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Dhruva SS, Darrow JJ, Kesselheim AS, Redberg RF. Experts' Views on FDA Regulatory Standards for Drug and High-Risk Medical Devices: Implications for Patient Care. J Gen Intern Med 2022; 37:4176-4182. [PMID: 35138547 PMCID: PMC9708961 DOI: 10.1007/s11606-021-07316-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/07/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Drugs and high-risk medical devices are increasingly likely to receive Food and Drug Administration (FDA) approval through expedited pathways, which has implications for informed treatment consent (i.e., consent in clinical practice). OBJECTIVE To obtain expert opinion about the clinical and ethical implications of the increasing availability of new drugs and devices approved through expedited development and regulatory review pathways. DESIGN Qualitative study using individual semi-structured videoconference interviews. PARTICIPANTS National leaders in medicine, ethics, and law (n=12) with expertise in medical product regulation, payor policymaking, bioethics, physician practice, patient advocacy, public health expertise/advocacy, clinical trials, the pharmaceutical and device industry, institutional review board oversight, and real-world evidence. MAIN MEASURES Principal themes in 3 domains: expedited regulatory pathways, physician and patient understanding of and reliance on FDA approval, and informed treatment consent. KEY RESULTS Respondents pointed out that more common use of expedited pathways translates to increased reliance on surrogate measures, some with uncertain clinical significance. While expedited development and review can have advantages, participants expressed worry that physicians were unaware when medical products were expedited and did not communicate about uncertainties in knowledge about new drug or device approvals effectively with patients. Many participants felt that informed treatment consent discussions about new drugs or devices should include some explanations of expedited pathways and use of surrogate measures. CONCLUSIONS Experts identified advantages of expediting development and of FDA flexibility in applying its standards to new drugs and medical devices, but highlighted concerns that patients may not be adequately informed about the risks of shorter review times or about uncertainties in the evidence that result. There is a need to identify approaches to ensure effective clinical use of drugs and devices when approved through expedited pathways.
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Affiliation(s)
- Sanket S. Dhruva
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA USA
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA USA
| | - Jonathan J. Darrow
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
- Department of Law and Taxation, Bentley University, Waltham, MA USA
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA USA
| | - Rita F. Redberg
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA USA
- Division of Cardiology, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA USA
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2
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Zimmerman KO, Perry B, Hanlen‐Rosado E, Nsonwu A, Lane MD, Benjamin DK, Becker M, Corneli A. Developing lay summaries and thank you notes in paediatric pragmatic clinical trials. Health Expect 2022; 25:1029-1037. [PMID: 35246906 PMCID: PMC9122399 DOI: 10.1111/hex.13448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Better transparency of research results and participant engagement may help address poor participant accrual in paediatric clinical research. We conducted formative research to assess the acceptability of lay summaries and thank you notes, as well as to refine and expand guidance on participant and family engagement in Pediatric Trials Network's (PTN) pragmatic paediatric clinical research. METHODS Informed by draft PTN guidance, we conducted in-depth qualitative interviews with adolescent clinical trial participants and caregivers of paediatric participants in four trials conducted by PTN across eight sites. Participants were shown multiple versions of mock lay summaries and thank you notes and asked questions on their preferences for content and layout, and on trial communications. We used applied thematic analysis to analyse the data. RESULTS We interviewed 27 individuals engaged in PTN research: 24 caregivers and 3 adolescents. During a trial, participants want regular updates on study progress, reminders of the study purpose and reassurances of data confidentiality. After the trial, participants want to learn the aggregated results, particularly medication effectiveness. Participants reported that lay summaries should include a review of the study's purpose, methods and length, and that they expect to learn individual-level results. Participants stated that thank you notes must be of sufficient length to be meaningful. CONCLUSIONS This is the first study to describe stakeholder preferences for thank you note content and layout. Using these findings, we finalized PTN's trial communication guidance for use in future PTN trials. Research is needed to determine the effect of lay summaries and thank you notes on improving public transparency regarding clinical trials and paediatric trial recruitment and completion. PATIENT OR PUBLIC CONTRIBUTION By design, stakeholders (adolescent trial participants and caregivers of pediatric trial participants) contributed to PTN's guidance on the content and layout of lay summaries and thank you notes through their participation in the in-depth interviews.
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Affiliation(s)
- Kanecia O. Zimmerman
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
- Department of PediatricsDuke UniversityDurhamNorth CarolinaUSA
| | - Brian Perry
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
| | - Emily Hanlen‐Rosado
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
| | - Adora Nsonwu
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
| | - Morgan D. Lane
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
- Department of PediatricsDuke UniversityDurhamNorth CarolinaUSA
| | - Mara Becker
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
- Department of PediatricsDuke UniversityDurhamNorth CarolinaUSA
| | - Amy Corneli
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
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Jannini TB, Lorenzo GD, Bianciardi E, Niolu C, Toscano M, Ciocca G, Jannini EA, Siracusano A. Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs). Curr Neuropharmacol 2022; 20:693-712. [PMID: 33998993 PMCID: PMC9878961 DOI: 10.2174/1570159x19666210517150418] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/22/2021] [Accepted: 05/05/2021] [Indexed: 11/22/2022] Open
Abstract
Psychiatric drugs have primacy for off-label prescribing. Among those, selective serotonin reuptake inhibitors (SSRIs) are highly versatile and, therefore, widely prescribed. Moreover, they are commonly considered as having a better safety profile compared to other antidepressants. Thus, when it comes to off-label prescribing, SSRIs rank among the top positions. In this review, we present the state of the art of off-label applications of selective serotonin reuptake inhibitors, ranging from migraine prophylaxis to SARS-CoV-2 antiviral properties. Research on SSRIs provided significant evidence in the treatment of premature ejaculation, both with the on-label dapoxetine 30 mg and the off-label paroxetine 20 mg. However, other than a serotoninergic syndrome, serious conditions like increased bleeding rates, hyponatremia, hepatoxicity, and post-SSRIs sexual dysfunctions, are consistently more prominent when using such compounds. These insidious side effects might be frequently underestimated during common clinical practice, especially by nonpsychiatrists. Thus, some points must be addressed when using SSRIs. Among these, a psychiatric evaluation before every administration that falls outside the regulatory agencies-approved guidelines has to be considered mandatory. For these reasons, we aim with the present article to identify the risks of inappropriate uses and to advocate the need to actively boost research encouraging future clinical trials on this topic.
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Affiliation(s)
- Tommaso B. Jannini
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giorgio D. Lorenzo
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy;,IRCCS-Fondazione Santa Lucia, Rome, Italy
| | | | - Cinzia Niolu
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Massimiliano Toscano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy;,Department of Neurology, Fatebenefratelli Hospital, Isola Tiberina, Rome, Italy
| | - Giacomo Ciocca
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome, Italy
| | | | - Alberto Siracusano
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy;,Address correspondence to this author at the Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; E-mail:
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Horvitz-Lennon M, Volya R, Hollands S, Zelevinsky K, Mulcahy A, Donohue JM, Normand SLT. Factors Associated With Off-Label Utilization of Second-Generation Antipsychotics Among Publicly Insured Adults. Psychiatr Serv 2021; 72:1031-1039. [PMID: 34074139 PMCID: PMC8410611 DOI: 10.1176/appi.ps.202000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Off-label utilization of second-generation antipsychotic medications may expose patients to significant risks. The authors examined the prevalence, temporal trends, and factors associated with off-label utilization of second-generation antipsychotics among publicly insured adults. METHODS A retrospective repeated panel was used to examine monthly off-label utilization of second-generation antipsychotics among fee-for-service Medicare, Medicaid, and dually eligible White, Black, and Latino adult beneficiaries filling prescriptions for second-generation antipsychotics in California, Georgia, Mississippi, and Oklahoma from July 2008 through June 2013. RESULTS Among 301,367 users of second-generation antipsychotics, between 36.5% and 41.9% had utilization that was always off-label. Payer did not modify effects of race-ethnicity on off-label utilization. Compared with Whites, Blacks had lower monthly odds of off-label utilization in all four states, and Latinos had lower odds of utilization in California and Georgia. Payer was associated with off-label utilization in California, Mississippi, and Oklahoma. California Medicaid beneficiaries were 1.12 (95% confidence interval=1.10-1.13) times as likely as dually eligible beneficiaries to have off-label utilization. Off-label utilization increased relative to the baseline year in all states, but a downward trend followed in three states. CONCLUSIONS Off-label utilization of second-generation antipsychotics was prevalent despite the drugs' cardiometabolic risks and little evidence of their effectiveness. The lower likelihood of off-label utilization among patients from racial-ethnic minority groups might stem from prescribers' efforts to minimize risks, given a higher baseline risk for these groups, or from disparities-associated factors. Variation among payers suggests that payer policies can affect off-label utilization.
