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

Two decades of off-label prescribing in children: a literature review

BACKGROUND

In the past two decades, many legislative and regulatory initiatives were taken globally to improve drug use in children. However, children are still found to be prescribed with off-label drugs. This study was conducted to provide an overview of the worldwide trend in off-label prescribing in children from the year 1996 to 2016.

DATA SOURCES

The articles published in PubMed, MEDLINE and Google Scholar were searched using text words: off-label, unlicensed, paediatric and children. Additional articles were identified by reviewing the bibliography of the retrieved articles. Full-text articles published in English which reported on the prevalence of off-label prescribing in children between January 1996 and December 2016 were included.

RESULTS

A total of 101 studies met the inclusion criteria. Off-label prescribing definition included four main categories: age, indication, dose and route of administration. The three most common reference sources used in the studies were summary of product characteristics, national formularies and package inserts. Overall, the off-label prescribing rates in children ranged from 1.2 to 99.7%. The most common category of off-label prescribing in children was dose and age.

CONCLUSIONS

This review highlighted that off-label prescribing in children was found to be highly prevalent throughout the past two decades, persistently in the neonatal intensive care units. This suggests that besides legislative and regulatory initiatives, behavioural, knowledge aspects and efforts to integrate evidence into practice related to off-label prescribing also need to be evaluated and consolidated as part of the concerted efforts to narrow the gaps in prescribing for children.

Analysis of analgesic, antipyretic, and nonsteroidal anti-inflammatory drug use in pediatric prescriptions

OBJECTIVE

Data on clinical practice in pediatrics on the use of analgesic, antipyretic, and nonsteroidal anti-inflammatory drugs considering the best available evidence and regulatory-agency approved use are uncertain. This study aimed to determine the frequency of prescription of these drugs according to the best scientific evidence and use approved by regulatory agencies.

METHODS

This was a cross-sectional study of 150 pediatric prescriptions containing analgesic, antipyretic, and nonsteroidal anti-inflammatory drugs, followed by interview with caregivers at 18 locations (nine private drugstores and nine Basic Health Units of the Brazilian Unified Health System). The assessed outcomes included recommended use or use with no contraindication, indications with benefit evidence, and health surveillance agency-approved use. Data were analyzed in electronic databases and the variables were summarized by simple frequency.

RESULTS

A total of 164 analgesic, antipyretic, and nonsteroidal anti-inflammatory drugs were prescribed to 150 children aged 1-4 years (38.6%). Dipyrone was included in 82 (54.6%) and ibuprofen in 40 (26.6%) prescriptions. Non-recommended uses were identified in 15% of prescriptions and contraindicated uses were observed in 13.3%. Nimesulide (1.5%) is still prescribed to children younger than 12 years. The dose was incorrect in 74.3% of prescriptions containing dipyrone. Of the 211 reported clinical indications, 56 (26.5%) had no evidence of benefit according to the best available scientific evidence and 66 (31.3%) had indications not approved by the regulatory agencies.

CONCLUSION

There are significant discrepancies between clinical practice and recommended use of analgesic, antipyretic, and nonsteroidal anti-inflammatory drugs in pediatrics.

[Drug prescriptions study in the outpatient setting: assessment of off-label uses in children]

OBJECTIVE

to evaluate the prescription profile and to assess the off-label and unlicensed uses of medicines among non-hospitalised pediatric patients.

DESIGN

cross-sectional study.

SETTING

pediatric units in two urban health centers and general emergency room (Hospital Materno-Infantil, Málaga).

MAIN MEASUREMENTS

sociodemographics variables, reasons for consultation and information about therapeutic medications. The classification of prescriptions was established according to information requirements contained in the Summary of Products Characteristics (SPC).

RESULTS

A total of 388 children were included (a subsample of 105 treated in the emergency room). Four hundred sixty-two prescriptions (involving 74 different active ingredients) were evaluated. Each infant received and average of 1,7 drugs (95% CI: 1,6-1,9). The most prescribed medicines were ibuprofen, paracetamol, amoxicillin-clavulanate and budesonide. The therapeutic group with the greatest variety of drugs was the respiratory group. 27,4% (95% CI: 23,5-31) of prescriptions were off-label and the main cause was different age (60%; 95% CI: 54,1-63), followed by different dose (21,5%; 95% CI: 18-25), different indication (12%; 95% CI: 9,2-15) and different route of administration (7%; 95% CI: 5,4-10).

