharmacometrics analyses. The objective of the current report is to assess the role of pharmacometrics at the US Food and Drug Administration (FDA) in making drug approval and labeling decisions. The New Drug Applications (NDAs) submitted between 2000 and 2004 to the Cardio-renal, Oncology, and Neuropharmacology drug products divisions were surveyed. For those NDA reviews that included a pharmacometrics consultation, the clinical pharmacology scientists ranked the impact on the regulatory decision(s). Of about a total of 244 NDAs, 42 included a pharmacometrics component. Review of NDAs involved independent, quantitative evaluation by FDA pharmacometricians, even when such analysis was not conducted by the sponsor. Pharmacometric analyses were pivotal in regulatory decision making in more than half of the 42 NDAs. Of the 14 reviews that were pivotal to approval related decisions, 5 identified the need for additional trials, whereas 6 reduced the burden of conducting additional trials. Collaboration among the FDA clinical pharmacology, medical, and statistical reviewers and effective communication with the sponsors was critical for the impact to occur. The survey and the case studies emphasize the need for early interaction between the FDA and sponsors to plan the development more efficiently by appreciating the regulatory expectations better.

Patient Characteristics Influencing Evaluation of Written Medicine Information: Lessons for Patient Education

BACKGROUND:

Written medicine information (WMI) is considered an important component of patient education. Despite the wealth of information on many aspects of WMI, there is a paucity of studies examining how patient characteristics influence use and evaluation of WMI.

OBJECTIVE:

To investigate the influence of patient characteristics on the evaluation and intended future use of consumer medicine information (CMI), a form of WMI.

METHODS:

A questionnaire was administered to patients from 3 rheumatology/pain clinics in teaching hospitals and 40 community pharmacies. The questionnaire examined patients' perceptions of CMI (comprehension, perceived usefulness, design rating) and likelihood of using CMI in the future. Information on patient characteristics (demographic data, health literacy level) was also collected. Multiple regression analysis was used to examine associations between patient characteristics and their evaluation and intended future use of CMI.

RESULTS:

A total of 479 patients participated. Comprehension of CMI was associated with speaking primarily English at home, having attained secondary education or higher, and having adequate health literacy levels. Perceived usefulness of CMI was influenced by age and number of medications. Design rating was influenced by type of CMI, patient age, gender, and highest level of education. Intended future use was affected by health literacy level. In addition to individual patient characteristics, overall comprehension and perceived usefulness of CMI also influenced its intended future use.

CONCLUSIONS:

Patient characteristics were found to influence evaluation and intended future use of CMI. These findings should be taken into consideration in future research, development of WMI, and education of patients in everyday practice.

A literature review on off-label drug use in children

The aim was to compare results of studies performed in different settings worldwide and identify common therapeutic areas to allow for focused interventions, because off-label drug use can be a measure of the lack of knowledge concerning paediatric treatments. A secondary objective was to provide a brief review of efforts to date. A literature review of articles on off-label and unlicensed drug use in children involving general prescription samples was performed using Medline and Embase. In all, 30 studies from 1985-2004 were included. Eleven involved paediatric hospital wards, seven neonatal hospital wards, and 12 the community setting. The off-label and unlicensed classification methods varied, making results difficult to compare. In general, off-label/unlicensed prescription rates ranged from 11%-80%, and higher rates were found in younger versus older patients and in the hospital versus community settings. On the paediatric hospital wards, off-label/unlicensed prescriptions ranged from 16%-62% and most often concerned acetaminophen, cisapride, chloral hydrate, and salbutamol. In the neonatal wards, rates ranged from 55%-80% and often involved caffeine. In the community setting, rates ranged from 11%-37% and the most commonly implicated drugs were salbutamol and amoxicillin.

CONCLUSION

A lack of harmonization between the evidence, the information available to doctors, and its use in clinical practice exists and this is part of the reason off-label therapies are so common. Attempts have been made to improve knowledge concerning paediatric treatments, but more focused interventions are needed, also taking into consideration this lack of harmonization.

[Improvement of package insert CYP information for prescription drugs marketed in Japan]

In clinical practice, one drug is frequently used in combination with one or more other drugs, rather than as a sole regimen, and therefore healthcare providers need to carefully consider drug interactions. As mechanisms of drug interactions, metabolic enzymes of drugs are seen as one of the most likely interactive sites, where a majority of drugs are metabolized by cytochrome P450 (CYP). For this reason, providing appropriate information on CYP in package inserts is of grave importance. In fact, the package insert is the primary tool for supplying information on drugs to healthcare providers. The present study was designed to determine how many package inserts of prescription drugs marketed in Japan were providing CYP information. We searched the April 2003 version of "Drugs in Japan DB," which listed 2,022 prescription drugs, and found that only 239 package inserts (11.8%) mentioned CYP information and that only 194 (9.6%) specified CYP isozymes. To assess the improvement of package inserts, we searched "Drugs in Japan DB" from the January 2000 version to the April 2003 version. We found that CYP information had increased year by year (eg, 7.8-11.8% annually). For newly approved drugs, an analysis of the relationship between approval year and CYP information in package inserts (April 2003 version) revealed that recently approved drugs had more CYP information (eg, 45.5-51.3% of drugs in 1999-2002, compared to 6.8-26.1% in 1991-1996). A search for regulatory review documents for new drugs approved from 1999 to 2002 suggested that this recent improvement could be related to the increased number of studies identifying CYP isozymes involved in the metabolism or interaction with other drugs. Another reason for the recent improvement may be the fact that the guideline for package inserts for prescription drugs was revised in 1997, and the guidelines for drug interaction and pharmacokinetic studies were published between 1997 and 1999.

