Switching of Prescription Drugs to Over-the-Counter Status

Self-medication with NSAIDs and purchase of branded and over-the-counter medicines: Analysis of a national survey in Peru

Background

This study aimed to determine the association between self-medications with nonsteroidal anti-inflammatory drugs (NSAIDs) and the purchase of branded and over-the-counter medications in Peru.

Design and methods

This secondary analysis used a representative survey of Peru from 2014 to 2016. The exposure variable was self-medication with NSAIDs, defined as "the purchase of NSAIDs for oneself without a prescription." The outcome was the purchase of branded and over-the-counter medications. Crude prevalence ratios (cPR) and adjusted prevalence ratios (aPR) with their respective 95% confidence intervals (95% CI) were calculated.

Results

Of the total of 2158 participants, 52.80% were women with an average age of 40.24 years. The prevalence of self-medication with NSAIDs was 68.21%, whereas the rates of purchasing branded and over-the-counter medications were 63.78% and 13.16%, respectively. The adjusted Poisson regression analysis showed an association between self-medication with NSAIDs and the purchase of branded (aPR = 1.18; 95% CI: 1.12-1.25; p < 0.001) and over-the-counter (aPR = 2.38; 95% CI: 1.95-2.90; p < 0.001) medications.

Conclusions

Approximately 7/10 users who self-medicate with NSAIDs chose branded medications, whereas nearly 1/5 opt for over-the-counter medications. Self-medication with NSAIDs was associated with a higher likelihood of purchasing branded and over-the-counter medications.

Pharmacists' perspectives on recommending herbal medicines for acute infections: a qualitative study

BACKGROUND

Community pharmacists have an essential role in antimicrobial stewardship by providing self-care advice for self-limiting infections.

AIM

To explore community pharmacists' perceptions and experiences of advising patients on management of acute respiratory tract infections (RTIs) and urinary tract infections (UTIs), and to explore issues regarding use of over-the-counter (OTC) medicines, including herbal medicines.

DESIGN & SETTING

A qualitative study using semi-structured interviews with community pharmacists in England.

METHOD

Qualitative interviews with community pharmacists were carried out face to face and by telephone between November 2019 and March 2020. Data were collected through in-depth, semi-structured interviews, recorded and transcribed. A reflexive thematic analysis was undertaken.

RESULTS

In total, 18 community pharmacists were interviewed. Three main themes were identified. Theme 1 was self-management recommendations. Community pharmacists considered patients' preferences when recommending self-management strategies. Some believed that conventional OTC medications had quicker and stronger effects, while others preferred herbal OTCs as a more natural approach, particularly for less severe symptoms. Theme 2 was factors influencing pharmacists' recommendations for acute infections. This included pharmacists' perceptions of patient preferences, nature or severity of illness, research evidence, training, commercial pressures, and patient concerns about medication cost. Theme 3 was pharmacist-patient communication. Pharmacists sometimes experienced challenges with language barriers and patients' expectations of receiving antibiotics. Pharmacists emphasised the importance of being trusted by their patients. There was widespread acceptance of their role in self-management advice for acute illness and interest in the role of herbal medicines, but pharmacists did not feel confident in recommending these.

CONCLUSION

Pharmacists are central to the management of self-limiting infections. There is a need to educate the public about appropriate use of antibiotics and provide training and support for pharmacists on self-management strategies including herbal medicine.

Attitudes, attributions, and usage patterns of primary care patients with regard to over-the-counter drugs-a survey in Germany

Studies show that over-the-counter drugs are widely used by consumers. Moreover, there is a huge selection available and they are prominently featured in advertising. To date, there exist only a few studies that shed light on the attitudes, attributions, and usage patterns of patients with regard to use of over-the-counter drugs. An anonymized explorative waiting room survey was conducted among 900 patients in 60 GP practices in the German states of North Rhine-Westphalia, Hesse, and Rhineland-Palatinate. As well as the descriptive analysis, a t test was applied to independent random samples, in order to identify significant differences between two groups. 65% of respondents reported using over-the-counter drugs frequently or occasionally. With regard to effects, risks, and side effects, 54% state that they usually take advice from their GP and/or pharmacist before purchasing or taking over-the-counter preparations. For 56%, the package information leaflet is a frequent source of information about the over-the-counter drugs used. The respondents consider over-the-counter preparations to be particularly suitable for (preventive) treatment of colds, flu symptoms, and pain management. The widespread perception of over-the-counter drugs as simple to use (62%), low-dose (69%), and low-efficacy (73%) products does not always correspond to the actual capabilities and risks of over-the-counter self-medication. Given the easy availability of over-the-counter drugs and their strong presence in advertising, it is important that patients have a realistic idea of the capabilities and risks of over-the-counter products. In addition to the advice provided by pharmacists, the trusting, long-standing support provided by GPs and their ongoing information and advice services play a central role in this. It would be advisable to give more attention to this public health concern and to promote initiatives to make patients more aware of the risks regarding consumption of drugs without medical consultation.

Does self-medication reduce medical expenditure among the middle-aged and elderly population? A four-wave longitudinal study in China

Introduction

Self-medication has a high prevalence in the middle-aged and elderly population in China. Despite the published evidence demonstrating the economic benefits of self-medication, limited research has addressed the relationship between self-medication and individual medical expenditures, especially within the Chinese population. This study examined the effect of self-medication on individual medical expenditures in China and analyzed the heterogeneity between outpatient and inpatient cases.

Methods

We conducted a panel data analysis using data from four waves of the China Health and Retirement Longitudinal Study (CHARLS). Two-part mixed-effect models were implemented to estimate the effect of self-medication on total outpatient and inpatient expenses and out-of-pocket (OOP) costs, where mixed-effects logit regression was used as the first part, and generalized linear mixed models with log link and gamma distribution was used as the second part.

Results

We identified 72,041 responses representing 24,641 individuals, of which 13,185 responses incurred outpatient expenses and 9,003 responses incurred inpatient costs. Controlling for all covariates, we found that self-medication behaviors were significantly associated with a higher probability of outpatient service utilization (OR = 1.250, 95% CI = 0.179 to 0.269; P < 0.001), but displayed no significant association with outpatient expenses. Respondents who had taken self-medication were less likely to use inpatient services (OR = 0.865, 95% CI = -0.201 to -0.089; P < 0.001), and their inpatient expenses were significantly reduced by 9.4% (P < 0.001). Inpatient OOP costs were significantly reduced by 10.7% (P < 0.001), and outpatient OOP costs were significantly increased by 11.3% (P < 0.001) among respondents who had self-medicated.