CONCLUSIONS

The rate of off-label uses presents intermediate figures. Around one third of the paediatric outpatients in our sample are exposed to at least one off-label or unlicensed prescription. We should, however, point out that such usage is based on scant official, quality information, although it is not necessarily incorrect. Evidence-based medicine should be encouraged to improve drug therapy in children, as well as following the rules on drugs in special situations.

Off-label and unlicensed paediatric prescribing in a community setting: a prospective longitudinal cohort study in Malta

BACKGROUND

In children, the incidence of off-label prescriptions in primary care varies between 10.5% and 22.7%, whilst the incidence of unlicensed prescriptions in primary care varies between 0.3% and 16.6%. This information has not been investigated in Malta.

OBJECTIVE

To identify therapeutic areas which warrant research in children in the community setting in Malta according to the proportion and nature of off-label and unlicensed medicinal use.

METHODS

Interim analysis involving the assessment of prescriptions for children in a prospective pharmaco-epidemiological study. Data regarding prescriptions in 37 private clinics and pharmacies attended by paediatricians and family doctors were collected for a cohort of 209 patients aged 0-14 years. The medicines were categorised as licensed, unlicensed or off-label. They were also classified into various categories such as patient age-group, data collection period, prescriber type and Anatomical Therapeutic Chemical classification system.

RESULTS

113 of 209 (54.1%) medicinal products were used in an off-label and unlicensed manner, the highest number being in the 2-11-years age range (76/209). The majority of drugs were for the respiratory system. The proportion off-label drug prescribing because of age decreased progressively with increasing age whilst the proportion off-label prescribing because of dose increased with age.

CONCLUSION

The main cause of off-label prescribing appears to be a failure to adhere to licensed dose recommendations and a lack of agreement between the existing literature and drug licences.

Quality use of an unlicensed medicine and off label use of a medicine

This paper gives an overview of the concept and process of quality use of unlicensed medicines and off label use of medicines, with special attention on the professional roles and responsibilities of prescribers and pharmacists. It also focuses on the policy requirements, sets of guidelines, recommendations, best practices, and other aspects addressed under this topic that represent the state of update knowledge. As a complex and specific issue, the use of an unlicensed medicine and off label prescribed medicine in different health care levels is of particular importance for the healthcare settings in the Republic of Macedonia since, the existing regulatory structure requires adoption and development of a comprehensive strategy relating to this topic in the near future with an aim of encouraging and supporting the development and maintenance of a sound health system with high standards of medication-use policies.

Outpatient treatment of children and adolescents with antidepressants in Croatia

OBJECTIVE

This study is aimed to determine the prevalence and patterns of antidepressants prescription in outpatient setting in Croatia.

METHODS

Retrospective analysis of outpatient visits to child psychiatrists by persons aged 18 and younger that included prescription of antidepressants during the year 2010. Antidepressant prescription data were identified by medication class, drug entity and were analyzed in relation to age group, gender, psychiatric diagnosis.

RESULTS

Antidepressants were prescribed to 139 youths (0.24‰), significantly more to adolescents than pre-adolescents and for the treatment of depressive disorders in females, and mixed disorders of emotions and conduct in males. Sertraline was the most prescribed antidepressant for the treatment of major depressive disorder, followed by fluvoxamine and tianeptine. Fluvoxamine was the most prescribed antidepressant for the treatment of anxiety disorders and mixed disorders of emotions and conduct. Off-label prescribing of antidepressants was found in 85.6% of young patients.

CONCLUSIONS

This study found considerably lower prevalence and higher off-label rate of antidepressant prescriptions to young people in Croatia to that in other European Countries and in the United States. Selective serotonine reuptake inhibitors comprise most of the antidepressant medications prescribed to young people, reflecting trends in the developed countries.

Paediatric drug use with focus on off-label prescriptions in Swedish outpatient care--a nationwide study

AIM

To determine drug prescription and proportion of off-label dispensing in the Swedish paediatric outpatient population.

METHODS

All dispensed outpatient prescriptions to children aged 0 < 18 years as well as the proportion of off-label drug use during 2007 were analysed using data from the Swedish Prescribed Drug Register.

RESULTS

In total, 2.19 million drug prescriptions of 898 different drug substances were dispensed to paediatric patients, and of those substances, 64% had been dispensed off-label at least once. The overall off-label rate of all prescriptions was 13.5%, among which topical drugs as well as sex hormones were the most commonly prescribed off-label drugs. More than half of all children in Sweden had received at least one prescribed drug in 2007.

CONCLUSIONS

There is a high prescribing of medicines to children in outpatient care in Sweden with a considerable amount of off-label prescriptions. Topically administered drugs, sex hormones, antidepressants, hypnotics, cardiovascular drugs and nonsteroidal anti-inflammatory drugs were commonly prescribed off-label.