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Affiliation(s)
- Marcela Horvitz-Lennon
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Rita Volya
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Simon Hollands
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Katya Zelevinsky
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Andrew Mulcahy
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Julie M Donohue
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
| | - Sharon-Lise T Normand
- RAND Corporation, Boston (Horvitz-Lennon), Santa Monica, California (Hollands), and Washington, D.C. (Mulcahy); Institute for Health Care Policy, Massachusetts General Hospital, Boston (Volya); Department of Health Care Policy, Harvard Medical School, Boston (Zelevinsky, Normand); Department of Biostatistics, Harvard School of Public Health, Boston (Normand); Department of Health Policy and Management, University of Pittsburgh, Pittsburgh (Donohue)
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5
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Galanter W, Eguale T, Gellad W, Lambert B, Mirica M, Cashy J, Salazar A, Volk LA, Falck S, Shilka J, Van Dril E, Jarrett J, Zulueta J, Fiskio J, Orav J, Norwich D, Bennett S, Seger D, Wright A, Linder JA, Schiff G. Personal Formularies of Primary Care Physicians Across 4 Health Care Systems. JAMA Netw Open 2021; 4:e2117038. [PMID: 34264328 PMCID: PMC8283562 DOI: 10.1001/jamanetworkopen.2021.17038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE More conservative prescribing has the potential to reduce adverse drug events and patient harm and cost; however, no method exists defining the extent to which individual clinicians prescribe conservatively. One potential domain is prescribing a more limited number of drugs. Personal formularies-defined as the number and mix of unique, newly initiated drugs prescribed by a physician-may enable comparisons among clinicians, practices, and institutions. OBJECTIVES To develop a method of defining primary care physicians' personal formularies and examine how they differ among primary care physicians at 4 institutions; evaluate associations between personal formularies and patient, physician, and practice site characteristics; and empirically derive and examine the variability of the top 200 core drugs prescribed at the 4 sites. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted at 4 US health care systems among 4655 internal and family medicine physicians and 4 930 707 patients who had at least 1 visit to these physicians between January 1, 2017, and December 31, 2018. EXPOSURES Personal formulary size was defined as the number of unique, newly initiated drugs. MAIN OUTCOMES AND MEASURES Personal formulary size and drugs used, physician and patient characteristics, core drugs, and analysis of selected drug classes. RESULTS The study population included 4655 primary care physicians (2274 women [48.9%]; mean [SD] age, 48.5 [4.4] years) and 4 930 707 patients (16.5% women; mean [SD] age, 51.9 [8.3] years). There were 41 378 903 outpatient prescriptions written, of which 9 496 766 (23.0%) were new starts. Institution median personal formulary size ranged from 150 (interquartile range, 82.0-212.0) to 296 (interquartile range, 230.0-347.0) drugs. In multivariable modeling, personal formulary size was significantly associated with panel size (total number of unique patients with face-to-face encounters during the study period; 1.2 medications per 100 patients), physician's total number of encounters (5.7 drugs per 10% increase), and physician's sex (-6.2 drugs per 100 patients for female physicians). There were 1527 unique, newly prescribed drugs across the 4 sites. Fewer than half the drugs (626 [41.0%]) were used at every site. Physicians' prescribing of drugs from a pooled core list varied from 0% to 100% of their prescriptions. CONCLUSIONS AND RELEVANCE Personal formularies, measured at the level of individual physicians and institutions, reveal variability in size and mix of drugs. Similarly, defining a list of commonly prescribed core drugs in primary care revealed interphysician and interinstitutional differences. Personal formularies and core medication lists enable comparisons and may identify outliers and opportunities for safer and more appropriate prescribing.
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Affiliation(s)
- William Galanter
- Department of Medicine, University of Illinois at Chicago, Chicago
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago
| | | | - Walid Gellad
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | | | - John Cashy
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | | | - Suzanne Falck
- Department of Medicine, University of Illinois at Chicago, Chicago
| | - John Shilka
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago
| | - Elizabeth Van Dril
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago
| | - Jennie Jarrett
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago
| | - John Zulueta
- Department of Psychiatry, University of Illinois at Chicago, Chicago
| | | | - John Orav
- Mass General Brigham, Boston, Massachusetts
| | | | | | | | | | - Jeffrey A. Linder
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Gopal AD, Wallach JD, Shah SA, Regillo C, Ross JS. On-Label and Off-Label Clinical Studies of FDA-Approved Ophthalmic Therapeutics. Ophthalmology 2021; 128:332-334. [PMID: 32682839 PMCID: PMC9900733 DOI: 10.1016/j.ophtha.2020.07.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/23/2020] [Accepted: 07/07/2020] [Indexed: 02/08/2023] Open
Affiliation(s)
| | - Joshua D Wallach
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Saloni A Shah
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Carl Regillo
- Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania
| | - Joseph S Ross
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Tiwari N, Baldwin DS. Clinical characteristics and unlicensed applications of licensed psychotropic drugs within a regional tertiary service for patients with affective disorders. Ther Adv Psychopharmacol 2020; 10:2045125318795132. [PMID: 32742633 PMCID: PMC7377598 DOI: 10.1177/2045125318795132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 04/20/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Referral to tertiary services is recommended when patients with mood and anxiety disorders have not responded to multiple treatments in primary or secondary care. Within specialist services, some patients undergo treatment with licensed psychotropic medications outside the narrow terms of their market authorization ('unlicensed applications'). We examined the demographic and clinical characteristics of patients referred to a regional specialist service to determine the extent of and factors associated with recommendations for unlicensed ('off label') prescriptions. METHODS Retrospective examination of demographic and clinical characteristics and treatment recommendations in patients seen within a 5-year period. Patients were allocated to three broad diagnostic clusters (unipolar depressive disorders, bipolar disorder, anxiety disorders), and two groups (with or without comorbid disorders). We compared patients in whom all treatment recommendations were for licensed applications with patients in whom at least one treatment was for an unlicensed application, across a range of variables reflecting illness 'burden' (duration, inpatient treatment, electroconvulsive therapy, nonfatal self-harm, psychosis). RESULTS From 177 new referrals, 148 patients (91 females, 57 males) could be placed within one of the three clusters. Many patients with bipolar disorder had not undergone treatment with lithium or formal psychological interventions in secondary care. Treatment recommendations involving unlicensed applications of medications were common (approximately 50%) in all clusters, but there were no significant differences in measures of illness burden between groups of patients, categorized according to licensed or unlicensed prescriptions. LIMITATIONS Retrospective examination of notes recorded for other purposes, within a single service, in which treatment recommendations might reflect idiosyncratic practice is a limitation of our findings. Also, examined variables could not provide a comprehensive indication of illness severity or functional impairment. CONCLUSION Our findings confirm that 'off label' prescribing is common in psychiatric practice. Treatment decisions relating to unlicensed applications appear to be influenced by factors other than overall illness burden.
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Affiliation(s)
- Nupur Tiwari
- Southern Health NHS Foundation Trust, University Department of Psychiatry, College Keep, 4-12 Terminus Terrace, Southampton SO14 3DT, UK
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Simsek M, Lissenberg‐Witte BI, van Riswijk MLM, Verschuren S, Hoentjen F, Oldenburg B, Ponsioen CY, van der Woude CJ, van der Meulen AE, Pierik M, Dijkstra G, de Boer NKH. Off-label prescriptions of drugs used for the treatment of Crohn's disease or ulcerative colitis. Aliment Pharmacol Ther 2019; 49:1293-1300. [PMID: 30908719 PMCID: PMC6593662 DOI: 10.1111/apt.15229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/16/2019] [Accepted: 02/25/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Off-label prescribing is encountered across various fields of medicine and creates alternative treatment options, but is associated with unknown safety risks. The use of off-label drugs for the treatment of patients with inflammatory bowel diseases (IBD) has not been characterised before. AIM To assess the proportion and characteristics of off-label prescribing for IBD in tertiary care centres in the Netherlands. METHODS A prospective database of IBD patients from all Dutch university hospitals was used to collect data on drug prescriptions for IBD and demographics. Drugs were classified as off-label if they were unlicensed for Crohn's disease and/or ulcerative colitis by the Medicines Evaluation Board. Uni- and multivariable analyses were used to identify patient-specific characteristics predictive of increased off-label use. RESULTS For the induction and/or maintenance treatment of 4583 IBD patients, 12 651 historical and current drug records were available in the database. Of these, 2374 (19%) were considered off-label prescriptions. Out of 4583 IBD patients, 1477 (32%) were exposed to off-label drugs. Commonly prescribed off-label IBD drugs were mercaptopurine (18%), beclomethasone (12%), thioguanine (4%) and allopurinol (3%). Non-thiopurine/methotrexate off-label drugs were prescribed in 243 patients (6%), including biological agents or tofacitinib in 47 IBD patients (1%). Off-label prescriptions were more common in ulcerative colitis than Crohn's disease (37% vs 29%, P < 0.001). Smokers and patients that received ≥5 drug types during their disease course were more likely to be exposed to off-label drugs (smoking 33% vs 27% and multiple drug use 66% vs 22%, both P < 0.001). CONCLUSION About one-fifth of prescriptions for IBD were off-label and one-third of IBD patients, especially ulcerative colitis patients, were exposed to off-label drugs.
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Affiliation(s)
- Melek Simsek
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit Amsterdam, AG&M research instituteAmsterdamThe Netherlands
| | | | - Milou L. M. van Riswijk
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit Amsterdam, AG&M research instituteAmsterdamThe Netherlands
| | - Sander Verschuren
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit Amsterdam, AG&M research instituteAmsterdamThe Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and HepatologyRadboud University Medical CentreNijmegenThe Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and HepatologyUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Cyriel Y. Ponsioen
- Department of Gastroenterology and HepatologyAmsterdam UMC, Academical Medical CentreAmsterdamThe Netherlands
| | - C. Janneke van der Woude
- Department of Gastroenterology and HepatologyErasmus University Medical CentreRotterdamThe Netherlands
| | - Andrea E. van der Meulen
- Department of Gastroenterology and HepatologyLeiden University Medical CentreLeidenThe Netherlands
| | - Marieke Pierik
- Department of Gastroenterology and HepatologyMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and HepatologyUniversity Medical Centre Groningen and University of GroningenGroningenThe Netherlands
| | - Nanne K. H. de Boer
- Department of Gastroenterology and HepatologyAmsterdam UMC, Vrije Universiteit Amsterdam, AG&M research instituteAmsterdamThe Netherlands
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Yackey K, Stukus K, Cohen D, Kline D, Zhao S, Stanley R. Off-label Medication Prescribing Patterns in Pediatrics: An Update. Hosp Pediatr 2019; 9:186-193. [PMID: 30745323 DOI: 10.1542/hpeds.2018-0168] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To describe the frequency of off-label drug use in 2014 as defined by the Food and Drug Administration (FDA)-approved age ranges in patients ≤18 years of age, to determine the rate of off-label drug use in 2014 by drug classification, and to compare current off-label medication usage rates with historical rates. METHODS This is a retrospective cohort study of an administrative database containing inpatient resource use data from January 1, 2014, to December 31, 2014. Patients ≤18 years of age receiving 1 of 76 selected commonly prescribed medications are included. Off-label drug use is defined as use in a patient younger than the lower limit of the FDA-approved age range for any indication or dosage form of that drug. RESULTS At least 1 drug was prescribed off label in 779 270 of 2 773 770 (28.1%) patient visits during the study period. Younger age, longer hospital stays, and mortality were associated with higher rates of off-label medication prescription. Off-label usage of certain medications differed between care settings. Rates of off-label medication use were higher in observational (45.5%), inpatient (53.9%), and ambulatory (54.2%) settings. CONCLUSIONS Although off-label drug use at major US pediatric hospitals is declining, 1 out of every 4 medications is not in accordance with FDA label indications for patient age. There exists substantial variation in off-label drug use among drug categories and encounter types. Although many commonly prescribed medications are FDA-approved for use in subpopulations of pediatric patients, studies of their safety, efficacy, pharmacokinetics, and optimal dosing are ongoing.
