Drug prescription in young children: results of a survey in France. Epicrèche Research Group

Acetylcysteine and carbocysteine for acute upper and lower respiratory tract infections in paediatric patients without chronic broncho-pulmonary disease

BACKGROUND

Acetylcysteine and carbocysteine are the most commonly prescribed mucolytic drugs in Brazil and many European and African countries. To our knowledge, no systematic review has been published on their efficacy and safety for acute upper and lower respiratory tract infections (RTIs) in children without chronic broncho-pulmonary disease.

OBJECTIVES

The objective was to assess the efficacy and safety and to establish a benefit-risk ratio of acetylcysteine and carbocysteine as symptomatic treatments for acute upper and lower RTIs in paediatric patients without chronic broncho-pulmonary disease.

SEARCH METHODS

We searched CENTRAL (2013, Issue 2), MEDLINE (1966 to February week 3, 2013), EMBASE (1980 to March 2013), Micromedex (2010), Pascal (1987 to 2004) and Science Citation Index (1974 to March 2013).

SELECTION CRITERIA

To study efficacy, we used randomised controlled trials (RCTs) comparing the use of acetylcysteine or carbocysteine versus placebo, either alone or as an add-on therapy. To study safety, we used trials comparing acetylcysteine or carbocysteine versus active treatment or no treatment and case reports.

DATA COLLECTION AND ANALYSIS

In this review update two review authors (YD, MC), with help from a colleague, extracted data and assessed trial quality. We performed a subgroup analysis of children younger than two years of age.

MAIN RESULTS

We included six trials involving 497 participants to study efficacy. They showed some benefit (e.g. reduction of cough at day seven) from mucolytic agents, although differences were of little clinical relevance. No conclusion was drawn about the subgroup of infants younger than two years because data were unavailable. Thirty-four studies, including the previous six trials involving 2064 children, were eligible to study safety. Overall safety was good but very few data were available to evaluate safety in infants younger than two years. However, 59 cases of paradoxically increased bronchorrhoea observed in infants were reported to the French pharmacovigilance system.

AUTHORS' CONCLUSIONS

The results have to be interpreted with caution because they are based on a limited number of participants included in studies whose methodological quality is questionable. Acetylcysteine and carbocysteine seem to have a limited efficacy and appear to be safe in children older than two years. These results should take into consideration the fact that acetylcysteine and carbocysteine are prescribed for self limiting diseases (for example, acute cough, bronchitis). Given strong concerns about safety, these drugs should only be used for acute upper and lower RTIs in the context of a RCT with regards to children younger than two years.

Use of prescribed and non-prescribed medications among children living in poor areas in the city of Salvador, Bahia State, Brazil

A cross-sectional study of children living in poor areas in the city of Salvador, Bahia State, Brazil, was carried out in 2006 to investigate the prevalence of use of prescribed and non-prescribed medication. This population-based study included 1,382 children aged 4-11 years. The use prescribed and non-prescribed medication during the 15 day period preceding the interview was adopted as the dependent variable. Of the 1,382 children, 663 (48%) had used at least one type of medication in the 15 days prior to the interview: in 267 cases (40.3%), mothers reported that the child had taken prescribed medication, while in 396 cases (59.7%), the child had taken medication that had not been prescribed by a physician. The most commonly prescribed drugs were analgesics (42.3%), systemic antibiotics (21.3%) and antiasthmatic (16.5%). With respect to non-prescribed drugs, the most common were analgesics (65.2%), antitussives (15.7%) and vitamins (9.3%). The results show a high prevalence of the use of non-prescription drugs among poor children, and large drug purchases of drugs by the head of household, highlighting deficiencies in coverage of the health system.

Respiratory paradoxical adverse drug reactions associated with acetylcysteine and carbocysteine systemic use in paediatric patients: a national survey

Objective

To report pediatric cases of paradoxical respiratory adverse drug reactions (ADRs) after exposure to oral mucolytic drugs (carbocysteine, acetylcysteine) that led to the withdrawal of licenses for these drugs for infants in France and then Italy.

Design

The study followed the recommendations of the European guidelines of pharmacovigilance for medicines used in the paediatric population.

Setting

Cases voluntarily reported by physicians from 1989 to 2008 were identified in the national French pharmacovigilance public database and in drug company databases.

Patients

The definition of paradoxical respiratory ADRs was based on the literature. Exposure to mucolytic drugs was arbitrarily defined as having received mucolytic drugs for at least 2 days (>200 mg) and at least until the day before the first signs of the suspected ADR.

