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Gazarian M, Horton DB, Carleton B, Kinlaw AC, Bushnell GA, Czaja AS, Durrieu G, Gorman EF, Titievsky L, Zito J, Slaughter JL, dosReis S. Optimizing therapeutic decision-making for off-label medicines use: A scoping review and consensus recommendations for improving practice and research . Pharmacoepidemiol Drug Saf 2023; 32:1200-1222. [PMID: 37208845 PMCID: PMC10543391 DOI: 10.1002/pds.5640] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 05/02/2023] [Accepted: 05/11/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE Off-label medicines use is a common and sometimes necessary practice in many populations, with important clinical, ethical and financial consequences, including potential unintended harm or lack of effectiveness. No internationally recognized guidelines exist to aid decision-makers in applying research evidence to inform off-label medicines use. We aimed to critically evaluate current evidence informing decision-making for off-label use and to develop consensus recommendations to improve future practice and research. METHODS We conducted a scoping review to summarize the literature on available off-label use guidance, including types, extent and scientific rigor of evidence incorporated. Findings informed the development of consensus recommendations by an international multidisciplinary Expert Panel using a modified Delphi process. Our target audience includes clinicians, patients and caregivers, researchers, regulators, sponsors, health technology assessment bodies, payers and policy makers. RESULTS We found 31 published guidance documents on therapeutic decision-making for off-label use. Of 20 guidances with general recommendations, only 35% detailed the types and quality of evidence needed and the processes for its evaluation to reach sound, ethical decisions about appropriate use. There was no globally recognized guidance. To optimize future therapeutic decision-making, we recommend: (1) seeking rigorous scientific evidence; (2) utilizing diverse expertise in evidence evaluation and synthesis; (3) using rigorous processes to formulate recommendations for appropriate use; (4) linking off-label use with timely conduct of clinically meaningful research (including real-world evidence) to address knowledge gaps quickly; and (5) fostering partnerships between clinical decision-makers, researchers, regulators, policy makers, and sponsors to facilitate cohesive implementation and evaluation of these recommendations. CONCLUSIONS We provide comprehensive consensus recommendations to optimize therapeutic decision-making for off-label medicines use and concurrently drive clinically relevant research. Successful implementation requires appropriate funding and infrastructure support to engage necessary stakeholders and foster relevant partnerships, representing significant challenges that policy makers must urgently address.
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Affiliation(s)
- Madlen Gazarian
- School of Biomedical Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, AUSTRALIA
| | - Daniel B. Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA; Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Bruce Carleton
- Division of Translational Therapeutics, Department of Paediatrics, Faculty of Medicine, University of British Columbia, Vancouver, CANADA
- Pharmaceutical Outcomes Programme, BC Children’s Hospital, Vancouver, CANADA
- BC Children’s Hospital Research Institute, Vancouver, CANADA
| | - Alan C. Kinlaw
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina School of Pharmacy, Chapel Hill, NC USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Greta A Bushnell
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Angela S. Czaja
- Department of Pediatrics, Critical Care section, University of Colorado School of Medicine, Aurora, CO, USA
| | - Geneviève Durrieu
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Faculty of Medicine, Toulouse University Hospital (CHU), Toulouse, FRANCE
| | - Emily F. Gorman
- Health Sciences and Human Services Library, University of Maryland, Baltimore, Baltimore, MD, USA
| | | | - Julie Zito
- Professor Emerita, Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Jonathan L. Slaughter
- Center for Perinatal Research, Nationwide Children’s Hospital
- Department of Pediatrics, College of Medicine, and Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Susan dosReis