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Affiliation(s)
- Katelyn Yackey
- Department of Emergency Medicine, University of Kentucky, Lexington, Kentucky;
- Nationwide Children's Hospital, Columbus, Ohio; and
| | | | - Daniel Cohen
- Nationwide Children's Hospital, Columbus, Ohio; and
| | - David Kline
- Nationwide Children's Hospital, Columbus, Ohio; and
- Center for Biostatistics, The Ohio State University, Columbus, Ohio
| | - Sonia Zhao
- Nationwide Children's Hospital, Columbus, Ohio; and
- Center for Biostatistics, The Ohio State University, Columbus, Ohio
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10
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Deferio JJ, Levin TT, Cukor J, Banerjee S, Abdulrahman R, Sheth A, Mehta N, Pathak J. Using electronic health records to characterize prescription patterns: focus on antidepressants in nonpsychiatric outpatient settings. JAMIA Open 2018; 1:233-245. [PMID: 30474077 PMCID: PMC6241504 DOI: 10.1093/jamiaopen/ooy037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/13/2018] [Accepted: 08/30/2018] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To characterize nonpsychiatric prescription patterns of antidepressants according to drug labels and evidence assessments (on-label, evidence-based, and off-label) using structured outpatient electronic health record (EHR) data. METHODS A retrospective analysis was conducted using deidentified EHR data from an outpatient practice at a New York City-based academic medical center. Structured "medication-diagnosis" pairs for antidepressants from 35 325 patients between January 2010 and December 2015 were compared to the latest drug product labels and evidence assessments. RESULTS Of 140 929 antidepressant prescriptions prescribed by primary care providers (PCPs) and nonpsychiatry specialists, 69% were characterized as "on-label/evidence-based uses." Depression diagnoses were associated with 67 233 (48%) prescriptions in this study, while pain diagnoses were slightly less common (35%). Manual chart review of "off-label use" prescriptions revealed that on-label/evidence-based diagnoses of depression (39%), anxiety (25%), insomnia (13%), mood disorders (7%), and neuropathic pain (5%) were frequently cited as prescription indication despite lacking ICD-9/10 documentation. CONCLUSIONS The results indicate that antidepressants may be prescribed for off-label uses, by PCPs and nonpsychiatry specialists, less frequently than believed. This study also points to the fact that there are a number of off-label uses that are efficacious and widely accepted by expert clinical opinion but have not been included in drug compendia. Despite the fact that diagnosis codes in the outpatient setting are notoriously inaccurate, our approach demonstrates that the correct codes are often documented in a patient's recent diagnosis history. Examining both structured and unstructured data will help to further validate findings. Routinely collected clinical data in EHRs can serve as an important resource for future studies in investigating prescribing behaviors in outpatient clinics.
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Affiliation(s)
- Joseph J Deferio
- Department of Healthcare Policy and Research, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | | | - Judith Cukor
- Department of Psychiatry, Collaborative and Integrative Care, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Samprit Banerjee
- Department of Healthcare Policy and Research, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Rozan Abdulrahman
- Department of Healthcare Policy and Research, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Amit Sheth
- Kno.e.sis Center, Wright State University, Dayton, Ohio, USA
| | - Neel Mehta
- Department of Anesthesiology, Pain Medicine/Management, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Jyotishman Pathak
- Department of Healthcare Policy and Research, Weill Cornell Medicine, Cornell University, New York, New York, USA
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11
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Shea MB, Stewart M, Van Dyke H, Ostermann L, Allen J, Sigal E. Outdated Prescription Drug Labeling: How FDA-Approved Prescribing Information Lags Behind Real-World Clinical Practice. Ther Innov Regul Sci 2018; 52:771-777. [PMID: 29714570 DOI: 10.1177/2168479018759662] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prescription drug labeling is an authoritative source of information that guides the safe and effective use of approved medications. In many instances, however, labeling may fail to be updated as new information about drug efficacy emerges in the postmarket setting. When labeling becomes outdated, it loses its value for prescribers and undermines a core part of the FDA's mission to communicate accurate and reliable information to patients and physicians. METHODS We compared the number of drug uses indicated on product labels to the number of uses contained in a leading drug compendium for 43 cancer drugs approved between 1999 and 2011. We defined a "well-accepted off-label use" of a drug as one that was not approved by the FDA and received a category 1 or 2A evidence grade. RESULTS Of the 43 drugs reviewed in this study, 34 (79%) had at least one well-accepted off-label use. In total, 253 off-label uses were identified; 91% were well accepted, and 65% were in cancer types not previously represented on labeling. Off-patent drugs had more well-accepted off-label uses than brand-name drugs, on average (mean 13.7 vs 3.8, P = .018). CONCLUSIONS The labeling for many cancer drugs, particularly for older drugs, is outdated. Although FDA-approved labeling can never be fully aligned with real-world clinical practice, steps should be taken to better align the two when high-quality data exist. Such steps, if taken, will assist patients and prescribers in discerning which uses of drugs are supported by the highest quality evidence.
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Affiliation(s)
| | - Mark Stewart
- 1 Friends of Cancer Research, Washington, DC, USA
| | | | | | - Jeff Allen
- 1 Friends of Cancer Research, Washington, DC, USA
| | - Ellen Sigal
- 1 Friends of Cancer Research, Washington, DC, USA
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12
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Choi Y, Jung C, Chae Y, Kang M, Kim J, Joung K, Lim J, Cho S, Sung S, Lee E, Kim S. Comparison of Validity of Mapping between Drug Indications and ICD-10. Methods Inf Med 2018; 53:195-201. [DOI: 10.3414/me13-01-0053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 02/28/2014] [Indexed: 11/09/2022]
Abstract
SummaryBackground: Mapping of drug indications to ICD-10 was undertaken in Korea by a public and a private institution for their own purposes. A different mapping approach was used by each institution, which presented a good opportunity to compare the validity of the two approaches.Objectives: This study was undertaken to compare the validity of a direct mapping approach and an indirect terminology based mapping approach of drug indications against the gold standard drawn from the results of the two mapping processes.Methods: Three hundred and seventy-five cardiovascular reference drugs were selected from all listed cardiovascular drugs for the study. In the direct approach, two experienced nurse coders mapped the free text indications directly to ICD-10. In the indirect terminology based approach, the indications were extracted and coded in the Korean Standard Terminology of Medicine. These terminology coded indications were then manually mapped to ICD-10. The results of the two approaches were compared to the gold standard. A kappa statistic was calculated to see the compatibility of both mapping approaches. Recall, precision and F1 score of each mapping approach were calculated and analyzed using a paired t-test.Results: The mean number of indications for the study drugs was 5.42. The mean number of ICD-10 codes that matched in direct approach was 46.32 and that of indirect terminology based approach was 56.94. The agreement of the mapping results between the two approaches were poor (kappa = 0.19). The indirect terminology based approach showed higher recall (86.78%) than direct approach (p < 0.001). However, there was no difference in precision and F1 score between the two approaches.Conclusions: Considering no differences in the F1 scores, both approaches may be used in practice for mapping drug indications to ICD-10. However, in terms of consistency, time and manpower, better results are expected from the indirect terminology based approach.
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13
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Lee SM. Appropriate off-label drug use. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2018. [DOI: 10.5124/jkma.2018.61.3.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Sang Moo Lee
- Health Insurance Review and Assessment Service, Seoul, Korea
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14
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Herbst JL, Richards VE, Schramm ME, Mattie A. First Amendment Protection of Evidence-Based Promotion of Prescription Drugs: A Study of Published Clinical Evidence Supporting Off-Label Promotion in the USA. Pharmaceut Med 2017. [DOI: 10.1007/s40290-017-0202-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Saiyed MM, Ong PS, Chew L. Perception of oncology practitioners towards off-label use of anticancer medicines in Singapore. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2017. [DOI: 10.1111/jphs.12175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mohd Masnoon Saiyed
- Department of Pharmacy; National University of Singapore; Singapore Singapore
| | - Pei Shi Ong
- Department of Pharmacy; National University of Singapore; Singapore Singapore
| | - Lita Chew
- Department of Pharmacy; National University of Singapore; Singapore Singapore
- Department of Pharmacy; National Cancer Centre Singapore; Singapore
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16
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Ghinea N, Kerridge I, Little M, Lipworth W. Challenges to the validity of using medicine labels to categorize clinical behavior: An empirical and normative critique of "off-label" prescribing. J Eval Clin Pract 2017; 23:574-581. [PMID: 27859988 DOI: 10.1111/jep.12673] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 08/11/2016] [Accepted: 10/13/2016] [Indexed: 11/28/2022]
Abstract
This study aimed to determine whether the label status of a medicine penetrates into the clinical reasoning of Australian medical practitioners and to explore the possible reasons for our findings using semistructured interviews with 14 Australian physicians. The interviews revealed 3 broad catalysts for off-label prescribing. The first of these was lack of awareness or understanding of the regulatory process in general and labels more specifically. The second was the perception that labels are not meaningful guides for clinical practice. The third was the recognition of alternative mechanisms for ensuring safe, rational, and evidence-based prescribing occurs. This research suggests that Australian physicians do not consider whether a medicine is off-label to be a reliable measure of the appropriateness of their prescribing practices. Rather, the legitimacy of prescribing practices is determined by the abilities, skills, and knowledge base of particular prescribers by a culture that encourages and supports evidence-based practice, and safe prescribing. Although labels are of minimal clinical significance, there are real conceptual, practical, and moral problems associated with conflating "good" or "better" practice with "on-label" practice, and "bad" or "worse" practice with off-label prescribing as often occurs. To ascribe greater meaning to the term "off-label" than is warranted can have the unintended consequence of casting suspicion on and making it more difficult for physicians to provide appropriate clinical care. We conclude that labeling can, in some cases, provide assurances to both clinicians and patients that their medications have been demonstrated to be safe and effective, but that clinicians should be able to continue to prescribe responsibly off-label without having any stigma attached to their practice.
