Is it time for a European formulary of paediatric medicines?

Guideline for the management of pediatric off-label use of drugs in China (2021)

BACKGROUND

The "Law on Doctors of the People's Republic of China," which was officially implemented on March 1, 2022, emphasizes the requirements for rational drug use and the necessity for appropriate management of off-label drug use. The safety and ethical considerations related to off-label drug use are different in children than in adults. There is so far no management guideline for pediatric off-label use of drugs in China, and the applicability of foreign guidelines is limited. Establishing a localized evidence-based management guideline for pediatric off-label use of drugs to support the national legislation and clinical practice is of critical importance.

METHODS

We established a guideline working group, including experts from a broad range of disciplines and developed recommendations following the guidance of the World Health Organization Handbook and the Chinese Medical Association. The following themes were identified by questionnaires and expert interviews to be of great concern in the management of off-label drug use in children: general principles and characteristics of management of pediatric off-label drug use; establishment of expert committees; evidence evaluation; risk-benefit assessment; informed consent; monitoring and assessment of the risk; and monitoring and patient education. Two rounds of Delphi surveys were organized to determine the final recommendations of this guideline. We graded the recommendations based on the body of evidence, referring to the evaluation tool of the Evidence-based management (EBMgt) and the Oxford Center for Evidence-Based Medicine: Level of Evidence (March 2009).

RESULTS

We developed the first guideline for the management of pediatric off-label use of drugs in China.

CONCLUSIONS

The guideline is to offer guidance for pediatricians, pharmacists, medical managers, policymakers, and primary care physicians on how to manage off-label drug use in pediatrics and to provide recommendations for Chinese healthcare policy in the future.

Off-label use of medicines in neonates, infants, children, and adolescents: a joint policy statement by the European Academy of Paediatrics and the European society for Developmental Perinatal and Pediatric Pharmacology

Health-care professionals who prescribe medicines have the professional duty to choose medicines that are in the best interest of their individual patient, irrespective if that patient is an adult or a child. However, the availability of medicines with an appropriate label for pediatric use is lagging behind those for adults, and even available pediatric drugs are sometimes not suitable to administer to children. Consequently, health-care professionals often have no other option than to prescribe off-label medicines to children. An important reason for use of off-label medicines is to improve access to (innovative) treatments or to address medical needs and preferences of patients, especially when no other options are available. However, off-label use of medicines is in general not supported by the same level of evidence as medicines licensed for pediatric use. This may result in increased uncertainty on efficacy as well as the risk for toxicity and other side effects. In addition, liability may also be of concern, counterbalanced by professional guidelines.Conclusion: The purpose of this joint EAP/ESDPPP policy statement is to offer guidance for HCPs on when and how to prescribe off-label medicines to children and to provide recommendations for future European policy.

Recommended strategies for the oral administration of paediatric medicines with food and drinks in the context of their biopharmaceutical properties: a review

OBJECTIVES

This review focuses on the recommended strategies for the oral administration of paediatric medicines with food in the context of their biopharmaceutical properties.

KEY FINDINGS

Acceptability of oral medicines in young patients is more challenging than in adult patients. Mixing oral dosage forms with foods and drinks is sometimes suggested to administer a specific dose and enhance compliance in the paediatric population. In this review, the strategies for the co-administration of paediatric medicines with food and drinks are discussed. Current administration practices as reported by healthcare professionals and parents/carers are compared with the relevant guidelines. Differences in the type of vehicles recommended to be used and actually used in current practice were identified. Correlations of the type of food recommended, the type of formulation and the drug's biopharmaceutical classification system (BCS) class were performed and revealed that recommendations should be made on a case-by-case basis.

SUMMARY

The propensity for physiochemical or bioavailability changes that may occur from the co-administration of medicines with food and drinks in the paediatric population should be considered, and harmonisation of the recommended administration strategies is needed.

Review of Italian primary care paediatricians identifies 38 commonly prescribed drugs for children

AIM

Most Italian children are cared for by a family paediatrician until they are 14 years old, and their duties include prescribing drugs recommended by specialists so that they are free. This study aimed to draw up a list of the drugs most commonly prescribed by family paediatricians.

METHODS

We surveyed 64 experienced family paediatricians to find out what drugs they prescribed over an 8-week period, including those recommended by a specialist, using cartons of drugs as the unit of measurement. A list of commonly prescribed drugs was then drawn up.

RESULTS

A total of 381 active substances were prescribed. The most commonly prescribed drugs were amoxicillin (25.8% of the cartons), amoxicillin clavulanate (9.2%) and cetirizine (9.0%). The most commonly prescribed drug classes were antibiotics (43.8%), anti-asthmatics (12.9%) and antihistamines (11.8%). A list of 38 commonly prescribed drugs belonging to 16 therapeutic subgroups and covering 83.1% of cartons was identified. Of these, 33 were prescribed by 50% or more of the paediatricians and five were mainly prescribed following the recommendation of a specialist.

CONCLUSION

Our review of the prescribing habits of family paediatricians showed that 38 commonly prescribed drugs were sufficient to treat most common diseases in children under 15 years of age.