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Young MJ, Bodien YG, Freeman HJ, Fecchio M, Edlow BL. Toward Uniform Insurer Coverage for Functional MRI Following Severe Brain Injury. J Head Trauma Rehabil 2023; 38:351-357. [PMID: 36854104 PMCID: PMC10329974 DOI: 10.1097/htr.0000000000000864] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Functional magnetic resonance imaging (fMRI) now promises to improve diagnostic and prognostic accuracy for patients with disorders of consciousness, and accordingly has been endorsed by professional society guidelines, including those of the American Academy of Neurology, American College of Rehabilitation Medicine, National Institute on Disability, Independent Living, and Rehabilitation Research, and the European Academy of Neurology. Despite multiple professional society endorsements of fMRI in evaluating patients with disorders of consciousness following severe brain injury, insurers have yet to issue clear guidance regarding coverage of fMRI for this indication. Lack of insurer coverage may be a rate-limiting barrier to accessing this technique, which could uncover essential diagnostic and prognostic information for patients and their families. The emerging clinical and ethical case for harmonized insurer recognition and reimbursement of fMRI for vulnerable persons following severe brain injury with disorders of consciousness is explained and critically evaluated.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
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Loeb GE, Richmond FJ. Turning Neural Prosthetics Into Viable Products. Front Robot AI 2021; 8:754114. [PMID: 34660704 PMCID: PMC8513865 DOI: 10.3389/frobt.2021.754114] [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] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/20/2021] [Indexed: 11/13/2022] Open
Abstract
Academic researchers concentrate on the scientific and technological feasibility of novel treatments. Investors and commercial partners, however, understand that success depends even more on strategies for regulatory approval, reimbursement, marketing, intellectual property protection and risk management. These considerations are critical for technologically complex and highly invasive treatments that entail substantial costs and risks in small and heterogeneous patient populations. Most implanted neural prosthetic devices for novel applications will be in FDA Device Class III, for which guidance documents have been issued recently. Less invasive devices may be eligible for the recently simplified “de novo” submission routes. We discuss typical timelines and strategies for integrating the regulatory path with approval for reimbursement, securing intellectual property and funding the enterprise, particularly as they might apply to implantable brain-computer interfaces for sensorimotor disabilities that do not yet have a track record of approved products.
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Affiliation(s)
- Gerald E Loeb
- Medical Device Development Facility, Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, United States
| | - Frances J Richmond
- DK Kim International Center for Regulatory Science, Department of Regulatory and Quality Sciences, University of Southern California, Los Angeles, CA, United States
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Retchkiman M, El-Khatib A, Nazhat Al Yafi M, Danino MA. Biocell-Initial patents versus user instructions guide: A discrepancy at the core of a crisis. ANN CHIR PLAST ESTH 2021; 66:277-284. [PMID: 34140175 DOI: 10.1016/j.anplas.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/01/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Our aim is to do a comparative qualitative analysis of patents and "User Manuals" of the Biocell textured implants in order to determine if red flags were omitted when marketing and using Biocell textured implants. MATERIALS AND METHODS We performed a systematic qualitative analysis using the NVivo software version 11 of the patents describing the Biocell textured implants prior to their approval by the FDA and of user guides published by the 3 companies owning the patents (McGhan, Inamed, Allergan). To guide our thematic analysis, we used a form of systems theory known as the complexity theory. RESULTS Four patents related to Biocell and 2 user manuals (McGhan- Inamed and Allergan) were analyzed. Four themes emerged from the patents: invention description, mechanism of action (Tissue ingrowth), the timing of the mechanism of action and hypothetical actions on capsular contractures prevention. Of all patent's content, 34% described the invention, 29% the mechanism of action (tissue ingrowth), 1% the timing of this mechanism of action and 34% a hypothetical action against capsular contracture. Solid evidence was found on the concept of anchoring and very little on capsular contracture. On the user guide side, the main themes were indications and contraindications, surgical techniques and long-term effects. The "directed" content analysis approach of the user guides regarding the patent's themes reflected that 94% of the user guides content related to the patent thematics was about the hypothetical role on capsular contracture while only 4% was about invention description and 1.5% about tissue ingrowth. CONCLUSIONS This analysis highlights the discrepancies between patents of Biocell textured implants and user guides for these implants. The indications of use of a treatment or device can evolve quicker than the study of its potential complications and side effects. The BIA-ALCL crisis should serve as a cautionary tale to the plastic surgery community which embraces new technologies eagerly, and sometimes precariously, in a mission to advance patient care.