Conclusions

This study allowed us to identify the economic value of self-medication among the middle-aged and elderly population in China. Future work should guide the middle-aged and elderly to take responsible self-medication to reduce their economic burden.

Self-medication with ophthalmic drugs and its associated factors among ophthalmic patients attending three hospitals in Asmara, Eritrea: a cross-sectional study

OBJECTIVE

To assess the prevalence and practice of self-medication and its associated factors among ophthalmic patients.

DESIGN

An analytical cross-sectional study design was employed.

SETTING

Three hospitals inAsmara, Eritrea.

PARTICIPANTS

Samples of ophthalmic outpatients aged >18 years who visited the three hospitals in Asmara, Eritrea. Systematic random sampling was used to select the study participants.

DATA COLLECTION AND ANALYSIS

Data were collected from September 2021 to October 2021 in a face-to-face interview using a structured questionnaire. The collected data were double entered and analysed using CSPro (V.7.2) and SPSS (V.26), respectively. Descriptive statistics and logistic regression were performed. P values less than 0.05 were considered as significant.

PRIMARY AND SECONDARY OUTCOME MEASURES

Main outcome variable was practice of self-medication with ophthalmic drugs (SMOD). Secondary outcome measure was the determinants of self-medication practice.

RESULTS

A total of 351 participants were recruited with a response rate of 97.7%. The prevalence of SMOD was found to be 14.9% (95% CI (11.1% to 18.7%)). The most frequently preferred ophthalmic drug groups were antibiotics (63.6%), followed by corticosteroids (22.7%). The main reasons for SMOD were easy accessibility (52.9%) and previous familiarity of the eye medication (27.5%). Eye redness (n=19/51) and foreign body sensation (n=18/51) were the most self-recognised complaints that required self-medication. The most common source of information for SMOD was pharmacy professionals (41.1%). Only attitude score (Crude odds ratio (COR)= 1.25, 95% CI 1.12, 1.39) was significantly associated with the practice of SMOD at bivariate logistic regression.

CONCLUSION

Though the majority of respondents considered self-medication with ophthalmic drugs as inappropriate, a significant number of them practising it. This mandates relevant bodies to take stricter measures to protect the public from the misuse of eye medications.

Effects of Demographic Characteristics and Consumer Behavior in the selection of Retail Pharmacies and Over-the-Counter Medicine

Aim

The study aimed to provide new insights into consumer behaviour by identifying the key demographic factors that influence the choice of pharmacy and over-the-counter (OTC) medicine.

Materials and Methods

A cross-sectional study was conducted in an urban area (Thessaloniki, Greece), surveying a convenience sample of 314 consumers with a structured questionnaire. Data analysis was conducted using the chi-square test, one-way analyses of variance (ANOVAs) and Spearman's rho correlation coefficient.

Results

Respondents with a lower educational level and retired consumers tended to make their purchases in a single pharmacy (p < 0.001). Older participants were more likely to consider the pharmacy staff and additional services to be important factors (p < 0.01). Students were the only group to prefer a formal relationship with the pharmacy staff (p < 0.001). Participants with a lower educational level tended to know exactly what they would buy (p < 0.05), whereas women made more unscheduled purchases of OTCs (p < 0.05). Respondents with a higher income assigned more importance to the product's country of origin (p < 0.05) and manufacturing company (p < 0.01) and less importance to the pharmacist's opinion than those of a lower income (p < 0.05).

Conclusions

The educational level, occupation and age of consumers have a marked effect in their selection of pharmacy, and along with gender and personal income, in their choice of OTC medicine. Our findings yield implications for the management of community pharmacies.

Over-The-Counter Remedies in Older Adults: Patterns of Use, Potential Pitfalls, and Proposed Solutions

Over-the-counter (OTC) products such as pharmaceuticals, dietary supplements, vitamins, and herbal remedies are widely available and copiously used by older adults for health maintenance and symptom management. Owing to physiology, multimorbidity, and polypharmacy, this population is particularly vulnerable to inappropriate use of OTC products, adverse effects, and drug interactions. While OTC pharmaceuticals are bound by FDA-approved standards, dietary supplements are regulated differently, resulting in variable quality and increased possibility for adulteration. Internationally, standards for OTC products vary widely. Accessible educational information, improved provider-patient communication, and revision of regulatory policy could improve safety for older adult users of OTC products.

A Knowledge, Attitude, and Practice Survey on Medication Safety in Korean Older Adults: An Analysis of an Ageing Society

Background: Older adults have certain limitations in acquiring and understanding information regarding medication safety. This study surveyed their medication habits and analysed the importance of relevant education to improve knowledge, attitudes, and practice (KAP). Methods: Our survey included adults aged 65 years or older. We developed a questionnaire on medication safety based on the KAP model. To identify the interrelationships among KAP, we calculated the correlation coefficients using Pearson’s correlation analysis. A t-test was performed to verify the differences in KAP associated with the respondents’ medication safety education experience. Results: We found that 79.4% of respondents self-administered their medications. Of the respondents, 28.2% had received medication safety education. Overall, the respondents had typical levels of knowledge, attitude responses, and behavioural practices associated with medication safety. The results showed significant differences between knowledge and practice; those who were educated on medication safety performed higher levels of safe practice than those who were not (p < 0.05). Conclusion: The KAP survey confirmed that knowledge about the safe use of medication positively affected older adults’ attitudes and practices. To improve their medication usage habits, older adults should receive well-organised medication safety education.

Evaluating Drug Risk Using GAN and SMOTE Based on CFDA's Spontaneous Reporting Data

Adverse drug reactions (ADRs) pose health threats to humans. Therefore, the risk re-evaluation of post-marketing drugs has become an important part of the pharmacovigilance work of various countries. In China, drugs are mainly divided into three categories, from high-risk to low-risk drugs, namely, prescription drugs (Rx), over-the-counter drugs A (OTC-A), and over-the-counter drugs B (OTC-B). Until now, there has been a lack of automated evaluation methods for the three status switch of drugs. Based on China Food and Drug Administration's (CFDA) spontaneous reporting database (CSRD), we proposed a classification model to predict risk level of drugs by using feature enhancement based on Generative Adversarial Networks (GAN) and Synthetic Minority Over-Sampling Technique (SMOTE). A total of 985,960 spontaneous reports from 2011 to 2018 were selected from CSRD in Jiangsu Province as experimental data. After data preprocessing, a class-imbalance data set was obtained, which contained 887 Rx (accounting for 84.72%), 113 OTC-A (10.79%), and 47 OTC-B (4.49%). Taking drugs as the samples, ADRs as the features, and signal detection results obtained by proportional reporting ratio (PRR) method as the feature values, we constructed the original data matrix, where the last column represents the category label of each drug. Our proposed model expands the ADR data from both the sample space and the feature space. In terms of feature space, we use feature selection (FS) to screen ADR symptoms with higher importance scores. Then, we use GAN to generate artificial data, which are added to the feature space to achieve feature enhancement. In terms of sample space, we use SMOTE technology to expand the minority samples to balance three categories of drugs and minimize the classification deviation caused by the gap in the sample size. Finally, we use random forest (RF) algorithm to classify the feature-enhanced and balanced data set. The experimental results show that the accuracy of the proposed classification model reaches 98%. Our proposed model can well evaluate drug risk levels and provide automated methods for status switch of post-marketing drugs.