Results

The non-exclusive paradoxical respiratory ADRs reported in 59 paediatric patients (median age 5 months, range 3 weeks to 34 months, 98% younger than 2 years old) were increased bronchorrhea or mucus vomiting (n = 27), worsening of respiratory distress during respiratory tract infection (n = 35), dyspnoea (n = 18), cough aggravation or prolongation (n = 11), and bronchospasm (n = 1). Fifty-one (86%) children required hospitalization or extended hospitalization because of the ADR; one patient died of pulmonary oedema after mucus vomiting.

Conclusion

Parents, physicians, pharmacists, and drug regulatory agencies should know that the benefit risk ratio of mucolytic drugs is at least null and most probably negative in infants according to available evidence.

Acetylcysteine and carbocysteine for acute upper and lower respiratory tract infections in paediatric patients without chronic broncho-pulmonary disease

BACKGROUND

Acetylcysteine and carbocysteine are the most commonly prescribed mucolytic drugs in many European countries. To our knowledge, no systematic review has been published on their efficacy and safety for acute upper and lower respiratory tract infections (ARTIs) in children without chronic broncho-pulmonary disease.

OBJECTIVES

The objective was to assess the efficacy and safety and to establish a benefit-risk ratio of acetylcysteine and carbocysteine as symptomatic treatments for ARTIs in children without chronic broncho-pulmonary disease.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, issue 4) which contains the Acute Respiratory Infections (ARI) Group's Specialized Register, MEDLINE (1966 to 2008), EMBASE (1980 to 2008); Micromedex (2008), Pascal (1987 to 2004), and Science Citation Index (1974 to 2008).

SELECTION CRITERIA

To study efficacy, we used randomised controlled trials (RCTs) comparing the use of acetylcysteine or carbocysteine versus placebo either alone or as an add-on therapy.To study safety, we also used trials comparing the use of acetylcysteine or carbocysteine versus active treatment or no treatment and case reports.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and assessed trial quality. We performed a subgroup analysis of children younger than two years of age.

MAIN RESULTS

Six trials involving 497 participants were included to study efficacy. They showed some benefit from mucolytic agents, although differences were of little clinical relevance. No conclusion was drawn about the subgroup of infants younger than two years because the data were unavailable. Thirty-four studies including the previous six trials involving 2064 children were eligible to study safety. Overall safety was good but very few data were available to evaluate safety in infants younger than two years. However, 48 cases of paradoxically increased bronchorrhoea observed in infants were reported to the French pharmacovigilance system.

AUTHORS' CONCLUSIONS

The results of this review have to be interpreted with caution because it was based on a limited number of participants included in studies whose methodological quality is questionable. Acetylcysteine and carbocysteine seem to have a limited efficacy and appear to be safe in children older than two years. These results should take into consideration the fact that acetylcysteine and carbocysteine are prescribed for self-limiting diseases (for example, acute cough, bronchitis). Regarding children younger than two years, given concerns about safety, these drugs should only be used for ARTIs in the context of an RCT.

How to measure non-consistency of medical practices with available evidence in therapeutics: a methodological framework

Since the early 1980s many studies showed a gap between available evidence and medical practice. They were designed to assess the real impact of randomized clinical trials on the practice of medicine. Their results substantiated a knowledge translation problem. However, they were qualitative findings, i.e. a gap exists or not, although the problem is quantitative (how large is the gap?) and has several components that should be documented according to the objective of the study. In this article, we explored the components and the various contexts in which the measure of the distance between practice and knowledge is considered. All these features should be taken into account for a more accurate and relevant assessment of the distance.

Pattern of drug prescription for children under the age of four years in a population in Greenland

AIM

To provide knowledge of drug prescription patterns in general and of antibiotics in particular, and number of consultations and diagnoses leading to prescriptions among children aged 0-4 y in the Arctic.

METHODS

A population-based cohort of children aged 0-4 y, living in Sisimiut, the second largest town in Greenland, was followed from August 1996 to December 1998. Information on consultations, diagnoses and drug prescriptions was obtained from medical files at the local health centre.

RESULTS

Among 280 participating children, the mean number of consultations per child was 5.64 per year at risk (range 0-17), of prescriptions 4.02 per year at risk (range 0-17.2), and of prescribed systemic antibiotics per child 1.47 per year at risk (range 0-7.25). Systemic antibiotics formed the therapeutic subgroup most often issued for children, constituting 33.5% of all prescriptions. Of the systemic antibiotics, 50% were broad-spectrum penicillins, 34% penicillin V, 14% macrolides and 2% other antibiotics. The most frequent diagnoses leading to drug prescription in general as well as to prescription of systemic antibiotics were respiratory tract infections, accounting for 59% of all prescriptions and 81% of prescriptions of systemic antibiotics. Children aged 1/2-1 y of age had the highest prescription rates of drugs in general and of systemic antibiotics.