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Affiliation(s)
- M Retchkiman
- Division of Plastic and Reconstructive Surgery, University of Montreal Medical Center, Montreal, Quebec, Canada
| | - A El-Khatib
- Division of Plastic and Reconstructive Surgery, University of Montreal Medical Center, Montreal, Quebec, Canada
| | - M Nazhat Al Yafi
- Division of Plastic and Reconstructive Surgery, University of Montreal Medical Center, Montreal, Quebec, Canada
| | - M A Danino
- Division of Plastic and Reconstructive Surgery, University of Montreal Medical Center, Montreal, Quebec, Canada.
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- Division of Plastic and Reconstructive Surgery, University of Montreal Medical Center, Montreal, Quebec, Canada
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Mulberg AE, Cripps T. Global Harmonization of Pediatric Drug Development: Critical for Progress for Developing Safe and Effective Therapeutic Agents for Children. CURRENT THERAPEUTIC RESEARCH 2019; 90:109-112. [PMID: 31388364 PMCID: PMC6677566 DOI: 10.1016/j.curtheres.2019.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/16/2019] [Indexed: 11/28/2022]
Abstract
The article, "Questionable Industry-Sponsored Studies in Children and Adolescents in Slovenia" provides an opportunity to discuss evolving US and EU legislative measures to improve the available clinical trial-derived pediatric data and provide coherent labeling for pediatric providers in dosing of drugs for children.
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Waddell C, Schwartz C, Andres C, Barican JL, Yung D. Fifty years of preventing and treating childhood behaviour disorders: a systematic review to inform policy and practice. EVIDENCE-BASED MENTAL HEALTH 2018; 21:45-52. [PMID: 29703717 PMCID: PMC5950520 DOI: 10.1136/eb-2017-102862] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 03/19/2018] [Accepted: 03/26/2018] [Indexed: 01/16/2023]
Abstract
QUESTION Oppositional defiant and conduct disorders (ODD and CD) start early and persist, incurring high individual and collective costs. To inform policy and practice, we therefore asked: What is the best available research evidence on preventing and treating these disorders? STUDY SELECTION AND ANALYSIS We sought randomised controlled trials (RCTs) evaluating interventions addressing the prevention or treatment of behaviour problems in individuals aged 18 years or younger. Our criteria were tailored to identify higher-quality RCTs that were also relevant to policy and practice. We searched the CINAHL, ERIC, MEDLINE, PsycINFO and Web of Science databases, updating our initial searches in May 2017. Thirty-seven RCTs met inclusion criteria-evaluating 15 prevention programmes, 8 psychosocial treatments and 5 medications. We then conducted narrative synthesis. FINDINGS For prevention, 3 notable programmes reduced behavioural diagnoses: Classroom-Centered Intervention; Good Behavior Game; and Fast Track. Five other programmes reduced serious behaviour symptoms such as criminal activity. Prevention benefits were long term, up to 35 years. For psychosocial treatment, Incredible Years reduced behavioural diagnoses. Three other interventions reduced criminal activity. Psychosocial treatment benefits lasted from 1 to 8 years. While 4 medications reduced post-test symptoms, all caused important adverse events. CONCLUSIONS Considerable RCT evidence favours prevention. CLINICAL IMPLICATIONS Effective prevention programmes should therefore be made widely available. Effective psychosocial treatments should also be provided for all children with ODD/CD. But medications should be a last resort given associated adverse events and given only short-term evidence of benefits. Policymakers and practitioners can help children and populations by acting on these findings.