Patterns of self-medication in Qassim Province, Saudi Arabia: A cross-sectional study

BACKGROUND

Selling medicines in pharmacies without a prescription is a common practice in the Kingdom of Saudi Arabia. The aim of this study was to determine the attitudes about and prevalence of non-prescribed medication for those attending community pharmacies in Qassim Province, Saudi Arabia.

METHODS

This is a cross-sectional survey based study that was designed and administered to individuals attending four community pharmacies in the main cites of Qassim Province, Saudi Arabia to obtain Over The Counter (OTC) drug use, exposure to health education, awareness of risks, important causes, and side-effects.

RESULTS

Approximately 75% of 109 individuals attending the studied pharmacies purchased non-prescribed medicines. Most participants (80%) had read the drug pamphlets and followed the instructions for use. The most common reasons for buying non-prescribed medicines were repetition of a previous prescription by a healthcare provider (30.3%), belief that the disease was minor (26.6%), convenience of pharmacist prescription (19.3%), and the low cost and shortness of time to attend health services. The most commonly used drugs were analgesics (18.3%) followed by anti-allergic medications and antibiotics, and the least commonly used drugs were laxatives and anti-diarrheal medications. There were no significant differences in the purchase of non-prescribed drugs with respect to age, gender, and educational level. Only 9% of respondents were opposed to buying non-prescribed drugs and 34% were willing to use them only when necessary.

CONCLUSIONS

There was a high prevalence of non-prescribed medicine purchase from community pharmacies in the study area. Education efforts are needed to change this behavior.

Medicine self-administration errors in the older adult population: A systematic review

BACKGROUND

Medicine self-administration errors (MSEs) are a longstanding issue in patient safety. Although many studies have examined MSEs in the general adult population, the MSEs that occur specifically in the older adult population and their contributing factors are not well understood.

OBJECTIVE

To identify the types of MSEs and their contributing factors among community-dwelling older adults.

METHODS

PubMed, Medline, Embase, CINAHL and Scopus were searched for primary studies published between January 1, 2014 and June 12, 2020. Studies which reported MSEs among community-dwelling older adults (≥50 years of age) and written in English were included in the review.

RESULTS

Eleven studies met the inclusion criteria. The most commonly reported MSE was a dosing error, followed by missed dose, wrong medicine, incorrect administration methods, wrong administration time and wrong frequency. Seven of the included studies also described factors which contributed to the occurrence of MSEs. The most commonly reported factor contributing to MSEs was complex treatment regimens due to use of multiple medicines. Other factors identified included cognitive decline, decline in physical abilities, lack of social support, lack of knowledge about treatment regimens and negative attitudes and beliefs towards medicines. In most cases, MSEs occurred when multiple contributing factors were present.

CONCLUSION

The literature highlights a number of types of MSEs and their contributing factors which occur in the older adult population. Given that many MSEs are preventable, future research is needed into how pharmacists can support the identification and mitigation of factors contributing to MSEs in the older adult population.

Over-The-Counter Codeine: Can Community Pharmacy Staff Nudge Customers into Its Safe and Appropriate Use?

The misuse of opioids, including codeine which is sold over-the-counter (OTC) in United Kingdom (UK) community pharmacies, is a growing public health concern. An educational Patient Safety Card was developed and piloted to see if it nudged customers into the safe and appropriate use of OTC codeine. Exploratory analysis was conducted by (i) recording quantitative interactions for people requesting OTC codeine in community pharmacies; and (ii) a web-based pharmacy staff survey. Twenty-four pharmacies submitted data on 3993 interactions using the Patient Safety Card. Staff found the majority of interactions (91.3%) to be very or quite easy. Following an interaction using the card, customers known to pharmacy staff as frequent purchasers of OTC codeine were more likely not to purchase a pain relief medicine compared to customers not known to staff (5.5% of known customers did not purchase any pain relief product versus 1.1% for unknown customers (χ² = 41.73, df = 1, p < 0.001)). These results support both the use of a visual educational intervention to encourage appropriate use of OTC codeine in community pharmacy and the principles behind better self-care.

Utilization of Medications With Cognitive Impairment Side Effects and the Implications for Older Adults' Cognitive Function

Objectives: Many medications have cognitive impairment, memory loss, amnesia, or dementia as side effects ("cognitive side effects" hereafter), but little is known about trends in the prevalence of these medications or their implications for population-level cognitive impairment. Method: We use data from the National Health and Nutrition Examination Survey (1999-2016) to describe trends in the use of medications with cognitive side effects among adults aged 60+ (N = 16,937) and their implications for cognitive functioning (measured using word learning and recall, animal fluency, and digit symbol substitution assessments). Results: Between 1999 to 2000 and 2015 to 2016, the prevalence of older adults taking one, two, and at least three medications with cognitive side effects increased by 10.2%, 57.3%, and 298.7%, respectively. Compared to non-users, respondents who simultaneously used three or more medications with cognitive side effects scored 0.22 to 0.27 standard deviations lower in word learning and recall (p = .02), digit symbol substitution (p < .01), and the average standardized score of the three assessments (p < .001). Limitation: Dosage of medications associated with cognitive side effects was not measured. Discussion: Concurrent use of medications with cognitive side effects among older adults has increased dramatically over the past two decades. The use of such medications is associated with cognitive impairment and may explain for disparities in cognitive function across subgroups. These findings highlight the need for cognitive screenings among patients who consume medications with cognitive side effects. They also highlight the synergic effects of polypharmacy and potential drug-drug interactions that result in cognitive deficits.

Can Blood Oxygenation Level Dependent Functional Magnetic Resonance Imaging Be Used Accurately to Compare Older and Younger Populations? A Mini Literature Review

A wealth of research has investigated the aging brain using blood oxygenation level dependent functional MRI [Blood oxygen level dependent (BOLD) functional magnetic resonance imaging (fMRI)]. However, many studies do not consider the aging of the cerebrovascular system, which can influence the BOLD signal independently from neural activity, limiting what can be inferred when comparing age groups. Here, we discuss the ways in which the aging neurovascular system can impact BOLD fMRI, the consequences for age-group comparisons and possible strategies for mitigation. While BOLD fMRI is a valuable tool in this context, this review highlights the importance of consideration of vascular confounds.