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Affiliation(s)
- Narcyz Ghinea
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, NSW, 2010, Australia.,Centre for Values, Ethics and the Law in Medicine, University of Sydney, NSW, 2006, Australia
| | - Ian Kerridge
- Centre for Values, Ethics and the Law in Medicine, University of Sydney, NSW, 2006, Australia.,Haematology Department, Royal North Shore Hospital, Sydney, NSW, 2065, Australia
| | - Miles Little
- Centre for Values, Ethics and the Law in Medicine, University of Sydney, NSW, 2006, Australia
| | - Wendy Lipworth
- Centre for Values, Ethics and the Law in Medicine, University of Sydney, NSW, 2006, Australia
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17
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Pease AM, Krumholz HM, Downing NS, Aminawung JA, Shah ND, Ross JS. Postapproval studies of drugs initially approved by the FDA on the basis of limited evidence: systematic review. BMJ 2017; 357:j1680. [PMID: 28468750 PMCID: PMC5421452 DOI: 10.1136/bmj.j1680] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective To characterize the prospective controlled clinical studies for all novel drugs that were initially approved by the Food and Drug Administration on the basis of limited evidence.Design Systematic review.Data sources Drugs@FDA database and PubMed.Study inclusion All prospective controlled clinical studies published after approval for all novel drugs initially approved by the FDA between 2005 and 2012 on the basis of a single pivotal trial, pivotal trials that used surrogate markers of disease as primary endpoints, or both. Results Between 2005 and 2012 the FDA approved 117 novel drugs for 123 indications on the basis of a single pivotal trial, pivotal trials that used surrogate markers of disease, or both (single surrogate trials). We identified 758 published controlled studies over a median of 5.5 years (interquartile range 3.4-8.2) after approval, most of which (554 of 758; 73.1%) were studies for indications approved on the basis of surrogate markers of disease. Most postapproval studies used active comparators-67 of 77 (87.0%) indications approved on the basis of single pivotal trials, 365 of 554 (65.9%) approvals based on surrogate marker trials, and 100 of 127 (78.7%) approvals based on single surrogate trials-and examined surrogate markers of efficacy as primary endpoints-51 of 77 (66.2%), 512 of 554 (92.4%), and 110 of 127 (86.6%), respectively. Overall, no postapproval studies were identified for 43 of the 123 (35.0%) approved indications. The median total number of postapproval studies identified was 1 (interquartile range 0-2) for indications approved on the basis of a single pivotal trial, 3 (1-8) for indications approved on the basis of pivotal trials that used surrogate markers of disease as primary endpoints, and 1 (0-2) for single surrogate trial approvals, and the median aggregate number of patients enrolled in postapproval studies was 90 (0-509), 533 (122-3633), and 38 (0-666), respectively. The proportion of approved indications with one or more randomized, controlled, double blind study using a clinical outcome for the primary endpoint that was published after approval and showed superior efficacy was 18.2% (6 of 33), 2.0% (1 of 49), and 4.9% (2 of 41), respectively.Conclusions The quantity and quality of postapproval clinical evidence varied substantially for novel drugs first approved by the FDA on the basis of limited evidence, with few controlled studies published after approval that confirmed efficacy using clinical outcomes for the original FDA approved indication.
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Affiliation(s)
- Alison M Pease
- State University of New York Downstate College of Medicine, Brooklyn, NY, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, CT, USA
| | - Nicholas S Downing
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jenerius A Aminawung
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Nilay D Shah
- Division of Health Care Policy and Research and Kern Center for the Science of Health Care Delivery, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Joseph S Ross
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, CT, USA
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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18
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Wong J, Motulsky A, Abrahamowicz M, Eguale T, Buckeridge DL, Tamblyn R. Off-label indications for antidepressants in primary care: descriptive study of prescriptions from an indication based electronic prescribing system. BMJ 2017; 356:j603. [PMID: 28228380 PMCID: PMC5320934 DOI: 10.1136/bmj.j603] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective To examine off-label indications for antidepressants in primary care and determine the level of scientific support for off-label prescribing.Design Descriptive study of antidepressant prescriptions written by primary care physicians using an indication based electronic prescribing system.Setting Primary care practices in and around two major urban centres in Quebec, Canada.Participants Patients aged 18 years or older who visited a study physician between 1 January 2003 and 30 September 2015 and were prescribed an antidepressant through the electronic prescribing system.Main outcome measures Prevalence of off-label indications for antidepressant prescriptions by class and by individual drug. Among off-label antidepressant prescriptions, the proportion of prescriptions in each of the following categories was measured: strong evidence supporting use of the prescribed drug for the respective indication; no strong evidence for the prescribed drug but strong evidence supporting use of another drug in the same class for the indication; or no strong evidence supporting use of the prescribed drug and all other drugs in the same class for the indication. Results 106 850 antidepressant prescriptions were written by 174 physicians for 20 920 adults. By class, tricyclic antidepressants had the highest prevalence of off-label indications (81.4%, 95% confidence interval, 77.3% to 85.5%), largely due to a high off-label prescribing rate for amitriptyline (93%, 89.6% to 95.7%). Trazodone use for insomnia was the most common off-label use for antidepressants, accounting for 26.2% (21.9% to 30.4%) of all off-label prescriptions. For only 15.9% (13.0% to 19.3%) of all off-label prescriptions, the prescribed drug had strong scientific evidence for the respective indication. For 39.6% (35.7% to 43.2%) of off-label prescriptions, the prescribed drug did not have strong evidence but another antidepressant in the same class had strong evidence for the respective indication. For the remaining 44.6% (40.2% to 49.0%) of off-label prescriptions, neither the prescribed drug nor any other drugs in the class had strong evidence for the indication.Conclusions When primary care physicians prescribed antidepressants for off-label indications, these indications were usually not supported by strong scientific evidence, yet often another antidepressant in the same class existed that had strong evidence for the respective indication. There is an important need to generate and provide physicians with evidence on off-label antidepressant use to optimise prescribing decisions.
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Affiliation(s)
- Jenna Wong
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
| | - Aude Motulsky
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
- Centre de recherche du Centre hospitalier de l'Université de Montréal, School of Public Health, University of Montréal, Montréal, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
| | - Tewodros Eguale
- Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA
| | - David L Buckeridge
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
| | - Robyn Tamblyn
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
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19
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Saiyed MM, Ong PS, Chew L. Off-label drug use in oncology: a systematic review of literature. J Clin Pharm Ther 2017; 42:251-258. [DOI: 10.1111/jcpt.12507] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/04/2017] [Indexed: 11/29/2022]
Affiliation(s)
- M. M. Saiyed
- Department of Pharmacy; Faculty of Science, National University Singapore; Singapore
| | - P. S. Ong
- Department of Pharmacy; Faculty of Science, National University Singapore; Singapore
| | - L. Chew
- Department of Pharmacy; Faculty of Science, National University Singapore; Singapore
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20
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Collins SL, Carr DF, Pirmohamed M. Advances in the Pharmacogenomics of Adverse Drug Reactions. Drug Saf 2016; 39:15-27. [PMID: 26650062 DOI: 10.1007/s40264-015-0367-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rapid developments in pharmacogenomics have been noticeable in recent years, and much of this knowledge has improved understanding of adverse drug reactions. This improved knowledge has largely been the result of improved sequencing technologies and falling costs in this area, as well as improved statistical techniques to analyse the data derived from studies. While the genetic reasons behind adverse drug reactions are becoming better understood, translation of this knowledge, particularly in terms of biomarkers that might be clinically applicable at the bedside, has been more difficult. Understanding of the technologies and their application is limited among practising clinicians. The cost of some of the technologies available may also be prohibitive in stretched healthcare economies. As education about the potential for applying pharmacogenomics improves and costs fall, understanding of adverse drug reactions and application of this knowledge in a clinical setting should improve.
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Affiliation(s)
- Susannah L Collins
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Daniel F Carr
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.
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21
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Sarkees ME, Fitzgerald MP. The changing landscape of off-label prescription drug promotion. INTERNATIONAL JOURNAL OF PHARMACEUTICAL AND HEALTHCARE MARKETING 2016. [DOI: 10.1108/ijphm-08-2015-0042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Off-label drug prescribing by healthcare providers is a growing practice. Yet, the US Food and Drug Administration bans the marketing of drugs for off-label uses. In recent years, legal challenges by the pharmaceutical industry have chipped away government restrictions on off-label drug promotion. Although the changing legal landscape has been discussed, this paper aims to examine how key stakeholders and policy-makers might interact to provide a more transparent marketing environment for off-label drug discussions in the patient–provider relationship.
Design/methodology/approach
Drawing on a variety of sources, the authors assess the current marketing landscape of off-label drugs and some of the issues that challenge the healthcare provider–patient relationship. The authors then examine opportunities to improve the off-label promotion environment and the relevant decision-making theories that key stakeholders need to consider when formulating marketing efforts and policies.