CONCLUSIONS

Compared to other countries, prescription rates of drugs in general and of systemic antibiotics in particular were high. The use of broad-spectrum penicillins was higher than recommended in Greenlandic national guidelines, and might be reduced.

Planning of clinical trials

This article focuses on steps of planning clinical trials most relevant to the question the clinician asks and how this question is properly transformed in a design and a protocol. All steps are important for the data quality or the validity of the results. A clinical trial is an experiment aimed at testing an hypothesis regarding the efficacy of a given intervention on an event, symptom or impaired quality of life in patients with a defined condition and a particular profile. As such, it should meet the fundamentals of scientific discovery that guarantee causality between the observed difference and the intervention. All the planning components are thought according to these fundamentals.

Drug utilisation in outpatient children. A comparison among Tenerife, Valencia, and Barcelona (Spain), Toulouse (France), Sofia (Bulgaria), Bratislava (Slovakia) and Smolensk (Russia)

INTRODUCTION

Scarce information about comparative diagnostic and therapeutic patterns in paediatric outpatients of different countries is found in the literature.

OBJECTIVE

To describe the similarities and differences observed in diagnosis and therapeutic patterns of paediatric patients of seven locations in different countries.

DESIGN

Cross-sectional, prospective, international comparative, descriptive study.

PATIENTS AND METHODS

A randomly selected sample of 12,264 paediatric outpatients seen in consultation rooms of urban and rural areas and attended by paediatricians or general practitioners of the participating locations. Data on patient demographic information, diagnosis and pharmacological treatment were collected using pre-designed forms. Diagnoses were coded using the ICD-9 and drugs according to the ATC classification.

RESULTS

Among the ten most common diagnoses, upper respiratory tract infections are in the first position in all locations; asthma prevalence is highest in Tenerife (8.4%). Tonsillitis, otitis, bronchitis and dermatological affections are the most common diagnoses in all locations. Pneumonia is only reported in Sofia (3.8%) and Smolensk (2.3%). The average number of drugs prescribed per child varied from 1.3 in Barcelona to 2.9 in Smolensk. There are no great differences in the profile of pharmacological groups prescribed, but a considerable range of variations in antibiotic therapy is observed: prescription of cephalosporins is low in Smolensk (0.7%) and higher in the other locations, from 16.5% (Bratislava) to 28% (Tenerife). Macrolides prescriptions range from 12.6% (Toulouse) to 24.7% (Smolensk), except in Sofia where they drop to 5.6%. Trimethoprim and its combinations are used in Smolensk (23.3%), Sofia (11.8%) and Bratislava (8.7%). Check-up consultations are not recorded in Smolensk and Bratislava, whereas in Toulouse these visits account for 16.2% of all consultations and in the other locations the percentage varies from 6.1% (Tenerife) to 1.9% (Sofia). Homeopathic treatments are registered only in Toulouse.

CONCLUSION

Except in asthma prevalence, there are no great differences in diagnostic maps among locations. Significant variations in the number of drugs prescribed per child and antibiotic therapies are observed. Areas for improvement have been identified.

How should therapeutic information be transferred to users?

Without an efficient solution to the problems that prevent prescribers and consumers having easy access to published and unpublished evidence, Evidence-Based Medicine will never become a reality. Among the problems, dissemination of the summarized evidence is a major one. It involves representing the summarized evidence in a format that corresponds to the users' needs and knowledge, interpreting it within the context of other related evidence, putting it in perspective, and then delivering it physically to the users at the appropriate time. The current formats, vehicles and representation models, e.g. those for guidelines or textbooks, do not seem efficient enough to fill in the gap of knowledge. We suggest that a new approach is possible by reducing the transferred information to its core and integrating it through appropriate representation models into the doctor's decision-making process.

Drug use of children in the community assessed through pharmacy dispensing data

AIMS

: To determine the extent of drug use in children and the types of drugs that children use. METHODS Cross-sectional study and cohort study, using computerized pharmacy dispensing records for all children aged 0-16 years in the northern part of The Netherlands in 1998. The main outcome measures were proportion of children that used drugs (per sex and age group), mean number of drugs per child, 10 most widely used drug groups and cumulative proportions of drugs users (per drug group) during the first 2 years of life.