Diagnosis and Treatment of Primary Headache Disorders in Older Adults

OBJECTIVES

To provide a unique perspective on geriatric headache and a number of novel treatment options that are not well known outside of the headache literature.

DESIGN

Review of the most current and relevant headache literature for practitioners specializing in geriatric care.

RESULTS

Evaluation and management of headache disorders in older adults requires an understanding of the underlying pathophysiology and how it relates to age-related physiological changes. To treat headache disorders in general, the appropriate diagnosis must first be established, and treatment of headaches in elderly adults poses unique challenges, including potential polypharmacy, medical comorbidities, and physiological changes associated with aging.

CONCLUSION

The purpose of this review is to provide a guide to and perspective on the challenges inherent in treating headaches in older adults. J Am Geriatr Soc 66:2408-2416, 2018.

Medication usage change in older people (65+) in England over 20 years: findings from CFAS I and CFAS II

Background

medical practice has changed over the last decades reflecting the ageing population, when multi-morbidity requiring multiple medications is more common.

Objective

describe and quantify self-reported medicine use including both prescription and over the counter medicines in two comparable population-based studies of older people (65+) in England and to assess the nature and scale of polypharmacy.

Methods

data used were from two separate population-based studies; the Cognitive Function Ageing Study I and II. Descriptive analyses were performed to summarise and quantify general medicine use. Negative binomial regression models were fitted to determine factors associated with the number of medicines used.

Results

medication use, including both prescribed medicines and over the counter products has increased dramatically over the last 2 decades. The number of people taking five or more items quadrupled from 12 to 49%, while the proportion of people who did not take any medication has decreased from around 1 in 5 to 1 in 13. Cardiovascular drugs were the most frequently taken medication. Polypharmacy is associated with increases in the number of diagnosed long-term conditions.

Conclusions

comparison between CFAS I and II reveals marked increases in medication usage and polypharmacy in the older population. The influence of healthcare organisation, introduction of new guidelines and technology changes leading to diagnosis of earlier, milder chronic diseases and treatment may be contributing to this changing pattern. Further research is needed to develop practical solutions to optimise medication management in older people, reducing the harming associated with medication.

Community pharmacy customer segmentation based on factors influencing their selection of pharmacy and over-the-counter medicines

Background

Within the competitive pharmacy market environment, community pharmacies are required to develop efficient marketing strategies based on contemporary information about consumer behavior in order to attract clients and develop customer loyalty.

Objectives

This study aimed to investigate the consumers' preferences concerning the selection of pharmacy and over-the-counter (OTC) medicines, and to identify customer segments in relation to these preferences.

Methods

A cross-sectional study was conducted between February and March 2016 on a convenient quota sample of 300 participants recruited in the metropolitan area of Thessaloniki, Greece. The main instrument used for data collection was a structured questionnaire with close-ended, multiple choice questions. To identify customer segments, Two-Step cluster analysis was conducted.

Results

Three distinct pharmacy customer clusters emerged. Customers of the largest cluster (49%; 'convenience customers') were mostly younger consumers. They gave moderate to positive ratings to factors affecting the selection of pharmacy and OTCs; convenience, and previous experience and the pharmacist's opinion, received the highest ratings. Customers of the second cluster (35%; 'loyal customers') were mainly retired; most of them reported visiting a single pharmacy. They gave high ratings to all factors that influence pharmacy selection, especially the pharmacy's staff, and factors influencing the purchase of OTCs, particularly previous experience and the pharmacist's opinion. Customers of the smallest cluster (16%; 'convenience and price-sensitive customers') were mainly retired or unemployed with low to moderate education, and low personal income. They gave the lowest ratings to most of the examined factors; convenience among factors influencing pharmacy selection, whereas previous experience, the pharmacist's opinion and product price among those affecting the purchase of OTCs, received the highest ratings.

Conclusions

The community pharmacy market comprised of distinct customer segments that varied in the consumer preferences concerning the selection of pharmacy and OTCs, the evaluation of pharmaceutical services and products, and demographic characteristics.

Factors associated with self-medication in Spain: a cross-sectional study in different age groups

Objective

The identification of factors which may influence a patient’s decision to self-medicate.

Methods

Descriptive, cross-sectional study of the adult population (at least 16 years old), using data from the 2009 European Health Interview Survey in Spain, which included 22 188 subjects. Logistic regression models enabled us to estimate the effect of each analysed variable on self-medication.

Key findings

In total, 14 863 (67%) individuals reported using medication (prescribed and non-prescribed) and 3274 (22.0%) of them self-medicated. Using logistic regression and stratifying by age, four different models have been constructed. Our results include different variables in each of the models to explain self-medication, but the one that appears on all four models is education level. Age is the other important factor which influences self-medication. Self-medication is strongly associated with factors related to socio-demographic, such as sex, educational level or age, as well as several health factors such as long-standing illness or physical activity.

Conclusions

When our data are compared to those from previous Spanish surveys carried out in 2003 and 2006, we can conclude that self-medication is increasing in Spain.

Consumer views on safety of over-the-counter drugs, preferred retailers and information sources in Sweden: after re-regulation of the pharmacy market

BACKGROUND

The availability of over-the-counter drugs (OTCs) has increased in Sweden since a re-regulation of the pharmacy market in 2009, through which non-pharmacy retailers became permitted to provide certain OTCs.

OBJECTIVE

To examine the adult general public's views on safety, purchasing and information channels, storage and disposal of OTCs in Sweden, three years after the re-regulation of the pharmacy market.

METHODS

A questionnaire study in 2012-13 in a stratified, random sample of all inhabitants in Sweden ≥ 18 years old.

RESULTS

Totally 8,302 people (42%) answered the questionnaire. Seven percent found OTCs completely harmless regardless of how they are being used, 18% felt they should be used only on health professionals' recommendation. Differences in how OTCs are perceived were however found with regards to respondents' country of birth, family type, educational level and income. The pharmacy was still the preferred OTC drug retailer by 83% of the respondents and preferred information source by 80% Reasons for preferred retailers were primarily due to out of habit (45%), counseling provided (35%), the product range (34%) and the confidence in staff (27%). Analgesics are the most common OTCs to have at home (90%). The bathroom cabinet is the primary site for storage (42%) and 16% throw their OTC leftovers in the trash.

