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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: 0] [Impact Index Per Article: 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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Predicting response to rFVIIa in neonates with intractable bleeding or severe coagulation disturbances. J Pediatr Hematol Oncol 2013; 35:221-6. [PMID: 23511491 DOI: 10.1097/mph.0b013e318286d27e] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To date, clinical experience with recombinant factor VIIa (rFVIIa) in neonates is rather limited because of the lack of controlled studies. ΑIM: The objective of this study was to present further experience from our center with regard to the use of rFVIIa in newborns with severe bleeding or coagulopathy resistant to conventional therapy and to determine factors affecting the clinical outcome. METHODOLOGY We performed a retrospective data analysis of 29 neonates with intractable bleeding or severe coagulation disturbances. All patients received 100 μg/kg of rFVIIa per dose bolus intravenously (maximum of 23 doses), as rescue procedure after other interventions had failed to achieve hemostasis. RESULTS Fourteen neonates survived (group A), whereas 15 died (group B). There was no difference in birth weight, gestational age, and bleeding site and causes between the 2 groups. In the neonates who survived, rFVIIa had been administered earlier in the disease process (<24 h of beginning of bleeding) compared with those who died (P=0.009). In all 29 neonates, international normalized ratio was directly restored (from 2.99±1.4 before rFVIIa administration to 1.6±1.1 afterward, P<0.001) and prothrombin time and activated partial thromboplastin time were significantly decreased after administration of rFVIIa (from 28 to 16.4 and from 180 to 67, respectively; P=0.001 and 0.05, respectively). Blood products administered were significantly less in group A than in group B, as time from the beginning of bleeding to the administration of rFVIIa was significantly less in group A than in group B. Neither acute adverse events nor thromboembolic complications were observed. CONCLUSIONS In this neonatal group with intractable bleeding and/or severe coagulation disturbances, rFVIIa was more effective in early intervention as rescue therapy, without any adverse events in all neonates. Upon failure to achieve hemostasis with initial administration of blood products, fast intervention with rFVIIa could be considered in neonates with serious bleeding and coagulation disorders.
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Masotti L, Di Napoli M, Godoy DA, Rafanelli D, Liumbruno G, Koumpouros N, Landini G, Pampana A, Cappelli R, Poli D, Prisco D. The practical management of intracerebral hemorrhage associated with oral anticoagulant therapy. Int J Stroke 2011; 6:228-40. [PMID: 21557810 DOI: 10.1111/j.1747-4949.2011.00595.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Oral anticoagulant-associated intracerebral hemorrhage is increasing in incidence and is the most feared complication of therapy with vitamin K1 antagonists. Anticoagulant-associated intracerebral hemorrhage has a high risk of ongoing bleeding, death, or disability. The most important aspect of clinical management of anticoagulant-associated intracerebral hemorrhage is represented by urgent reversal of coagulopathy, decreasing as quickly as possible the international normalized ratio to values ≤1·4, preferably ≤1·2, together with life support and surgical therapy, when indicated. Protocols for anticoagulant-associated intracerebral hemorrhage emphasize the immediate discontinuation of anticoagulant medication and the immediate intravenous administration of vitamin K1 (mean dose: 10-20 mg), and the use of prothrombin complex concentrates (variable doses calculated estimate circulating functional prothrombin complex) or fresh-frozen plasma (15-30 ml/kg) or recombinant activated factor VII (15-120 μg/kg). Because of cost and availability, there is limited randomized evidence comparing different reversal strategies that support a specific treatment regimen. In this paper, we emphasize the growing importance of anticoagulant-associated intracerebral hemorrhage and describe options for acute coagulopathy reversal in this setting. Additionally, emphasis is placed on understanding current consensus-based guidelines for coagulopathy reversal and the challenges of determining best evidence for these treatments. On the basis of the available knowledge, inappropriate adherence to current consensus-based guidelines for coagulopathy reversal may expose the physician to medico-legal implications.
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Affiliation(s)
- Luca Masotti
- Internal Medicine, Cecina Hospital, Cecina, Italy Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy.
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Curry N, Stanworth S, Hopewell S, Dorée C, Brohi K, Hyde C. Trauma-induced coagulopathy--a review of the systematic reviews: is there sufficient evidence to guide clinical transfusion practice? Transfus Med Rev 2011; 25:217-231.e2. [PMID: 21377318 DOI: 10.1016/j.tmrv.2011.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Systematic reviews are accepted as a robust and less biased means of appraising and synthesizing results from high-quality studies. This report collated and summarized all the systematic review evidence relating to the diagnosis and management of trauma-related coagulopathy and transfusion, thereby covering the widest possible body of literature. We defined 4 key clinical questions: (1) What are the best methods of predicting and diagnosing trauma-related coagulopathy? (2) Which methods of clinical management correct coagulopathy? (3) Which methods of clinical management correct bleeding? and (4) What are the outcomes of transfusion in trauma? Thirty-seven systematic reviews were identified through searches of MEDLINE (1950-July 2010), EMBASE (1980-July 2010), The Cochrane Library (Issue 7, 2010), National Guidelines Clearing House, National Library for Health Guidelines Finder, and UKBTS SRI Transfusion Evidence Library (www.transfusionevidencelibrary.com). The evidence from the systematic review literature was scanty with many gaps, and we were not able to conclusively answer any of our 4 questions. Much more needs to be understood about how coagulopathy and bleeding in trauma are altered by transfusion practices and, most importantly, whether this translates into improved survival. There is a need for randomized controlled trials to answer these questions. The approach described in this report provides a framework for incorporating new evidence.