Findings
The authors suggest that fewer restrictions on truthful, non-misleading off-label drug promotion provide an opportunity to improve drug knowledge and, importantly, healthcare provider and consumer decision-making. Key stakeholders should consider, among other solutions, criteria for defining truthful information on off-label drugs, alternative methods of approval of off-label uses and ubiquitous icons to identify off-label prescribing to all stakeholders.
Originality/value
Rather than rehash the legal landscape of off-label drug promotion, this paper focuses on how the healthcare provider–patient relationship is impacted and how stakeholders can improve information flow in this changing environment.
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22
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Mackey TK, Liang BA. After Amarin v FDA: What Will the Future Hold for Off-label Promotion Regulation? Mayo Clin Proc 2016; 91:701-6. [PMID: 27084416 DOI: 10.1016/j.mayocp.2016.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/27/2016] [Accepted: 02/23/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Tim K Mackey
- Department of Anesthesiology, Division of Global Public Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA; Joint Masters Program in Health Policy and Law, University of California, San Diego School of Medicine and California Western School of Law, San Diego, CA; Global Health Policy Institute, La Jolla, CA.
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23
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Hoffman SJ, Guindon GE, Lavis JN, Randhawa H, Becerra-Posada F, Dejman M, Falahat K, Malek-Afzali H, Ramachandran P, Shi G, Yesudian CAK. Surveying the Knowledge and Practices of Health Professionals in China, India, Iran, and Mexico on Treating Tuberculosis. Am J Trop Med Hyg 2016; 94:959-970. [PMID: 26903613 PMCID: PMC4856627 DOI: 10.4269/ajtmh.15-0538] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 01/04/2016] [Indexed: 01/05/2023] Open
Abstract
Research evidence continues to reveal findings important for health professionals' clinical practices, yet it is not consistently disseminated to those who can use it. The resulting deficits in knowledge and service provision may be especially pronounced in low- and middle-income countries that have greater resource constraints. Tuberculosis treatment is an important area for assessing professionals' knowledge and practices because of the effectiveness of existing treatments and recognized gaps in professionals' knowledge about treatment. This study surveyed 384 health professionals in China, India, Iran, and Mexico on their knowledge and practices related to tuberculosis treatment. Few respondents correctly answered all five knowledge questions (12%) or self-reported performing all five recommended clinical practices "often or very often" (3%). Factors associated with higher knowledge scores included clinical specialization and working with researchers. Factors associated with better practices included training in the care of tuberculosis patients, being based in a hospital, trusting systematic reviews of randomized controlled double-blind trials, and reading summaries of articles, reports, and reviews. This study highlights several strategies that may prove effective in improving health professionals' knowledge and practices related to tuberculosis treatment. Facilitating interactions with researchers and training in acquiring systematic reviews may be especially helpful.
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Affiliation(s)
- Steven J. Hoffman
- Global Strategy Lab, Faculty of Law, University of Ottawa, Ottawa, Ontario, Canada; Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada; Pan American Health Organization, Washington, DC; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Deputy of Research and Technology, Ministry of Health and Medical Education, Tehran, Iran; Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Valmar International, Mumbai, India; Department of Policy Research, Chinese Peasants' and Workers' Democratic Party, Beijing, China; Health Systems Consultant and Trainer, Mumbai, India
| | | | | | | | | | | | | | | | - Parasurama Ramachandran
- Global Strategy Lab, Faculty of Law, University of Ottawa, Ottawa, Ontario, Canada; Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada; Pan American Health Organization, Washington, DC; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Deputy of Research and Technology, Ministry of Health and Medical Education, Tehran, Iran; Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Valmar International, Mumbai, India; Department of Policy Research, Chinese Peasants' and Workers' Democratic Party, Beijing, China; Health Systems Consultant and Trainer, Mumbai, India
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Krishnamurti T, Argo N. A Patient-Centered Approach to Informed Consent: Results from a Survey and Randomized Trial. Med Decis Making 2016; 36:726-40. [PMID: 26964877 DOI: 10.1177/0272989x16636844] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 12/08/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE Traditional informed consent documents tend to be too lengthy and technical to facilitate proper patient engagement. Patient-centered, short informed consent content could be equally informative, while minimizing patient burden and producing greater patient engagement. This study aimed to develop and evaluate patient-centered, patient-designed paper and video informed consent formats. METHODS Two studies were conducted. In study 1, 118 self-identifying asthma patients recruited from a national, online pool completed survey tasks from their personal computers. Participants in study 1 were randomly assigned to examine sections of a standard informed consent document for an asthma trial and to select information they deemed critical to their decision making. In study 2, a sample of 83 self-identifying asthma patients completed experimental tasks in a university laboratory. Participants in study 2 were randomly assigned to a full informed consent document; a shortened, patient-designed informed consent document created from study 1; or a video with content matched to the shortened paper form. RESULTS Study 1 yielded a more readable, concise version of a standard informed consent document (5 v. 17 pages). This shortened, patient-designed form closely met normative criteria for good clinical practice. In study 2, participants who viewed either the shortened paper consent or video reported greater engagement than those viewing the standard paper consent, without lowered performance on any other decision-relevant variables (i.e., comprehension, judged risk/benefit, feelings of trust). The video consent format did not cause increased enrollment. CONCLUSIONS Results suggest that providing concise informed consent content, systematically developed from patients' self-reported information needs, may be more effective at engaging and informing clinical trial participants than the traditional consent approach, without detriment to trial comprehension, risk assessment, or enrollment.
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Affiliation(s)
- Tamar Krishnamurti
- Departments of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania(TK, NA)
| | - Nichole Argo
- Departments of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania(TK, NA),Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania(NA)
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Vilhelmsson A, Davis C, Mulinari S. Pharmaceutical Industry Off-label Promotion and Self-regulation: A Document Analysis of Off-label Promotion Rulings by the United Kingdom Prescription Medicines Code of Practice Authority 2003-2012. PLoS Med 2016; 13:e1001945. [PMID: 26812151 PMCID: PMC4727894 DOI: 10.1371/journal.pmed.1001945] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 12/15/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND European Union law prohibits companies from marketing drugs off-label. In the United Kingdom--as in some other European countries, but unlike the United States--industry self-regulatory bodies are tasked with supervising compliance with marketing rules. The objectives of this study were to (1) characterize off-label promotion rulings in the UK compared to the whistleblower-initiated cases in the US and (2) shed light on the UK self-regulatory mechanism for detecting, deterring, and sanctioning off-label promotion. METHODS AND FINDINGS We conducted structured reviews of rulings by the UK self-regulatory authority, the Prescription Medicines Code of Practice Authority (PMCPA), between 2003 and 2012. There were 74 off-label promotion rulings involving 43 companies and 65 drugs. Nineteen companies were ruled in breach more than once, and ten companies were ruled in breach three or more times over the 10-y period. Drawing on a typology previously developed to analyse US whistleblower complaints, we coded and analysed the apparent strategic goals of each off-label marketing scheme and the practices consistent with those alleged goals. 50% of rulings cited efforts to expand drug use to unapproved indications, and 39% and 38% cited efforts to expand beyond approved disease entities and dosing strategies, respectively. The most frequently described promotional tactic was attempts to influence prescribers (n = 72, 97%), using print material (70/72, 97%), for example, advertisements (21/70, 30%). Although rulings cited prescribers as the prime target of off-label promotion, competing companies lodged the majority of complaints (prescriber: n = 16, 22%, versus companies: n = 42, 57%). Unlike US whistleblower complaints, few UK rulings described practices targeting consumers (n = 3, 4%), payers (n = 2, 3%), or company staff (n = 2, 3%). Eight UK rulings (11%) pertaining to six drugs described promotion of the same drug for the same off-label use as was alleged by whistleblowers in the US. However, while the UK cases typically related to only one or a few claims made in printed material, several complaints in the US alleged multifaceted and covert marketing activities. Because this study is limited to PMCPA rulings and whistleblower-initiated federal cases, it may offer a partial view of exposed off-label marketing. CONCLUSION The UK self-regulatory system for exposing marketing violations relies largely on complaints from company outsiders, which may explain why most off-label promotion rulings relate to plainly visible promotional activities such as advertising. This contrasts with the US, where Department of Justice investigations and whistleblower testimony have alleged complex off-label marketing campaigns that remain concealed to company outsiders. UK authorities should consider introducing increased incentives and protections for whistleblowers combined with US-style governmental investigations and meaningful sanctions. UK prescribers should be attentive to, and increasingly report, off-label promotion.
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Affiliation(s)
- Andreas Vilhelmsson
- Department of Clinical Sciences, Division of Social Medicine and Global Health, Faculty of Medicine, Malmö University, Lund, Sweden
- Department of Gender Studies, Faculty of Social Sciences, Lund University, Lund, Sweden
| | - Courtney Davis
- Department of Social Science, Health and Medicine, King’s College London, London, United Kingdom
| | - Shai Mulinari
- Department of Sociology, Faculty of Social Sciences, Lund University, Lund, Sweden
- * E-mail:
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Ghinea N, Lipworth W, Kerridge I. Off-Label Promotion of Prescription Medicine: Is It Ever Justifiable? Ther Innov Regul Sci 2015; 49:359-363. [PMID: 30222394 DOI: 10.1177/2168479015570337] [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] [Indexed: 11/15/2022]
Abstract
Off-label promotion has attracted intense scrutiny from regulators in recent decades, resulting in many pharmaceutical companies paying hefty penalties for illegal marketing practices. At the same time, the pharmaceutical industry has accused governments of applying double standards by encouraging the use of cheaper off-label alternatives to registered treatments, and defended their "right" to promote off-label drugs on freedom of speech grounds. However, the debate about off-label promotion and the prescribing that results has largely failed to address the issue that really matters-what impact does off-label promotion and prescribing have on patients and the health system? This paper explores the benefits and problems with off-label prescribing to determine whether off-label promotion is ever justified and, if so, under what conditions.