CONCLUSIONS

The study population does not consider OTCs as harmless regardless of how they are used, but on the other hand feels they should not be taken on health professionals' recommendation only. The pharmacy is still the preferred retailer and information source, and there is room for further improvement in the storage and disposal of OTCs. A return of OTC drug leftovers to the pharmacy should be further encouraged. Due to several limitations, great caution should however be observed when generalizing the results to the adult population of Sweden.

Consumer preferences for over-the-counter drug retailers in the reregulated Swedish pharmacy market

Following a large regulatory reform in 2009, which ended the state's pharmacy monopoly, non-pharmacy retailers in Sweden today sell certain over-the-counter (OTC) drugs. The aim of this study was to investigate consumer preferences regarding OTC drug retailers and the reasons for choosing a pharmacy versus non-pharmacy retailer. We conducted a web survey aimed at Swedish adults. Out of a stratified sample of 4058 persons, 2594 agreed to take part (48% women; mean age: 50.3 years). Questions related to OTC drug use, retailer choice and factors affecting the participants' preferences for OTC drug retailers. Logistic regression was conducted to analyse OTC drug use and reasons for retailer choice in relation to sex, age and education. Nine in ten participants reported OTC drug use in the 6 months prior to the study. For their last OTC purchase, 76% had gone to a pharmacy, 20% to a grocery shop and 4% to a convenience store, gas station or online. Geographic proximity, opening hours and product range were reported as the most important factors in retailer choice. Counselling by trained staff was important to 57% of participants. The end of the state's pharmacy monopoly and the increase in number of pharmacies seem to have impacted more on Swedish consumers' purchase behaviours compared with the deregulation of OTC drug sales.

A literature review: polypharmacy protocol for primary care

The purpose of this literature review is to critically evaluate published protocols on polypharmacy in adults ages 65 and older that are currently used in primary care settings that may potentially lead to fewer adverse drug events. A review of OVID, CINAHL, EBSCO, Cochrane Library, Medline, and PubMed databases was completed using the following key words: protocol, guideline, geriatrics, elderly, older adult, polypharmacy, and primary care. Inclusion criteria were: articles in medical, nursing, and pharmacology journals with an intervention, protocol, or guideline addressing polypharmacy that lead to fewer adverse drug events. Qualitative and quantitative studies were included. Exclusion criteria were: publications prior to the year 1992. A gap exists in the literature. No standardized protocol for addressing polypharmacy in the primary care setting was found. Mnemonics, algorithms, clinical practice guidelines, and clinical strategies for addressing polypharmacy in a variety of health care settings were found throughout the literature. Several screening instruments for use in primary care to assess potentially inappropriate prescription of medications in the elderly, such as the Beers Criteria and the STOPP screening tool, were identified. However, these screening instruments were not included in a standardized protocol to manage polypharmacy in primary care. Polypharmacy in the elderly is a critical problem that may result in adverse drug events such as falls, hospitalizations, and increased expenditures for both the patient and the health care system. No standardized protocols to address polypharmacy specific to the primary care setting were identified in this review of the literature. Given the growing population of elderly in this country and the high number of medications they consume, it is critical to focus on the utilization of a standardized protocol to address the potential harm of polypharmacy in the primary care setting and evaluate its effects on patient outcomes.

Assessing a conceptual model of over-the-counter medication misuse, adverse drug events and health-related quality of life in an elderly population

AIM

The objectives of the present study were to test Spilker's quality of life model in the elderly population consuming over-the-counter (OTC) medications. It was hypothesized that OTC medication misuse increases adverse drug events (ADEs), ADEs as a result of OTC medication misuse decrease health-related quality of life (HRQoL) and the impact of OTC medication misuse on patients' HRQoL is fully medicated by ADEs associated with OTC medications.

METHODS

Data were used from a previously carried out cross-sectional study using survey instruments with elderly patients consuming OTC medications in Houston, Texas, USA. The presence/absence of OTC misuse was assessed by an expert panel based on patient reported information on drug use characteristics; ADE was self-reported and HRQoL was measured using the Short Form-12v2, which contains a physical component summary score (PCS) and a mental component summary score (MCS).

RESULTS

Of the 154 respondents, 18.2% misused OTC medications and 22.1% reported ADE as a result of OTC medications. The mean ± SD score of PCS and MCS was 40.6 ± 6.8 and 46.4 ± 7, respectively. The hypothesized framework provided a well-fitted solution to the data (χ(2)  = 1.387, d.f. = 2, P = 0.49; weighted root mean square residual = 0.317). Misuse of OTC medications significantly increased ADEs associated with OTC medications (β = 0.298) and increased ADEs significantly decreased patient reported PCS (β = -0.312), but not MCS (β = -0.213). OTC medication misuse indirectly decreased PCS and MCS by mediating the effect of an increase in ADE; however, the association was not statistically significant.

CONCLUSIONS

Misuse of OTC medications is highly associated with ADEs. ADEs are capable of decreasing the physical health of elderly patients.

“Doctor shopping and pharmacy hopping”: practice innovations relating to codeine

Purpose

– The misuse of pharmaceutical opioid analgesics is identified as a global public health concern. Codeine represents an interesting quandary in terms of its regulated status, with individuals varying in their metabolism of codeine, estimation of safe dosages, risk of adverse health consequences and abuse potential. Efforts to quantify and address hidden non-compliant medical codeine use, overuse and intentional misuse is compromised by availability to the public in prescribed and over the counter forms. The paper aims to discuss these issues.

Design/methodology/approach

– A review of literature on codeine use, misuse and dependence, and associated innovative medical and pharmacy interventions is presented, and was conducted as part of a larger scoping review on codeine.

Findings

– The review highlights the complexities associated with monitoring public health awareness of codeine's abuse potential, and customer/patients trends in non-compliant codeine use for therapeutic and recreational purposes. Aberrant codeine behaviours centre on visiting multiple doctors for prescriptions, repeated lost or stolen prescriptions, forging prescriptions and use of multiple pharmacies. Innovations to monitor misuse of codeine include national prescription databases and recent developments in real-time monitoring of dispensing activity.

Practical implications

– Further development of real-time monitoring processes with process evaluation is advised.

Originality/value

– This viewpoint is intended to demonstrate how efforts to quantify and address codeine use are compromised by its availability. It intends to encourage further policy and practitioner dialogue on how to monitor, support and intervene with consumers misusing codeine.

Medication and fall injury in the elderly population; do individual demographics, health status and lifestyle matter?

BACKGROUND

The simultaneous use of several medications is an important risk factor for injurious falls in older people. The aim of this study is to investigate the effect of the number of medications dispensed to elderly persons on fall injuries and to assess whether this relationship is explained by individual demographics, health habits and health status.