Psychotropic drug use among Icelandic children: a nationwide population-based study

OBJECTIVE

The aim of this study was to investigate psychotropic drug use among children in Iceland between 2003 and 2007.

METHODS

A nationwide population-based drug use study covering the total pediatric population (ages 0-17) in Iceland. Information was obtained from the National Medicines Registry to calculate prevalence of use by year and psychotropic drug group; incidence by year, psychotropic drug group, child's age and sex, and medical specialty of prescriber; the most commonly used psychotropic chemical substances, off-label and unlicensed use and concomitant psychotropic drug use.

RESULTS

The overall prevalence of psychotropic drug use was 48.7 per 1000 Icelandic children in 2007. Stimulants and antidepressants increased in prevalence from 2003 to 2007 and were the two most prevalent psychotropic drug groups, respectively, 28.4 and 23.4 per 1000 children in 2007. A statistically significant trend of declining prevalence (p = 0.00013) and incidence (p = 0.0018) of antidepressant use occurred during the study period. Out of 21,986 psychotropic drugs dispensed in 2007, 25.4% were used off-label.

CONCLUSIONS

With reference to reports from other European countries, the results indicate extensive psychotropic drug use among children in Iceland between 2003 and 2007. Further scrutiny is needed to assess the rationale behind this widespread use.

Off-label prescribing to children in the United States outpatient setting

OBJECTIVE

The aim of this study was to determine the frequency of off-label prescribing to children at United States outpatient visits and to determine how drug class, patient age, and physician specialty relate to off-label prescribing.

METHODS

Data from the 2001 through 2004 National Ambulatory Medical Care Surveys (NAMCS) consisted of a sample of 7901 outpatient visits by children aged 0 through 17 years in which prescriptions were given, representative of an estimated 312 million visits. We compared FDA-approved age and indication to the child's age and diagnoses. We used multivariate logistic regression to determine adjusted differences in probabilities of off-label prescribing.

RESULTS

Sixty-two percent of outpatient pediatric visits included off-label prescribing. Approximately 96% of cardiovascular-renal, 86% of pain, 80% of gastrointestinal, and 67% of pulmonary and dermatologic medication prescriptions were off label. Visits by children aged <6 years had a higher probability of off-label prescribing (P < .01), especially visits by children aged <1 year (74% adjusted probability). Visits to specialists also involved a significantly increased probability (68% vs 59% for general pediatricians, P < .01) of off-label prescribing.

CONCLUSIONS

Despite recent studies and labeling changes of pediatric medications, the majority of pediatric outpatient visits involve off-label prescribing across all medication categories. Off-label prescribing is more frequent for younger children and those receiving care from specialist pediatricians. Increased dissemination of pediatric studies and label information may be helpful to guide clinical practice. Further research should be prioritized for the medications most commonly prescribed off label and to determine outcomes, causes, and appropriateness of off-label prescribing to children.

Stimulation programs for pediatric drug research--do children really benefit?

Most drugs that are currently prescribed in pediatrics have not been tested in children. Pediatric drug studies are stimulated in the USA by the pediatric exclusivity provision under the Food and Drug Administration Modernization Act (FDAMA) that grants patent extensions when pediatric labeling is provided. We investigated the effectiveness of these programs in stimulating drug research in children, thereby increasing the evidence for safe and effective drug use in the pediatric population. All drugs granted pediatric exclusivity under the FDAMA were analyzed by studying the relevant summaries of medical and clinical pharmacology reviews of the pediatric studies or, if these were unavailable, the labeling information as provided by the manufacturer. A systematic search of the literature was performed to identify drug utilization patterns in children. From July 1998 to August 2006, 135 drug entities were granted pediatric exclusivity. Most frequent drug groups were anti-depressants and mood stabilizers, ACE inhibitors, lipid-lowering preparations, HIV antivirals, and non-steroidal anti-inflammatory and anti-rheumatic drugs. The distribution of the different drugs closely matched the distribution of these drugs over the adult market, and not the drug utilization by children. Many drug studies in children have been performed since the introduction of the FDAMA. However, children infrequently use the drugs granted pediatric exclusivity. The priorities for pediatric drug research should be set by the need of the patients, not by market considerations.