Drug use profile in outpatient children and adolescents in different Italian regions

BACKGROUND

Large differences exist in the prevalence rate of drugs prescribed to children and adolescents between and within countries. The aim of this study was to evaluate child and adolescent drug prescription patterns in Italy in an extra-hospital setting at the regional and Local Health Unit (LHU) levels.

METHODS

Data sources were three regional prescription databases. Data concerning the year 2008 were evaluated. A total of 3.3 million children and adolescents were included. Drug prevalence and prescription rates were evaluated at the regional and LHU levels. The correlation between mean latitude, average annual income, hospitalisation rate, number of paediatricians per 1,000 resident children, and prevalence rate was evaluated by LHU using a linear multiple regression analysis.

RESULTS

Large differences were found across Italian regions and LHUs. The mean prevalence rate was 56.4% (95% CI 56.3-56.5%; 51.2-65.4% among regions) and, at the LHU level, ranged from 43.1% to 70.0% (higher in the South). A total of 878 drugs were prescribed, 175 of which were shared by all LHUs. Amoxicillin clavulanate was the most used drug in all regions and in 31 of 33 LHUs. Amoxicillin was the drug with the highest variability in use between LHUs (9.1-52.1% of treated children). An inverse correlation was found between prevalence rate and both latitude (p < 0.0001) and average annual income (p = 0.0002).

CONCLUSIONS

The use of drugs in children and adolescents is higher in southern Italy and is inversely related to latitude and average annual income. More efforts should be devoted to informing physicians, patients and policy makers in order to plan effective initiatives to improve the situation.

The regional profile of antibiotic prescriptions in Italian outpatient children

PURPOSE

To evaluate paediatric antibiotic prescription patterns in Italy in an extra-hospital setting at the national, regional, and Local Health Unit (LHU) level.

METHODS

Data sources were regional prescription databases. Eight Italian regions participated in the study providing data for the year 2008, with two exceptions (where the data for 2009 and 2006 were provided instead). A total of 4,828,569 children were included: 58% of the Italian population under 15 years old. Antibiotic prevalence rates, prescription rates and prescriptions distribution by class were evaluated at the regional and LHU levels. The correlation among mean latitude, Human Development Index (HDI), hospitalisation rate, satisfaction index for the National Health Service, number of paediatricians per 1,000 resident children and prevalence rate was evaluated by regions.

RESULTS

The estimated pooled average prevalence rate was 50.5% (95%CI 45.7-55.3). Between-regions prevalence rates ranged from 42.6% to 62.1% and at the LHU level they ranged from 35.6% to 68.5%. There was a trend indicating that in southern regions antibiotics are more frequently prescribed than in the northern and central regions (Cochrane-Armitage test Z = -187.5 p < 0.0001). Overall, penicillin covered 53.1% of antibiotic prescriptions, with differences between regions ranging from 39.2% to 62.5%. A direct correlation was found between the prevalence rate and HDI (p = 0.031), while an inverse correlation was found with paediatricians per 1,000 resident children (p = 0.038).

CONCLUSIONS

We found that relevant differences exist between the northern and the southern part of the country, and the heterogeneity among LHUs is higher. The greater use of antibiotics in the southern regions is related to lower HDI and does not seems to be justified by the higher prevalence of infectious diseases.

Ocular medicines in children: the regulatory situation related to clinical research

Background

Many ocular medications are prescribed for paediatric patients, but the evidence for their rational use is very scant. This study was planned to compare the availability and the licensing status of ocular medications marketed in Italy, the United Kingdom (UK), and the United States of America (USA) related to the amount of published and un-published RCTs testing these drugs in the paediatric population.

Methods

A quantitative analysis was performed to evaluate the number of ocular medications with a paediatric license in Italy, the UK, and the USA. A literature search was also performed in MEDLINE, EMBASE, and The Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) on ophthalmic pharmacological therapy in children aged < 18 years, published up to December 2010. A search in the international clinical trial registries, the list of paediatric investigation plans (PIPs) approved by European Medicines Agency (EMA), and the table of medicines with new paediatric information approved by Food and Drug Administration (FDA) was also performed.

Results

In all, of 197 drugs identified, 68 (35%) single drugs are licensed for paediatric use at least in one considered country, while 23 (12%) were marketed in all three countries. More specifically, in Italy 43 single drugs (48% of those marketed) had a paediatric license, while 39 (64%) did in the UK and 22 (54%) did in the USA. Only 13 drugs were marketed with a paediatric license in all countries.

The percentage of drugs licensed for paediatric use and for which at least one RCT had been performed ranged between 51% in Italy and 55% in the USA. No published RCTs were found for 11 (48%) drugs licensed for paediatric use in all three countries. In all, 74 (35%) of the retrieved RCTs involved mydriatic/cycloplegic medications.

A total of 62 RCTs (56% completed) on 46 drugs were found in the international clinical trial registries. Cyclosporin and bevacizumab were being studied in many ongoing trials. Twenty-six drugs had new paediatric information approved by FDA based on new paediatric clinical trials, while only 4 PIPs were approved by EMA.

Conclusions

There is a pressing need for further research and clinical development in the pediatric ophthalmic area, where effective up-to-date treatments, and additional research and education on use in children, remain priorities.

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.