METHODS

A population-based, nested, case-control study on people 65 years and older (N = 20.906) was conducted using data from the Stockholm Public Health Cohort (SPHC) derived from self-administered surveys and linked at the individual level with various Swedish health registers. Fall injuries leading to hospitalization recorded in the Swedish National Patient Register (NPR) were considered as the outcome. The main exposure, obtained from the Swedish Prescribed Drug Register (SPDR), was the number of medications dispensed within 90 days prior to the injurious fall. The injury risk was estimated using adjusted odds ratios (ORs) from logistic regression. Results were adjusted by selected demographic, social circumstances, lifestyle and health status data extracted from the SPHC.

RESULTS

After adjusting for common risk factors within demographics, lifestyle, social circumstances and health status, using more than one medication increased the risk of fall injury but no clear dose-response relationship was observed, with point estimates ranging from 1.5-1.7 for the use of two, three, four or five or more medications as compared to using none. An increased risk remained, and was even elevated, after adjusting for the use of fall-risk-increasing drugs (FRIDs).

CONCLUSIONS

Using more than one medication affects the risk of injurious falls among older people. The effect of any given number of medications studied remains and is even strengthened after adjusting for individual demographics, health habits, health conditions and the use of FRIDs.

Does deregulation in community pharmacy impact accessibility of medicines, quality of pharmacy services and costs? Evidence from nine European countries

OBJECTIVE

To analyse the impact of deregulation in community pharmacy on accessibility of medicines, quality of pharmacy services and costs.

METHODS

We analysed and compared community pharmacy systems in five rather deregulated countries (England, Ireland, the Netherlands, Norway, Sweden) and four rather regulated countries (Austria, Denmark, Finland, Spain). Data were collected by literature review, a questionnaire survey and interviews.

RESULTS

Following a deregulation, several new pharmacies and dispensaries of Over-the-Counter (OTC) medicines tended to be established, predominantly in urban areas. Unless prevented by regulation, specific stakeholders, e.g. wholesalers, were seen to gain market dominance which limited envisaged competition. There were indications for an increased workload for pharmacists in some deregulated countries. Economic pressure to increase the pharmacy turnover through the sale of OTC medicines and non-pharmaceuticals was observed in deregulated and regulated countries. Prices of OTC medicines were not found to decrease after a deregulation in pharmacy.

CONCLUSIONS

Access to pharmacies usually increases after a deregulation but this is likely to favour urban populations with already good accessibility. Policy-makers are recommended to take action to ensure equitable accessibility and sustainable competition in a more deregulated environment. No association between pharmaceutical expenditure and the extent of regulation/deregulation appears to exist.

The practice of prescribing: discovering differences in what we tell patients about prescription medications

OBJECTIVE

This study explored patient recall of clinician presentation of information about prescription medication, looking specifically for communication patterns and differences by patient individual characteristics and by medication availability type.

METHODS

A cross sectional survey collected information about 216 patients' perceptions of clinician presentations of medication information.

RESULTS

Demographically, males recalled receiving more information about reasons, risks, and regimen in medication discussions. By medication type, patients reported receiving more medication information when the clinician presented a prescription-only medication as opposed to a medication that was also available over the counter.

CONCLUSION

Given the broad and unmonitored use of over-the-counter products, coupled with the increasing awareness of risks associated with many of these medications, it is concerning that patients report receiving less information about these products.

PRACTICE IMPLICATIONS

The emphasis on appropriate medication counseling should not be limited to medications available only by prescription. Prescribers should be mindful of these potential tendencies when discussing medications.

Safeguarding older adults from inappropriate over-the-counter medications: the role of community pharmacists

PURPOSE OF THE STUDY

To elicit the thought process or mental model that community pharmacists use when making recommendations on over-the-counter (OTC) medications to older adults and to elicit the current practices of community pharmacists in providing information, advice, and counseling to older adults about potentially inappropriate OTC medications.

DESIGN AND METHODS

Three separate focus groups with pharmacists were conducted with 5 to 8 pharmacists per group. A vignette about an elderly woman seeking an OTC sleep aid was used to elicit information that pharmacists seek to establish when making a recommendation. Focus groups were recorded, transcribed verbatim, and analyzed for themes using the initial and focused coding methods of grounded theory.

RESULTS

Community pharmacists' mental models were characterized by 2 similarities: a similarity in what community pharmacists seek to establish about patients and a similarity in when community pharmacists seek to establish it--the sequence in which they try to learn key details about patients. It was identified that pharmacists gather specific information about the patient's medication profile, health conditions, characteristics of the problem, and past treatments in order to make a recommendation. Community pharmacists recommended behavioral modifications and seeing their physician prior to recommending an OTC sleep aid, primarily due to medication safety concerns.

IMPLICATIONS

Pharmacists can play a key role in assisting older adults to select and use OTC medications.

Where to buy OTC medications? A cross-sectional survey investigating consumers' confidence in over-the-counter (OTC) skills and their attitudes towards the availability of OTC painkillers

OBJECTIVE

To examine consumers' confidence in their own, and also in other people's, over-the-counter (OTC) skills and to describe their attitude towards the availability of OTC painkillers. Moreover we examined the association between confidence in OTC skills and attitudes.

DESIGN

Cross-sectional survey. Mixed methods (postal and electronic) self-administered questionnaire.

PARTICIPANTS

Members of the Dutch Health Care Consumer Panel.

MAIN OUTCOME MEASURES

Consumers' confidence in their own, and in other people's, OTC skills was examined. Confidence was measured by three questions regarding obtaining information on, choosing and using OTC medication. Consumers' attitudes towards availability were assessed using six safety profiles, by asking which channel consumers prefer for each profile.

RESULTS

The response rate was 68% (n=972). Consumers feel confident about their own OTC skills (mean 3.74; 95% CI 3.69 to 3.79, on a 5-point Likert scale), but have less confidence in OTC skills of others (mean 2.92; 95% CI 2.88 to 2.96). Consumers are conservative in their attitudes towards the availability of OTC painkillers. Most consumers prefer painkillers to be available exclusively in pharmacies (41-71% per profile indicated pharmacy only). Moreover, there is an association between confidence in OTC skills and attitudes (p=0.005; β=-0.114). Consumers who are more confident about their own OTC skills prefer OTC painkillers to be more generally available.

CONCLUSIONS

Consumers feel confident about their own OTC skills. However, they would prefer painkillers with safety profiles resembling those currently available OTC, to be available as OTC in pharmacies exclusively. Consumers' confidence in the OTC skills of others is more consistent with their attitudes towards availability of OTC painkillers. Until consumers themselves realise that they are also one of the others, they may overestimate their own OTC skills, which may entail health risks.