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Affiliation(s)
- Charlotte Waddell
- Faculty of Health Sciences, Children's Health Policy Centre, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Christine Schwartz
- Faculty of Health Sciences, Children's Health Policy Centre, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Caitlyn Andres
- Faculty of Health Sciences, Children's Health Policy Centre, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Jenny Lou Barican
- Faculty of Health Sciences, Children's Health Policy Centre, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Donna Yung
- Faculty of Health Sciences, Children's Health Policy Centre, Simon Fraser University, Vancouver, British Columbia, Canada
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Raymond EG, Blanchard K, Blumenthal PD, Cleland K, Foster AM, Gold M, Grossman D, Pendergast MK, Westhoff CL, Winikoff B. Sixteen Years of Overregulation: Time to Unburden Mifeprex. N Engl J Med 2017; 376:790-794. [PMID: 28225670 DOI: 10.1056/nejmsb1612526] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | | | - Paul D Blumenthal
- Division of Family Planning Services and Research, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Kelly Cleland
- Office of Population Research, Princeton University, Princeton, NJ
| | - Angel M Foster
- Faculty of Health Sciences, University of Ottawa, Ottawa
| | - Marji Gold
- Albert Einstein College of Medicine, Bronx, NY
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA
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Off-label use of the expensive orphan drug eculizumab in France 2009-2013 and the impact of literature: focus on the transplantation field. Eur J Clin Pharmacol 2016; 72:737-46. [PMID: 26915814 DOI: 10.1007/s00228-016-2027-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/11/2016] [Indexed: 12/26/2022]
Abstract
PURPOSE The orphan drug eculizumab (Soliris ®) is one of the most expensive in the world and based on expenditures is classed among the highest in France, a scenario suggestive of off-label use. Given its pharmacological properties, it is likely to be used in organ transplantation. Our purposes were to describe the consumption trends of eculizumab for off-label indications overall and in the organ transplantation field and to assess the impact of publications on the latter use. METHODS We carried out a temporal ecological study within the French national hospitalization database (PMSI). First, the trend of eculizumab consumption (2009-2013) was compared to our estimate of the maximum on-label consumption (overall and for transplantation). Second, we evaluated the impact of the publications supporting the effectiveness of eculizumab in the transplantation field on temporal trends of eculizumab consumption. RESULTS Eculizumab total consumption exceeded our estimate of the maximum on-label consumption since the end of 2011 and increased until the end of the study. The off-label consumption represented at least 50 % of the total consumption. The off-label consumption in organ transplantation also increased since 2011. The amount of publications grew through the study period, but overall, the evidence level remained low. Statistically, publications were neither associated with the drug consumption for transplantation in the long term nor in the short term. CONCLUSION Eculizumab started being notably used for off-label indications in France since the end of 2011, and this use increased until the end of the study. We found only low-level evidence concerning the off-label use of eculizumab in the transplantation field through the studied period.
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Pisa FE, Cosano G, Giangreco M, Giorgini T, Biasutti E, Barbone F. Prescribing practice and off-label use of psychotropic medications in post-acute brain injury rehabilitation centres: A cross-sectional survey. Brain Inj 2014; 29:508-16. [DOI: 10.3109/02699052.2014.992474] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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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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Abstract
PURPOSE OF REVIEW To provide current information on off-label medication use in pediatric gastroenterology, including a discussion on US legislative efforts to address the issue. RECENT FINDINGS Medications used to treat pediatric gastrointestinal illnesses are frequently prescribed off-label. Acid suppressors, antiemetics, laxatives, and antitumor necrosis factor therapies are types of medications frequently used off-label in the pediatric gastroenterology arena. Pediatric studies conducted under US Federal laws are generating much-needed data on the safety and effectiveness of medications used to treat pediatric patients. Moreover, a new US law, the Food and Drug Administration Safety and Innovation Act, may further the development of pediatric medications in part by requiring pediatric-specific study plans earlier in the overall drug development process. As of today, there still are gaps in our knowledge about these medications, including for the treatment of pediatric gastroenterology diseases. SUMMARY Medications are widely used off-label in pediatrics, including medications intended to treat gastrointestinal diseases, such as antitumor necrosis factor and laxatives. Although legislation is helping to generate and make available important information about pediatric medications, most still do not contain pediatric data. Therefore, providers need to understand the potential risks and benefits of prescribing off-label products to pediatric patients.
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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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