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Affiliation(s)
- Narcyz Ghinea
- 1 St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Wendy Lipworth
- 2 Centre for Values, Ethics & Law in Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Ian Kerridge
- 2 Centre for Values, Ethics & Law in Medicine, University of Sydney, Sydney, New South Wales, Australia
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Abstract
Of the infertile couples unable to conceive without any identifiable cause, 30 % are defined as having unexplained infertility. Management depends on duration of infertility and age of female partner. The treatment of unexplained infertility is empirical, and many different regimens have been used. Among these are expectant management, ovarian stimulation with clomiphene citrate, gonadotropins and aromatase inhibitors, fallopian tube sperm perfusion, tubal flushing, intrauterine insemination, gamete intrafallopian transfer, and IVF. The first approach to treatment of unexplained infertility generally is the use of drugs that stimulate oocyte production. For over four decades, the first-line treatment for ovarian stimulation in unexplained infertility has been clomiphene citrate. Multiple reports suggest that aromatase inhibitors may be effective alternative agents for ovarian stimulation in couples with unexplained infertility. Their administration is reported to be associated with monofollicular development in most cases, which may result in enhanced fertility and a reduced risk of ovarian hyperstimulation and multiple births, as compared to current standard therapies such as gonadotropin and clomiphene. Despite world evidence to the contrary, letrozole has been banned for use for infertility management in India since 2011.
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Hwang J, Hwang TJ, Ciolino JB. Pivotal clinical trials of novel ophthalmic drugs and medical devices: retrospective observational study, 2002-2012. BMJ Open 2015; 5:e007987. [PMID: 26044760 PMCID: PMC4458635 DOI: 10.1136/bmjopen-2015-007987] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Novel therapeutics are an important part of ophthalmologists' armamentarium, and the risks and benefits of these therapies must be carefully evaluated. We sought to quantify the characteristics of the pivotal clinical trials supporting the regulatory approval of new ophthalmic drugs and medical devices. DESIGN Retrospective observational study. SETTING AND DATA SOURCE Medical review dossiers for new ophthalmic drug and high-risk device approvals released publicly by the US Food and Drug Administration (FDA). MAIN OUTCOME MEASURES Proportion of pivotal trials with randomisation, masking, active or placebo controls and subgroup analyses; total and median number of trial enrollees; and the number of drugs and devices approved with required postapproval studies. RESULTS From 2002 to 2012, the FDA approved 11 ophthalmic drugs and 25 devices. The pivotal trials underlying the approvals of ophthalmic drugs in our study cohort enrolled a median of 809 patients. Virtually all drug trials were randomised and masked (91%), of which 7 (70%) used a placebo control. Pivotal trials for ophthalmic devices enrolled 324 patients on average, and significantly fewer trials for ophthalmic devices versus drugs were randomised (16% vs 91%; p<0.001) or masked (12% vs 91%; p<0.001). 8 (32%) ophthalmic devices and 6 (55%) ophthalmic drugs were approved with required postapproval studies. CONCLUSIONS Ophthalmic therapeutics were approved based on varying levels of evidence. Postapproval studies could be used to confirm or refute early indications of safety and effectiveness of these therapeutics, with the study results accessible to patients and clinicians who need to make informed treatment decisions.
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Affiliation(s)
- Jenny Hwang
- St John's Riverside Hospital, Yonkers, New York, USA
| | - Thomas J Hwang
- Faculty of Arts and Sciences, Harvard University, Cambridge, Massachusetts, USA The Blackstone Group, London, UK
| | - Joseph B Ciolino
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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Shrier I, Matheson GO, Boudier-Revéret M, Steele RJ. Validating the three-step return-to-play decision model. Scand J Med Sci Sports 2014; 25:e231-9. [DOI: 10.1111/sms.12306] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2014] [Indexed: 11/26/2022]
Affiliation(s)
- I. Shrier
- Centre for Clinical Epidemiology; Lady Davis Institute for Medical Research; Jewish General Hospital; McGill University; Montreal Quebec Canada
| | - G. O. Matheson
- Division of Sports Medicine; Department of Orthopaedic Surgery; Stanford University School of Medicine; Palo Alto California USA
| | - M. Boudier-Revéret
- Division of Medicine and Physiatry; Centre Hospitalier de l'Université de Montréal; Montreal Quebec Canada
| | - R. J. Steele
- Department of Mathematics and Statistics; McGill University; Montreal Quebec Canada
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Vox F, Capron AM, Kraus MF, Alexander GC, Kirschner KL. Balancing burdens and benefits: ethical issues of off-label prescription pharmaceutical use. PM R 2014; 5:882-9. [PMID: 24160301 DOI: 10.1016/j.pmrj.2013.08.601] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 08/27/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Ford Vox
- Brain Injury Rehabilitation, Shepherd Center; Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA∗
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Abstract
Background Off-label use of a drug not according to its regulatory labeling has become common in medicine, especially in the field of psychiatry. Mood stabilizers are intended to be used to attenuate mood fluctuations in bipolar disorder, but their use has spread to patients with schizophrenia, as it provides greater control of impulsivity and aggressiveness. Sodium valproate is one of the most frequently used mood stabilizers in psychiatry. This study determined the prevalence of off-label use of sodium valproate for schizophrenia and schizoaffective disorder in Abarbanel Psychiatric Hospital and the demographic and clinical characteristics associated with its use. Methods Retrospective study of patients hospitalized in 2011–2012 with a diagnosis of schizophrenia or schizoaffective disorder in one of three general psychiatric wards. Results Valproate use was significantly lower in the geriatric group (11.6% vs. 20.1%, chi square = 4.7, p = .03), in patients with schizophrenia (14.1% vs. schizoaffective disorder (35.2%), chi square = 29, p<.001) and in patients receiving both atypical and typical antipsychotics (23.3% vs. 16.4%, p = .04). In multivariate logistic regression analysis, diagnosis and the combination of atypical and typical antipsychotics predicted the use of sodium valproate. The number of other medications prescribed did not predict sodium valproate use. Conclusions Off-label use of sodium valproate in psychiatric patients with schizophrenia or schizoaffective disorder is extensive, especially in younger patients and those with schizoaffective disorder. More research is needed to determine whether it is being prescribed appropriately.
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Jung K, LePendu P, Chen WS, Iyer SV, Readhead B, Dudley JT, Shah NH. Automated detection of off-label drug use. PLoS One 2014; 9:e89324. [PMID: 24586689 PMCID: PMC3929699 DOI: 10.1371/journal.pone.0089324] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 01/17/2014] [Indexed: 01/30/2023] Open
Abstract
Off-label drug use, defined as use of a drug in a manner that deviates from its approved use defined by the drug's FDA label, is problematic because such uses have not been evaluated for safety and efficacy. Studies estimate that 21% of prescriptions are off-label, and only 27% of those have evidence of safety and efficacy. We describe a data-mining approach for systematically identifying off-label usages using features derived from free text clinical notes and features extracted from two databases on known usage (Medi-Span and DrugBank). We trained a highly accurate predictive model that detects novel off-label uses among 1,602 unique drugs and 1,472 unique indications. We validated 403 predicted uses across independent data sources. Finally, we prioritize well-supported novel usages for further investigation on the basis of drug safety and cost.
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Affiliation(s)
- Kenneth Jung
- Program In Biomedical Informatics, Stanford University, Stanford, California, United States of America
| | - Paea LePendu
- Center for Biomedical Informatics Research, Stanford University, Stanford, California, United States of America
| | - William S. Chen
- Center for Biomedical Informatics Research, Stanford University, Stanford, California, United States of America
| | - Srinivasan V. Iyer
- Program In Biomedical Informatics, Stanford University, Stanford, California, United States of America
| | - Ben Readhead
- Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Joel T. Dudley
- Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Nigam H. Shah
- Center for Biomedical Informatics Research, Stanford University, Stanford, California, United States of America
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Downing NS, Aminawung JA, Shah ND, Krumholz HM, Ross JS. Clinical trial evidence supporting FDA approval of novel therapeutic agents, 2005-2012. JAMA 2014; 311:368-77. [PMID: 24449315 PMCID: PMC4144867 DOI: 10.1001/jama.2013.282034] [Citation(s) in RCA: 267] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Many patients and physicians assume that the safety and effectiveness of newly approved therapeutic agents is well understood; however, the strength of the clinical trial evidence supporting approval decisions by the US Food and Drug Administration (FDA) has not been evaluated. OBJECTIVES To characterize pivotal efficacy trials (clinical trials that serve as the basis of FDA approval) for newly approved novel therapeutic agents. DESIGN AND SETTING Cross-sectional analysis using publicly available FDA documents for all novel therapeutic agents approved between 2005 and 2012. MAIN OUTCOMES AND MEASURES Pivotal efficacy trials were classified according to the following design features: randomization, blinding, comparator, and trial end point. Surrogate outcomes were defined as any end point using a biomarker expected to predict clinical benefit. The number of patients, trial duration, and trial completion rates were also determined. RESULTS Between 2005 and 2012, the FDA approved 188 novel therapeutic agents for 206 indications on the basis of 448 pivotal efficacy trials. The median number of pivotal trials per indication was 2 (interquartile range, 1-2.5), although 74 indications (36.8%) were approved on the basis of a single pivotal trial. Nearly all trials were randomized (89.3% [95% CI, 86.4%-92.2%]), double-blinded (79.5% [95% CI, 75.7%-83.2%]), and used either an active or placebo comparator (87.1% [95% CI, 83.9%-90.2%]). The median number of patients enrolled per indication among all pivotal trials was 760 (interquartile range, 270-1550). At least 1 pivotal trial with a duration of 6 months or greater supported the approval of 68 indications (33.8% [95% CI, 27.2%-40.4%]). Pivotal trials using surrogate end points as their primary outcome formed the exclusive basis of approval for 91 indications (45.3% [95% CI, 38.3%-52.2%]), clinical outcomes for 67 (33.3% [95% CI, 26.8%-39.9%]), and clinical scales for 36 (17.9% [95% CI, 12.6%-23.3%]). Trial features differed by therapeutic and indication characteristics, such as therapeutic area, expected length of treatment, orphan status, and accelerated approval. CONCLUSIONS AND RELEVANCE The quality of clinical trial evidence used by the FDA as the basis for recent approvals of novel therapeutic agents varied widely across indications. This variation has important implications for patients and physicians as they make decisions about the use of newly approved therapeutic agents.