Clinical pharmacology in old persons

The epidemiological transition, with a rapid increase in the proportion in the global population aged over 65 years from 11% in 2010 to 22% in 2050 and 32% in 2100, represents a challenge for public health. More and more old persons have multimorbidities and are treated with a large number of medicines. In advanced age, the pharmacokinetics and pharmacodynamics of many drugs are altered. In addition, pharmacotherapy may be complicated by difficulties with obtaining drugs or adherence and persistence with drug regimens. Safe and effective pharmacotherapy remains one of the greatest challenges in geriatric medicine. In this paper, the main principles of geriatric pharmacology are presented.

Risk factors associated with opioid medication misuse in community-dwelling older adults with chronic pain

OBJECTIVES

The aim of the study was to identify physical, psychological, and social risk factors associated with opioid medication misuse among community-dwelling older adults with chronic pain.

METHODS

Using a cross-sectional research design, a confidential survey was administered at 11 outpatient clinics affiliated with the Baltimore Veterans Affairs Medical Center and the University of Maryland Medical System. A sample of 163 older adults (response rate 80.7%) with chronic pain and receiving opioid medications provided demographic information and responded to survey items. Severity of pain, alcohol problems, physical disability, depressive symptoms, spirituality, social support, and social network were assessed. Descriptive statistics and exploratory regression analyses were employed to determine factors independently associated with misuse.

RESULTS

Higher levels of pain severity and depressive symptoms, and lower physical disability scores were significantly associated with increased risk of opioid medication misuse. Alcohol problems, spirituality, social support, and social network were not associated with opioid medication misuse.

DISCUSSION

High pain intensity scores may indicate undertreatment of pain or may represent a rationalization to justify opioid medication use. Higher levels of depressive symptoms have been noted in the chronic pain population and may contribute to misuse of opioid medications for psychic effects. Less physically disabled persons are more likely to misuse opioid medications or older person receiving multiple medications may wish to avoid potential adverse drug effects. While there was an association between lower levels of disability and higher risk for opioid medication misuse, a causal relationship could not be determined.

Factor structure of pain medication questionnaire in community-dwelling older adults with chronic pain

OBJECTIVES

This study was to develop a version of the Pain Medication Questionnaire (PMQ) specific to the elderly chronic pain population and to identify relevant subscales and items for that population. Exploratory factor analysis (EFA) was conducted to assess the factor structure of the PMQ, to eliminate items that are not appropriate for this population, and to improve ease of administration in the elderly population.

METHODS

Data were obtained through a survey administered to older adults with chronic pain who consumed opioid medications in a cross-sectional study at outpatient clinics affiliated with the Baltimore Veterans Affairs Medical Center and the University of Maryland Medical System. EFA was conducted on the PMQ in the geriatric chronic pain population, which was compared with the PMQ studies from the general chronic pain population.

RESULTS

A two-factor solution yielded Factor 1 with four items and Factor 2 with three items; 18 items did not load significantly on either factor, and only seven items loaded significantly on either factor. All of the chosen factor loadings ranged from 0.41 to 0.88.

CONCLUSION

  The findings suggest that, although a small number of the items were identified from the overall scale, they adequately explain two relatively unique factors pertaining to pain management among older adults. This preliminary study suggests that the seven-item PMQ may be useful in assessing opioid medication misuse in community-dwelling older adults with chronic pain. Future studies are needed to confirm the reliability, validity, and factor structure of this modified PMQ in the geriatric population.

Appropriate use of non-prescription ibuprofen: a survey of patients' perceptions and understanding

Objectives

The aim was to investigate patients' perceptions and understanding on the appropriate use of non-prescription ibuprofen.

Methods

In this pilot study, a self-administered anonymous survey was completed by 183 patients presenting at one of the eight selected community pharmacy premises in South Australia and the Northern Territory during the study. The questionnaire comprised items on: demographics (age, gender), current medications, frequency of ibuprofen use, medical consultations, reading manufacturer's printed dosage/warning instructions, sources from which drug information was gathered and understanding of common indications for ibuprofen.

Key findings

Sixty per cent of patients (n= 110/183), predominantly females, were currently on other medications and 64.5% of patients (n= 118/183) did not seek medical advice before using non-prescription ibuprofen. Seventy-one per cent (n= 130) of these patients had used ibuprofen for more than a year. The majority of patients did not provide precise answers for the common indications of ibuprofen. Sixty-six per cent of patients (n= 110) reported rarely or never reading manufacturer's printed warning instructions on the potential drug interactions or adverse effects associated with the use of the product.

Conclusions

Many patients are unaware that non-presciption analgesics such as ibuprofen can cause potentially serious adverse effects when used in combination with other common medications.

[Self-medication and the elderly. The reality of the home medicine cabinet]

OBJECTIVE

To estimate the prevalence of self-medication in the elderly, to describe the characteristics of self-medication and home medicine cabinets.

DESIGN

Cross-sectional descriptive study.

SETTING

An urban primary health care (PHC) centre in Spain.

PARTICIPANTS

A total of 240 patients 75 years of age or older.

MAIN MEASUREMENTS

A structured questionnaire filled in by home care nurses from April to June 2006. Self-medication was classified into 4 sub-groups: pharmacological or herbal, exclusively pharmacological, exclusively herbal and pharmacological and herbal. The study variables were: age, sex, living alone, number of chronic diseases, number of chronic prescriptions and medicine cabinet characteristics (drugs accumulation, expired drugs, chronic drugs out of prescription, location of medicine chest and periodic review). Other variables were: drug types, source, and acute/chronic reason for self-medication.

RESULTS

Self-medication frequency was 31,2% (95% CI, 26-36), with 22.9% (95% CI, 17.5-27.5) being pharmacological and 15.4% (95% CI, 23.1-17.3), herbal. The drugs most used in self-medication were analgesics (30.9%) and cold remedies (27.2%). The pharmacy was the most usual source (49.3%). A total of 41.6% contained drugs that were out of chronic prescription, and 34.4% accumulated more than three boxes of the same medication.

CONCLUSIONS

There is a significant prevalence of self-medication among the elderly. Accumulating drugs in homes is a very extensive practice. Pharmacists and PHC professionals need to be trained in the responsible use of chronic and self-medication. Although self-care has to be encouraged, PHC professionals must make their patients aware of the harmful effects of self-medication.

How much time does it take to prescribe a new medication?

OBJECTIVE

To measure the length of time spent discussing all aspects of new prescriptions and guideline-recommended aspects of counseling, and to evaluate factors associated with duration of discussion.

METHODS

We analyzed tape recordings in which 181 patients received 234 new medication prescriptions from 16 family physicians, 18 internists, and 11 cardiologists in 2 healthcare systems in Sacramento, California between January and November 1999.