RESULTS

Drug use was the highest among infants, decreased till adolescence and increased from there. Overall, approximately 60% of all children used at least one drug in 1998. At younger ages, boys used more drugs than girls and at older ages girls used more drugs than boys. Systemic antibiotics were used by 21% of the children and were by far the most widely used drugs. Other frequently used drugs were analgesics (10%), corticosteroids for dermatologic use (9%), anthistamines (8%) and antiasthmatics (7%). Approximately 10% of the children had used at least one drug at the age of 1 month and at the age of 2 years this proportion was 81%.

CONCLUSIONS

The majority of children was exposed to one or more drugs and this exposure started at very young age. This shows the importance of good guidelines for drug use in children and emphasizes the necessity of research of pharmacokinetic and pharmacodynamic properties in children to obtain safety, efficacy and quality evidence of these drugs.

Comparison between two common methods for reporting cold and diarrhoea symptoms of children in daycare centre research

BACKGROUND

The increasing number of children attending day care centres (DCCs) in industrialized countries has refocused attention on the occurrence of infections and infectious diseases in these settings.

OBJECTIVE

To evaluate the agreement between two methods (parent method vs. educator method) for reporting the occurrence of respiratory and diarrhoeal infections.

METHODS

Fifty-two DCCs in Quebec, Canada, participated. Both educators and parents were invited to fill in calendars on which they would indicate the occurrence of colds and diarrhoea. For the parents' method, parents were telephoned biweekly to record their calendar information. For the educators' method, educators returned their calendar pages monthly (following prompting by phone, when necessary).

RESULTS

Three hundred and thirty-three parents of toddlers participated in the 15-month reporting period between September 1996 and November 1997. The average agreement between the two methods was low (13.5% for colds and 9.8% for diarrhoea). Overall estimates of the incidence rates of respiratory and diarrhoeal infections based on parents' method were higher than those based on educators' method.

CONCLUSIONS

Parents' data lead to larger estimations of incidence rates and are probably more valid than educators' data.

Outpatient prescription drug use by children enrolled in five drug benefit plans

This study examined prescription drug use among ambulatory children younger than 18 years of age enrolled in five drug benefit plans. Data for this study were obtained from the pharmacy benefit manager who administers the drug benefit plans. During the study period of December 29, 1992, through December 28, 1993, 3144 children younger than 18 years of age (34.0% of the total plan enrollment) were enrolled in the five drug benefit plans. A total of 8547 prescription drugs were dispensed to the study population. The mean prescription price was $16.38, and the mean duration of therapy was 11.7 days. The mean prescription price was $1.56 more for boys than for girls. The most frequently dispensed drugs were antibiotics (42.0%), followed by cold preparations (15.9%). The annual prevalence rate of prescription drug use was 59.1 cases per 100 children. The study population-based annual frequency rate was 3.2 prescriptions per child, and the drug user-based annual frequency rate was 5.5 prescriptions per child. The annual expenditures were $51.85 per child and $90.39 per drug users, with the out-of-pocket expenditures being $19.09 and $33.04, respectively. The prevalence rate varied little by sex. However, both frequency and expenditure rates differed by sex and decreased with age. Higher levels of cost sharing per prescription were associated with higher prevalence, frequency, and expenditure rates. Larger cost-sharing differentials between generic and brand name drugs were associated with higher rates of generic drug use but were not always associated with lower expenditure rates.

Epidemiologic evaluation of drug use in children

To define and evaluate the attention devoted to drug use in children rather than just review existing reviews, the present attempt is to seek out the primary sources of information in the hope that this effort would not only yield more reliable data, but would also provide an opportunity for reconsidering methodological problems which are possibly even more important. An English-language literature search for drug use in children from 1988 was conducted on two databases and a manual search was made of the literature, with a check of references quoted in main original articles, reviews and textbooks. The review was then organized in two main sections: an overall evaluation of the recent literature concerning drug use in children; the epidemiological profile of drug exposure as described cumulatively by the drug-utilization studies. A substantial lack of systematic attention to this area of drug epidemiology was found: drug use in the children is a 'hidden' reality in the literature; the wealth of methodologic developments that have taken place in the general field of drug use monitoring has scantly reached children. Children can be considered still "methodologic orphans" with respect to the transferable knowledge on the benefit/risk profile of therapies they receive. A network has to be developed to monitor clinical problems, including drug use, as part of an "audit" of the overall management of children.