Reported medication errors associated with methotrexate

PURPOSE

Medication errors reported to FDA as adverse events in which methotrexate was identified as a possible contributor were studied.

METHODS

All adverse-event reports submitted to FDA between November 1997 and December 2001 indicating potential medication errors involving methotrexate were analyzed to determine the indication for use, the type of error, and the point in the medication-use process where the error occurred.

RESULTS

A total of 106 cases of reported medication errors associated with methotrexate were identified, including errors resuiting in 25 deaths (24%) and 48 other serious outcomes (45%). The most common types of errors involved confusion about the once-weekly dosage schedule (30%) and other dosage errors (22%). The most frequently involved indication for use was rheumatoid arthritis (42%). Of the errors, 39 (37%) were attributable to the prescriber, 21 (20%) to the patient, 20 (19%) to dispensing, and 18 (17%) to administration by a health care professional.

CONCLUSION

A review of medication errors involving methotrexate revealed that errors occurred during all phases of use, often resulted from confusion about dosage, and often caused death or other serious adverse effects.

Widespread off-label prescribing of topical but not systemic drugs for 350,000 paediatric outpatients in Stockholm

OBJECTIVES

Many hospital-based studies throughout Europe have shown that a substantial number of children receive off-label prescribed drugs that lack marketing authorisation for paediatric use. Since information about the extent and characteristics of this prescribing pattern in paediatric primary health care is limited, we assessed the proportion of off-label drug prescribing for paediatric outpatients in a reference population of 350,000 children using a computerised prescription database. We also determined the adherence to a treatment guideline provided by the Stockholm county council as a quality of prescribing indicator.

METHODS

All drugs prescribed for children younger than 16 years of age in the Stockholm county in the year 2000 were ranked by the number of prescription items. The retrospective, descriptive analysis was restricted to those drugs that accounted for 90% of total prescribing. We calculated the proportion of off-label drug prescribing for different age and therapeutic groups with respect to age, formulation and route of administration using the Swedish Physician's Desk Reference. The quality of prescribing was estimated as the proportion of prescription items corresponding to recommended drugs in the local treatment guideline Kloka Listan (The Wise List).

RESULTS

Among the 317 drugs accounting for 90% of total prescribing, 575,526 prescription items were identified with an average proportion of off-label and recommended drug prescribing of 20.7% and 60.5%, respectively. The off-label proportion was similar in various age groups but widely different between therapeutic groups being much higher for topical (70.4%) than for systemic (5.4%) drugs. The extent to which recommended drugs were prescribed also greatly varied between therapeutic groups irrespectively of the off-label proportion.

CONCLUSIONS

Off-label drug prescribing for paediatric outpatients is a common phenomenon. However, it mainly applied to topical drugs and was to a substantial extent recommended by the local treatment guideline. Thus, off-label prescribing might represent a more administrative rather than clinical problem in the paediatric outpatient setting.

Postmarketing drug dosage changes of 499 FDA-approved new molecular entities, 1980-1999

PURPOSE

Risks and benefits of marketed drugs can be improved by changing their labels to optimize dosage regimens for indicated populations. Such postmarketing label changes may reflect the quality of pre-marketing development, regulatory review, and postmarketing surveillance. We documented dosage changes of FDA-approved new molecular entities (NMEs), and investigated trends over time and across therapeutic groups, on the premise that improved drug development methods have yielded fewer postmarketing label changes over time.

METHODS

We compiled a list of NMEs approved by FDA from 1 January 1980 to 31 December 1999 using FDA's website, Freedom of Information Act request, and PhRMA (Pharmaceutical Research and Manufacturers of America) database. Original labeled dosages and indicated patient populations were tracked in labels in the Physician's Desk Reference. Time and covariate-adjusted risks for dosage changes by 5-year epoch and therapeutic groups were estimated by survival analysis.

RESULTS

Of 499 NMEs, 354 (71%) were evaluable. Dosage changes in indicated populations occurred in 73 NMEs (21%). A total of 58 (79%) were safety-motivated, net dosage decreases. Percentage of NMEs with changes by therapeutic group ranged from 27.3% for neuropharmacologic drugs to 13.6% for miscellaneous drugs. Median time to change following approval fell from 6.5 years (1980-1984) to 2.0 years (1995-1999). Contrary to our premise, 1995-1999 NMEs were 3.15 times more likely to change in comparison to 1980-1984 NMEs (p = 0.008, Cox analysis).

CONCLUSIONS

Dosages of one in five NMEs changed, four in five changes were safety reductions. Increasing frequency of changes, independent of therapeutic group, may reflect intensified postmarketing surveillance and underscores the need to improve pre-marketing optimization of dosage and indicated population.