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Affiliation(s)
| | - Jenerius A Aminawung
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine
| | - Nilay D Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Harlan M Krumholz
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine4Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine5Section of Health Policy and Admini
| | - Joseph S Ross
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine4Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine5Section of Health Policy and Admin
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Shah C, Sharma TR, Kablinger A. Controversies in the use of second generation antipsychotics as sleep agent. Pharmacol Res 2013; 79:1-8. [PMID: 24184858 DOI: 10.1016/j.phrs.2013.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 10/15/2013] [Accepted: 10/21/2013] [Indexed: 10/26/2022]
Abstract
A growing number of patients present in clinics with complaints of insomnia. Over the past century, great advances have been made in our knowledge of mechanisms of sleep and wakefulness. Understanding sleep neurochemistry has led to better management of different types of insomnias with a variety of non-pharmacological and pharmacological treatments. Unfortunately, the increasing development and availability of second generation antipsychotics (SGA) have prompted their frequent use exclusively for insomnia. However, to date, no large randomized-controlled or placebo-controlled studies have shown the utility of SGAs in the realm of treating insomnia. Many clinicians use SGAs as "off-label" for sleep induction and maintenance, but this practice needs to be readdressed given their potential risks and the current lack of evidence base. This review will highlight the neurochemistry related to sleep, the mechanisms of action by which SGA may have some benefit in treating insomnia, and the risks associated with their utilization.
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Affiliation(s)
- Chintan Shah
- Carilion Clinic Virginia Tech-Carilion School of Medicine, Psychiatry Residency Program, Roanoke, VA, United States
| | - Taral R Sharma
- Carilion Clinic Virginia Tech-Carilion School of Medicine, Psychiatry Residency Program, Roanoke, VA, United States
| | - Anita Kablinger
- Carilion Clinic Virginia Tech-Carilion School of Medicine, Psychiatry Residency Program, Roanoke, VA, United States.
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Abstract
BACKGROUND Return-to-play (RTP) decision-making is required for every injured athlete. However, these decisions often lead to conflict between sport medicine professionals, athletes, coaches and sport associations. This study explores differences in professionals' opinion about which criteria should be used for RTP decisions, and who is best able to evaluate them. METHODS We surveyed Canadian sport medicine physicians, physiotherapists, athletic therapists, chiropractors, massage therapists, athletes, coaches and representatives from three sport associations. The 10 min online survey asked respondents to rate criteria as mandatory to irrelevant on a five-point Likert scale, and to indicate which profession was best able to evaluate the criteria. RESULTS In general, medical doctors, physiotherapists and athletic therapists were considered best able to assess factors related to risk of injury and complications from injury. Each clinician group (except sport massage therapists) generally believed their own profession has the best capacity to evaluate the criteria. Athletes, coaches and sport associations were considered to have the best capacity to assess factors related to competition (desire, psychological and financial impact and loss of competitive standing). There remained considerable heterogeneity both between and within stakeholder groups. CONCLUSIONS We found that differences in approach to RTP decisions were generally greater within versus between-stakeholder groups. If shared decision-making is to become the norm in clinical sport medicine, we need to begin a discussion on which discrepancies are due to lack of training (resolved through education) or scientific knowledge (resolved through research) or simply reflect the divergence of personal/societal values.
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Affiliation(s)
- Ian Shrier
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, , Montreal, Quebec, Canada
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Sugarman P, Mitchell A, Frogley C, Dickens GL, Picchioni M. Off-licence prescribing and regulation in psychiatry: current challenges require a new model of governance. Ther Adv Psychopharmacol 2013; 3:233-43. [PMID: 24167695 PMCID: PMC3805431 DOI: 10.1177/2045125312472530] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The growing worldwide use of pharmaceuticals is managed in some countries by a regulatory system which sharply divides legal use into licensed and unlicensed categories. We examine how for the range of psychotropics this simultaneously restricts the possible benefits to patients, prescribers and producers in some domains, while failing to manage the risks in others. A more flexible system, which shares at an earlier stage experience and evidence on benefits and risks in patients, previously marginalized on the grounds of age, diagnosis or comorbidity, would aid the development of safer, more effective 'real-world prescribing'. Practical recommendations are made for a new model of research and prescribing governance, to enable more effective repurposing of these treatments.
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Affiliation(s)
- Philip Sugarman
- Chief Executive Officer, St Andrew's Healthcare, Northampton, UK
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Kesselheim AS, Franklin JM, Avorn J, Duke JD. Speaking the same language? International variations in the safety information accompanying top-selling prescription drugs. BMJ Qual Saf 2013; 22:727-34. [PMID: 23620531 DOI: 10.1136/bmjqs-2012-001704] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The official prescribing information document distributed with a prescription drug is a key source of safety information, but it may include excessive or insufficient details. OBJECTIVES To compare prescribing information approved by the US Food and Drug Administration with the UK, Canada and Australia to identify content differences in safety warnings. METHODS For 20 top-selling prescription drugs, we used an automated natural language processing tool to calculate the number and severity of reported adverse drug reactions (ADRs). We fit hierarchical Poisson models and included fixed effects for other prescribing information characteristics. Separately, we analysed the appearance and content of 'black box' warnings. RESULTS There was substantial variation in safety content of approved prescribing information. Canada had the highest median ADRs per drug (138 (IQR 86-234)) and the UK had the lowest (84 (IQR 51-111)). The number of ADRs reported was on average 50% higher in Canada compared with the USA (ratio of ADRs/document: 1.5, 95% CI 1.4 to 1.6, p<0.001). By contrast, there were on average 15% fewer ADRs listed in the UK compared with the USA (ratio of ADRs/document 0.85 (95% CI 0.78 to 0.93, p<0.001), and 21% fewer ADRs listed in Australia compared with the USS (ratio of ADRs/document 0.79, 95% CI 0.74 to 0.85, p<0.001). There were no variations in ADR severity. The presence and qualitative content of boxed warnings also showed substantial diversity. CONCLUSIONS International variations exist in the presentation of safety data in drug prescribing information, which may have important implications for patient safety. Better international coordination is necessary to enhance use of this information for patient decision-making.
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Affiliation(s)
- Aaron S Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA.
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39
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Affiliation(s)
- Franco Toscani
- Lino Maestroni Foundation – Istituto di Ricerca in Medicina Palliativa, Cremona, Italy
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To THM, Agar M, Shelby-James T, Abernethy AP, Doogue M, Rowett D, Ko D, Currow DC. Off-label prescribing in palliative care - a cross-sectional national survey of palliative medicine doctors. Palliat Med 2013; 27:320-8. [PMID: 23128901 DOI: 10.1177/0269216312464263] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Regulatory bodies including the European Medicines Agency register medications (formulation, route of administration) for specific clinical indications. Once registered, prescription is at clinicians' discretion. Off-label use is beyond the registered use. While off-label prescribing may, at times, be appropriate, efficacy and toxicity data are often lacking. AIM The aim of this study was to document off-label use policies (including disclosure and consent) in Australian palliative care units and current practices by palliative care clinicians. DESIGN A national, cross-sectional survey was conducted online following an invitation letter. The survey asked clinicians their most frequent off-label medication/indication dyads and unit policies. Dyads were classified into unregistered, off-label and on-label, and for the latter, whether medications were nationally subsidised. SETTING/PARTICIPANTS All Australian palliative medicine Fellows and advanced trainees. RESULTS Overall, 105 clinicians responded (53% response rate). The majority did not have policies on off-label medications, and documented consent rarely. In all, 236 medication/indication dyads for 36 medications were noted: 45 dyads (19%) were for two unregistered medications, 118 dyads (50%) were for 26 off-label medications and 73 dyads (31%) were for 12 on-label medications. CONCLUSIONS Off-label prescribing with its clinical, legal and ethical implications is common yet poorly recognised by clinicians. A distinction needs to be made between where quality evidence exists but registration has not been updated by the pharmaceutical sponsor and the evidence has not been generated. Further research is required to quantify any iatrogenic harm from off-label prescribing in palliative care.
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Affiliation(s)
- Timothy H M To
- Discipline, Palliative & Supportive Services, Flinders University, Adelaide, Australia.
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Daughton CG, Ruhoy IS. Lower-dose prescribing: minimizing "side effects" of pharmaceuticals on society and the environment. THE SCIENCE OF THE TOTAL ENVIRONMENT 2013. [PMID: 23201698 DOI: 10.1016/j.scitotenv.2012.10.092] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
The prescribed use of pharmaceuticals can result in unintended, unwelcomed, and potentially adverse consequences for the environment and for those not initially targeted for treatment. Medication usage frequently results in the collateral introduction to the environment (via excretion and bathing) of active pharmaceutical ingredients (APIs), bioactive metabolites, and reversible conjugates. Imprudent prescribing and non-compliant patient behavior drive the accumulation of unused medications, which pose major public health risks from diversion as well as risks for the environment from unsound disposal, such as flushing to sewers. The prescriber has the unique wherewithal to reduce each of these risks by modifying various aspects of the practice of prescribing. By incorporating consideration of the potential for adverse environmental impacts into the practice of prescribing, patient care also could possibly be improved and public health better protected. Although excretion of an API is governed by its characteristic pharmacokinetics, this variable can be somewhat controlled by the prescriber in selecting APIs possessing environment-friendly excretion profiles and in selecting the lowest effective dose. This paper presents the first critical examination of the multi-faceted role of drug dose in reducing the ambient levels of APIs in the environment and in reducing the incidence of drug wastage, which ultimately necessitates disposal of leftovers. Historically, drug dose has been actively excluded from consideration in risk mitigation strategies for reducing ambient API levels in the environment. Personalized adjustment of drug dose also holds the potential for enhancing therapeutic outcomes while simultaneously reducing the incidence of adverse drug events and in lowering patient healthcare costs. Optimizing drug dose is a major factor in improving the sustainability of health care. The prescriber needs to be cognizant that the "patient" encompasses the environment and other "bystanders," and that prescribed treatments can have unanticipated, collateral impacts that reach far beyond the healthcare setting.