Drug related problems and off-label drug treatment in children as seen at a drug information centre

The aim of this work was to analyse the characteristics of Questions and Answers (Q&As) at a drug information centre (DIC) regarding drug related problems and off-label drug treatment in children. All questions concerning children 15 years or younger at a DIC in Stockholm, Sweden during the years 1995-2004 were analysed with respect to the main drug related problem, drug/s and drug group/s, whether the drugs were licensed or not, pediatric labelling of the drug/s and age and sex of the patient. Q&As were classified as whether or not they included evaluated literature information, adding to the labelling of the drugs. We identified 249 Q&As concerning pediatric drug treatment. Each question addressed an average of 1.5 drugs. More than two-thirds of the Q&As concerned adverse drug reactions and pediatric drug choice or dosing. Every second question was classified as off-label, psychotropic drugs being the most common. In half of all off-label Q&As, pediatric documentation on drug efficacy and safety outside the Swedish catalogue of medical products was found. Most Q&As concerned newborns and infants. However, the off-label proportion among questions was highest in adolescence as well as the evaluated literature information, adding to the labelling of the drugs. It was thus found that off-label drug treatment is common among pediatric questions at a DIC. This service can provide additional literature based information contributing to a safer use of drugs in children. There is still, however, a substantial need for clinical documentation of drug use in children.

Changes in drug prescription over a decade in an Arctic child population

AIM

To describe the changes in drug prescription to 0-14-y-old outpatient children from 1991 to 2001.

METHODS

ATC codes on prescriptions were compared.

MAIN RESULTS

Prescriptions rose from 2.00 to 2.18 drugs/child/year, and the proportion of prescribed drugs rose from 60.7% to 70.4% of the child population (p<0.001). The 10 most prescribed subgroups accounted for 92.7% of all drugs in 0-1-y-olds and 75.9% in the schoolchildren. The individual prescription of anti-asthmatics increased by 155% (p<0.001), the use of nasal preparations and drugs against cough decreased, and more of the antibiotics were penicillin V. In 0-1-y-olds, prescriptions halved, while they nearly doubled in schoolchildren (p<0.001).

CONCLUSION

In Nuuk, a unique possibility exists: to be able to study changes in drug use and prescriptions to individual children over time from one health clinic. In the last decade, major changes have occurred regarding the number of drugs, the distribution of therapeutic subgroups, and prescriptions to all age groups. If interpreting from the magnitude of prescriptions, the prevalence of asthma doubled in this period. In summary, this study has revealed changes in prescription that can hardly be explained by changes in disease patterns. Even if unrecognized, this might also be found elsewhere.

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

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

Validity of asthma diagnoses recorded in the Medical Services database of Quebec

The goal of this study was to evaluate the validity of asthma diagnoses recorded in the Medical Services (physician billing) database of the Canadian province of Quebec. The predictive positive value (PPV) and predictive negative value (PNV) of two operational definitions of asthma based on diagnoses recorded in the database were evaluated. Patients 16-80 years old treated by a respiratory or a family physician in 2002 were selected from the database. The diagnosis derived from the Medical Services database was compared to the diagnosis written in the patient's medical chart. The PPV and PNV of the first operational definition based on one asthma diagnosis or more recorded in the database over a 1-year period were found to be 0.75 and 0.96 for respiratory physicians and 0.67 and 0.99 for family physicians, for patients 16-44 years old. The PPV increased to 0.78 for family physicians and to 0.77 for respiratory physicians when the second operational definition based on two diagnoses of asthma or more was used. Results tended to be lower for 45-80 years old patients. We conclude that diagnoses recorded in the Medical Services database of Quebec are valid to identify patients with asthma.

A literature review on off-label drug use in children

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

CONCLUSION

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

Paediatric adverse drug reactions reported in Sweden from 1987 to 2001

PURPOSE

To describe frequency, seriousness and recovery of the patient in reported suspected paediatric adverse drug reactions (ADRs) in Sweden using data from a nation-wide ADR reporting system.

METHODS

Data from ADR reports submitted to the Swedish Medical Products Agency (MPA) were collected from the database SWEDIS and analysed for the period from 1987 to 2001. All reports with certain, probable or possible causality assessments referring to paediatric patients < 16 years of age were included.

RESULTS

In 5771 children an ADR report was documented during the whole 15-year period in a paediatric population of about 1.7 million individuals. The annual reporting frequency was about 385 reports per year. The most frequently reported reactions were application site reaction (24%) followed by fever (12%) and exanthema (6.7%). The clearly most frequently reported group of drugs were the vaccines (63.8%) followed by antibiotics for systemic use (10.1%). The proportion of children that suffered from a serious ADR was 13.0% and that for drug related deaths 0.14%. Nine per cent of the children had not recovered at the time of reporting and 1% recovered with sequelae. A male overrepresentation was observed regarding the total number of reports. About two-third of the reports concerned outpatients less than 4 years of age.