RESULTS

Of the mean total visit time of 15.9min (S.D.=434s), a mean of 26s (S.D.=28s) was allocated to guideline-recommended components and a mean of 23s (S.D.=25s) was allocated to discussion of all other aspects of new prescription medications. The majority of time spent discussing individual new prescriptions was dedicated to: medication purpose or justification, directions and duration of use, and side effects. On average, more complete discussion of these components was associated with more time. More time was spent talking about guideline-recommended information if patients were in better health, if there was a third party in the room, and if the medication belonged to a psychiatric, compared to an ear, nose, throat medication class. Less time was spent discussing over-the-counter (OTC) medications and those prescribed to patients with a previous visit to the physician.

CONCLUSION

Higher quality information transmission between physicians and patients about new medications requires more time, and may be difficult to achieve in short office visits.

PRACTICE IMPLICATIONS

Time-compressed office visits may need to be redesigned to promote improved provider-patient communication about new medications.

Over-the-counter medication use in older adults

Use of over-the-counter (OTC) medications is becoming more of a problem in the older adult population as the push to deregulate prescription medications grows. This article summarizes the side effects, adverse reactions, and medication interactions older adults face when using some common OTC medications.

Should cholesterol-lowering medications be available in Canada without a prescription?

Cardiovascular disease (CVD) presents an enormous and growing burden on the Canadian health care system. Elevated serum low-density lipoprotein cholesterol levels are an established, major risk factor in the development of premature CVD. There is strong evidence that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or statins, significantly lower both low-density lipoprotein cholesterol levels and CVD risk. However, there is currently a treatment gap, in that a large segment of the population who should be receiving statins due to elevated serum cholesterol levels are not. Individuals at moderate risk of developing CVD represent one large population segment that is currently being undertreated. This group may be a candidate for receiving over-the-counter (OTC) or behind-the-counter (BTC) statins, which may be a suitable primary prevention strategy. Nonetheless, it must be noted that hypercholesterolemia is a complex, chronic condition that must be carefully managed and requires close consultation with a health care practitioner. The advantages and disadvantages of OTC or BTC statin usage must therefore be carefully weighed before any potential introduction of OTC or BTC statins in Canada.

Practical considerations for the treatment of elderly patients with migraine

Treatment of migraine presents special problems in the elderly. Co-morbid diseases may prohibit the use of some medications. Moreover, even when these contraindications do not exist, older patients are more likely than younger ones to develop adverse events. Managing older migraine patients, therefore, necessitates particular caution, including taking into account possible pharmacological interactions associated with the greater use of drugs for concomitant diseases in the elderly. Paracetamol (acetaminophen) is the safest drug for symptomatic treatment of migraine in the elderly. Use of selective serotonin 5-HT(1B/1D) receptor agonists ('triptans') is not recommended, even in the absence of cardiovascular or cerebrovascular risk, and NSAID use should be limited because of potential gastrointestinal adverse effects. Prophylactic treatments include antidepressants, beta-adrenoceptor antagonists, calcium channel antagonists and antiepileptics. Selection of a drug from one of these classes should be dictated by the patient's co-morbidities. Beta-adrenoceptor antagonists are appropriate in patients with hypertension but are contraindicated in those with chronic obstructive pulmonary disease, diabetes mellitus, heart failure and peripheral vascular disease. Use of antidepressants in low doses is, in general, well tolerated by elderly people and as effective, overall, as in young adults. This approach is preferred in patients with concomitant mood disorders. However, prostatism, glaucoma and heart disease make the use of tricyclic antidepressants more difficult. Fewer efficacy data in the elderly are available for selective serotonin reuptake inhibitors, which can be tried in particular cases because of their good tolerability profile. Calcium channel antagonists are contraindicated in patients with hypotension, heart failure, atrioventricular block, Parkinson's disease or depression (flunarizine), and in those taking beta-adrenoceptor antagonists and monoamine oxidase inhibitors (verapamil). Antiepileptic drug use should be limited to migraine with high frequency of attacks and refractoriness to other treatments. Promising additional strategies include ACE inhibitors and angiotensin II type 1 receptor antagonists because of their effectiveness and good tolerability in patients with migraine, particularly in those with hypertension. Because of its favourable compliance and safety profile, botulinum toxin type A can be considered an alternative treatment in elderly migraine patients who have not responded to other currently available migraine prophylactic agents. Pharmacological treatment of migraine poses special problems in regard to both symptomatic and prophylactic treatment. Contraindications to triptan use, adverse effects of NSAIDs, and unwanted reactions to some antiemetics reduce the list of drugs available for the treatment of migraine attacks in elderly patients. The choice of prophylactic treatment (beta-adrenoceptor antagonists, calcium channel antagonists, antiepileptics, and more recently, some antihypertensive drugs) is influenced by co-morbidities and should be directed at those drugs that are believed to have fewer adverse effects and a better safety profile. Unfortunately, for most of these drugs, efficacy studies are lacking in the elderly.

The decision-making process of us food and drug administration advisory committees on switches from prescription to over-the-counter status: A comparative case study

BACKGROUND

The US Food and Drug Administration (FDA) and FDA advisory committees have been under increasing scrutiny as a result of media attention to safety concerns.

OBJECTIVE

This article compares the decision-making process of the FDA's Nonprescription Drugs Advisory Committee (NDAC) in 3 cases of a proposed switch from prescription to over-the-counter (OTC) status involving a nicotine replacement therapy product, 2 statins, and an emergency oral contraceptive.

METHODS

This comparative case study reviewed written transcripts and slides from 4 NDAC committee meetings and a digital video disc recording of a later meeting held to reconsider one of the proposed switches. The focus was on the committee's discussion and deliberation processes. Content analysis and iterative coding were used to assess the level of participation by committee members and the extent to which committee discussion adhered to both the key draft list questions provided by the FDA and the published DeLap criteria for switches from prescription to OTC status. Other major themes and discussion topics were identified, and the voting process was analyzed.

RESULTS

In the absence of clearly defined meeting procedures, the advisory committees developed their own procedural standards. There were major differences between meetings in terms of the extent of discussion of the key draft list questions and adherence to the DeLap principles, discussion of other themes and topics, and voting methods. In each case, at least 1 major topic of discussion was not directly related to safety, efficacy, or self-use. Additional identified themes were the public health significance of a switch to OTC status, costs, and access.

CONCLUSIONS

Variability in processes created discrepancies in the decision-making criteria used by the NDAC committees. There is a need to establish structured procedures to achieve an optimal level of uniformity and transparency in advisory committee processes.