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Affiliation(s)
- Christian G Daughton
- Environmental Sciences Division, National Exposure Research Laboratory, U.S. Environmental Protection Agency, 944 East Harmon Avenue, Las Vegas, NV 89119, USA.
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Association between the commercial characteristics of psychotropic drugs and their off-label use. Med Care 2013; 50:940-7. [PMID: 23047783 DOI: 10.1097/mlr.0b013e31826ec272] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Off-label prescribing, or the use of a medicine for non-Food and Drug Administration (FDA)-approved indications, is especially common for psychotropic therapies and often lacks scientific support. We quantified the association between 4 commercial characteristics of prescription medicines-product age, therapeutic class age, drug volume, and promotional expenditures-and off-label use of antidepressants, antipsychotics, and mood stabilizers from 1998 through 2009. METHODS We linked data from the IMS Health National Disease and Therapeutic Index, a nationally representative audit of office-based physicians, with data from FDA@gov and the drug compendium DrugDex, to derive information regarding off-label use. Our primary outcome was the rate (per 1000 uses) with which a drug was prescribed for non-FDA-approved indications during a given calendar year. We used mixed-effects regression models with random intercepts for each drug, adding measures of commercial characteristics as fixed effects within this model. RESULTS From 1998 through 2009, the average proportion of all uses that occurred off-label was 23.3% for antidepressants, 60.7% for antipsychotics, and 54.2% for mood stabilizers. There was a positive association between the annual rate of off-label use and drug volume [incidence rate ratio (IRR), 1.41; 95% confidence intervals (CI), 1.32-1.50], although the strength of this association was not uniform across the therapeutic classes examined. There was also a small but statistically significant association between product age (IRR, 0.96; 95% CI, 0.94-0.98) and class age (IRR, 1.03; 95% CI, 1.01-1.06) and the rate of off-label use, also varying across therapeutic class. There was a statistically significant inverse association between promotional expenditures and off-label use (IRR, 0.94; 95% CI, 0.93-0.96) when controlling for our other commercial characteristics. These associations were similar when examining scientifically unsupported rather than all off-label use. CONCLUSIONS Our findings suggest that drug prescription volume, rather than product age or therapeutic class age, should be scrutinized further to identify settings where the public health impact of unsupported off-label prescribing may be particularly important.
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Hresko A, Haga SB. Insurance coverage policies for personalized medicine. J Pers Med 2012; 2:201-16. [PMID: 25562360 PMCID: PMC4251376 DOI: 10.3390/jpm2040201] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 10/16/2012] [Accepted: 10/17/2012] [Indexed: 01/28/2023] Open
Abstract
Adoption of personalized medicine in practice has been slow, in part due to the lack of evidence of clinical benefit provided by these technologies. Coverage by insurers is a critical step in achieving widespread adoption of personalized medicine. Insurers consider a variety of factors when formulating medical coverage policies for personalized medicine, including the overall strength of evidence for a test, availability of clinical guidelines and health technology assessments by independent organizations. In this study, we reviewed coverage policies of the largest U.S. insurers for genomic (disease-related) and pharmacogenetic (PGx) tests to determine the extent that these tests were covered and the evidence basis for the coverage decisions. We identified 41 coverage policies for 49 unique testing: 22 tests for disease diagnosis, prognosis and risk and 27 PGx tests. Fifty percent (or less) of the tests reviewed were covered by insurers. Lack of evidence of clinical utility appears to be a major factor in decisions of non-coverage. The inclusion of PGx information in drug package inserts appears to be a common theme of PGx tests that are covered. This analysis highlights the variability of coverage determinations and factors considered, suggesting that the adoption of personal medicine will affected by numerous factors, but will continue to be slowed due to lack of demonstrated clinical benefit.
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Affiliation(s)
- Andrew Hresko
- Duke University, Institute for Genome Sciences & Policy, Durham, NC 27708, USA
| | - Susanne B Haga
- Duke University, Institute for Genome Sciences & Policy, Durham, NC 27708, USA.
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Shimazawa R, Ikeda M. Japanese regulatory system for approval of off-label drug use: evaluation of safety and effectiveness in literature-based applications. Clin Ther 2012; 34:2104-16. [PMID: 23036337 DOI: 10.1016/j.clinthera.2012.09.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although approved elsewhere, many drug indications remain unapproved in Japan. Many of these unapproved indications are off-label, which, despite strong supporting evidence, are not covered by the Japanese health insurance system. To address this situation, the Ministry of Health, Labour and Welfare of Japan announced in 1999 that, under certain conditions, it would approve a new supplement for a drug indication without clinical trials. This approval scheme involved application evaluation using literature-based evidence; however, the type of indications and the kind of evidence used in practical applications remain to be clarified. OBJECTIVE This commentary sought to investigate the factors that contribute to the approval of individual applications through an analysis of review reports and to assess the outcome of efforts to facilitate the approval of off-label drugs by this approval system that has been used for over a decade in Japan. METHODS Data from 80 approvals granted under this scheme were obtained from the official review reports of the Japanese regulatory agency. The following criteria were selected for the analysis of individual applications: review time, therapeutic class, application category under Japanese regulations, international approval status, postapproval monitoring plan, and variety and quantity of literature evidence. The literature used as a source of evidence was categorized into 4 types: (I) standard textbooks, (II) standard guidelines, (III) reviews, and (IV) application dossier submitted to the foreign regulatory authorities. RESULTS The number of approvals and applications per year showed no consistent trend. The median (SD) review time was 16.4 (9.0) months, which was not affected by the international approval status or the literature evidence. This approval scheme was applied to not only a new indication (56 applications [70%]) or dosage (9 [11%]) but also a new route of administration (13 [16%]). Of the 80 applications, 46 (58%) had been approved in the United States, the United Kingdom, or both; 11 (14%), in other countries; and 23 (29%), in no country. For 2 approvals, the review reports were not released; the other 78 were based on either standard textbooks or guidelines, while 67 (84%) were based on both. The variety and quantity of literature evidence provided in the application showed no consistent trend with respect to international approval status. CONCLUSIONS Prior approval by foreign authorities, although important, did not appear to be essential for approval in Japan. However, substantiating safety and effectiveness of agents by means of standard textbooks or guidelines was used consistently to obtain approval for off-label use.
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Affiliation(s)
- Rumiko Shimazawa
- Graduate School of Biomedical Sciences, Nagasaki University, Japan.
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English BA, Dortch M, Ereshefsky L, Jhee S. Clinically significant psychotropic drug-drug interactions in the primary care setting. Curr Psychiatry Rep 2012; 14:376-90. [PMID: 22707017 PMCID: PMC4335312 DOI: 10.1007/s11920-012-0284-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In recent years, the growing numbers of patients seeking care for a wide range of psychiatric illnesses in the primary care setting has resulted in an increase in the number of psychotropic medications prescribed. Along with the increased utilization of psychotropic medications, considerable variability is noted in the prescribing patterns of primary care providers and psychiatrists. Because psychiatric patients also suffer from a number of additional medical comorbidities, the increased utilization of psychotropic medications presents an elevated risk of clinically significant drug interactions in these patients. While life-threatening drug interactions are rare, clinically significant drug interactions impacting drug response or appearance of serious adverse drug reactions have been documented and can impact long-term outcomes. Additionally, the impact of genetic variability on the psychotropic drug's pharmacodynamics and/or pharmacokinetics may further complicate drug therapy. Increased awareness of clinically relevant psychotropic drug interactions can aid clinicians to achieve optimal therapeutic outcomes in patients in the primary care setting.
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Affiliation(s)
- Brett A English
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-8300, USA.
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Ruble J. Off-label prescribing of medications for pain: maintaining optimal care at an intersection of law, public policy, and ethics. J Pain Palliat Care Pharmacother 2012; 26:146-52. [PMID: 22764854 DOI: 10.3109/15360288.2012.671243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
For more than 60 years, regulations limited marketing of medications for off-label uses to very low levels. Some key policy changes in the late 1990s ushered in an era of deregulation of off-label marketing. Policy changes included revised United States federal law as well as modifications of Food and Drug Administration (FDA) regulations. Subsequent investigations documented an explosion in scope off-label prescribing. Attempts to limit off-label advertising by manufacturers were vigorously challenged in the courts. Other modalities are needed to maintain a clinical care environment that places the patients' best interests first. In many circumstances, an off-label medication may be in the patient's best interests; however, where there is a lower level of clinical justification, the informed consent of the patient and shared decision making of the patient is essential to optimize outcome.
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Affiliation(s)
- James Ruble
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT 84112-5820, USA.
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Czaja AS, Valuck R. Off-label antidepressant use in children and adolescents compared with young adults: extent and level of evidence. Pharmacoepidemiol Drug Saf 2012; 21:997-1004. [DOI: 10.1002/pds.3312] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 04/26/2012] [Accepted: 05/25/2012] [Indexed: 11/07/2022]
Affiliation(s)
- Angela S. Czaja
- Department of Pediatrics; University of Colorado School of Medicine; Aurora CO USA
- Children's Hospital Colorado; Aurora CO USA
| | - Robert Valuck
- Department of Clinical Pharmacy; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora CO USA
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Abstract
Off-label use of medicines is common. Because many off-label uses have not been carefully studied, it is important that postmarketing drug safety systems be able to identify, assess, and monitor adverse events that occur in the off-label setting. The full range of postmarketing surveillance and analysis tools can be utilized to study the adverse effects of medicines used off-label.
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Affiliation(s)
- G J Dal Pan
- Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA.
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Stafford RS. Off-Label Use of Drugs and Medical Devices: A Review of Policy Implications. Clin Pharmacol Ther 2012; 91:920-5. [DOI: 10.1038/clpt.2012.22] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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