CONCLUSIONS

In respect of the limited number of paediatric drug safety studies or availability of record-linkage databases, nation-wide reporting systems of ADRs represent a valuable hypothesis generating tool in evaluating the characteristics of ADRs occurring in the orphan paediatric population.

Italian paediatricians and off-label prescriptions: loyal to regulatory or guideline standards?

AIM

To evaluate the reason off-label use exists in paediatric general practice and to distinguish between non-compliance with respect to regulatory standards and non-compliance with respect to guidelines in order to determine what this difference means in terms of rational prescribing.

METHODS

Information on patients visited by 35 general paediatricians in southern Italy was collected and their prescriptions analysed for off-label status. Off-label drug use in the Italian paediatric community setting was assessed. A sample indication, pharyngotonsillitis, was chosen and the related prescriptions analysed, distinguishing between non-compliance with regulatory standards (i.e. off-label use) and non-compliance with guidelines, in order to determine the appropriateness of prescribing.

RESULTS

Information was collected on 9917 patients (8476 prescriptions). In all, 17% of prescriptions were off label. When the 1675 pharyngotonsillitis prescriptions were analysed, 8% were off label and 63% were not in accordance with the guidelines. On the other hand, 55% of these prescriptions did not adhere to the guidelines, but were not off label either.

CONCLUSION

The results of this study were surprising because off-label drug use for pharyngotonsillitis, a common paediatric condition, was low, while non-adherence to guidelines was high. In cases such as this one, in which guidelines exist, physicians' prescribing habits were irrational because they did not follow the evidence. Physicians should keep up to date with new knowledge and should be provided with updated product information.

Off-label prescribing to children in primary care: retrospective observational study

OBJECTIVES

To investigate the extent and pattern of off-label prescribing to children in primary care throughout Scotland.

DESIGN

Assessment of prescribing to 167,865 children aged 0-16 years during the period November 1999 to October 2000 using data from 161 general practices using the national Scottish primary care computer system General Practice Administration System for Scotland.

SETTING

One hundred and sixty one general practices in Scotland.

RESULTS

During the study period, at least one off-label prescription was issued to 17,715 (26.1%) children aged 0-16 years. Off-label prescribing due to lower than the recommended dose was the most common form of off-label prescribing (40-50%), with antibiotics and antihistamines making up the majority. Off-label prescribing due to higher than the recommended dose was also common (35% of all off-label prescribing), with antiasthmatics, topical corticosteroids and laxatives making up the majority. Off-label prescribing with respect to age was less common (6-16%) affecting mainly young children (less than 2 years old) and adolescents. Off-label prescribing with respect to formulation was the least common cause accounting for 5-10% of off-label prescribing.

CONCLUSIONS

This is the largest and most detailed study to date of paediatric off-label prescribing in primary care within the UK. Such off-label prescribing likely occurs as the result of several factors including a failure to update licensing information with currently accepted practice and confusion or unawareness of the licensing recommendations, further compounded by a lack of clinical trials data and suitable formulations for medicines commonly prescribed to young children and adolescents.

Adverse drug reactions and off-label prescribing for paediatric outpatients: a one-year survey of spontaneous reports in Sweden

PURPOSE

To investigate the extent and characteristics of off-label prescribing for paediatric outpatients among drugs reported to have caused an adverse reaction.

METHODS

A retrospective, cross-sectional, observational analysis of spontaneous adverse drug reaction (ADR) reports in Sweden in the year 2000. We included all reports concerning drugs prescribed for outpatients younger than 16 years. Each ADR was classified with respect to its causality, seriousness and type of reaction. Off-label prescribing was evaluated with respect to age, dose, indication, formulation and route and frequency of administration.

RESULTS

We identified 112 patient-linked reports corresponding to 158 ADRs of which 31% were serious. Antiasthmatic drugs were most frequently suspected as a cause of almost every third adverse reaction. The average proportion of off-label drug prescribing amounted to 42.4%. It was more frequently associated with serious than non-serious ADRs and mostly due to a non-approved age or dose. The most common clinical manifestations were psychiatric disorders and mucocutaneous inflammatory reactions.

CONCLUSIONS

Off-label prescribing for paediatric outpatients is common among drugs reported to have caused an ADR. It is suggested to further identify unlabelled drugs frequently contributing to, in particular serious ADRs in children for a proper benefit-risk assessment of off-label drug use.