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Affiliation(s)
- Nicola Curry
- NHS Blood and Transplant, Oxford Radcliffe Hospitals NHS Trust and University of Oxford, UK.
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Rama-Maceiras P, Ingelmo-Ingelmo I, Fàbregas-Julià N, Hernández-Palazón J. Rol del factor VII recombinante activado en pacientes neuroquirúrgicos y neurocríticos. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70016-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Hong I, Stachnik J. Unlabeled uses of factor VIIa (recombinant) in pediatric patients. Am J Health Syst Pharm 2010; 67:1909-19. [DOI: 10.2146/ajhp090667] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Irene Hong
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, NY; when this article was written, she was Postgraduate Year 2 Drug Information Resident, College of Pharmacy, University of Illinois at Chicago, Chicago
| | - Joan Stachnik
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago
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The Relationship Between Mortality and Preexisting Cardiac Disease in 5,971 Trauma Patients. ACTA ACUST UNITED AC 2010; 69:645-52. [DOI: 10.1097/ta.0b013e3181d8941d] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gerritsen-van Schieveen P, Malkoun I, Monasson S, Rougeot E, Kantelip JP. [Arterial and venous thrombosis by eptacog alpha. Review of the literature about one case]. Therapie 2010; 65:139-41. [PMID: 20578338 DOI: 10.2515/therapie/2010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Grottke O, Henzler D, Rossaint R. Activated recombinant factor VII (rFVIIa). Best Pract Res Clin Anaesthesiol 2010; 24:95-106. [DOI: 10.1016/j.bpa.2009.09.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ageno W, Garcia D, Aguilar MI, Douketis J, Finazzi G, Imberti D, Iorio A, Key NS, Lim W, Marietta M, Prisco D, Sarode R, Testa S, Tosetto A, Crowther M. Prevention and treatment of bleeding complications in patients receiving vitamin K antagonists, part 2: Treatment. Am J Hematol 2009; 84:584-8. [PMID: 19610020 DOI: 10.1002/ajh.21469] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Sartori MT, Imbergamo S, Zanon E, Bonaccorso G, Pittoni G, Feltracco P, Ori C, Pagnan A, Cella G. Effect of Recombinant Activated Factor VII in Critical Bleeding: Clinical Experience of a Single Center. Clin Appl Thromb Hemost 2009; 15:628-35. [DOI: 10.1177/1076029609335909] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Recombinant activated factor VII (rFVIIa) has been successfully used ‘‘off-label’’ in patients with refractory life-threatening hemorrhage. Intravenous rFVIIa was given to 31 patients unresponsive to standard therapy with blood products and surgical reexploration, who were bleeding due to trauma, surgery, organ transplantation, liver cirrhosis, ruptured uterus. We recorded their coagulation and hematologic profiles, acid-base balance, blood loss, number of red blood cells (RBC), plasma and platelet transfusions, complications, and survival. rFVIIa (mean dose 132.2 ± 56.3 μg/kg) effectively contained the hemorrhage in 28/31 (90.3%) cases, with a mean reduction in blood loss from 12.4 ± 10.2 to 2.7 ± 2.2 L (P < .0001). The need for RBC, platelet, and plasma transfusion decreased significantly after rFVIIa, with a consequent significant improvement in clotting of test hematocrit, pH, and bicarbonates. Four patients had adverse events potentially related to rFVIIa. The survival rates after 1 and 30 days were 48.4% and 29.1%, respectively.
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Affiliation(s)
- Maria Teresa Sartori
- Second Chair Internal Medicine, Department of Cardiologic, Thoracic and Vascular Sciences, University of Padua, Italy,
| | - Silvia Imbergamo
- Second Chair Internal Medicine, Department of Cardiologic, Thoracic and Vascular Sciences, University of Padua, Italy
| | - Ezio Zanon
- Second Chair Internal Medicine, Department of Cardiologic, Thoracic and Vascular Sciences, University of Padua, Italy
| | | | - Giovanni Pittoni
- Department of Anesthesiology and Critical Care Medicine, University of Padua, Italy
| | - Paolo Feltracco
- Department of Pharmacology and Anesthesia, University of Padua, Italy
| | - Carlo Ori
- Department of Pharmacology and Anesthesia, University of Padua, Italy
| | - Antonio Pagnan
- Second Chair Internal Medicine, Department of Cardiologic, Thoracic and Vascular Sciences, University of Padua, Italy
| | - Giuseppe Cella
- Second Chair Internal Medicine, Department of Cardiologic, Thoracic and Vascular Sciences, University of Padua, Italy
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Ingelmo Ingelmo I, Rama-Maceiras P, Fàbregas Julià N, Hernández Palazón J. [Use of activated recombinant factor VII in patients with brain injury or undergoing brain surgery]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:339-342. [PMID: 19725340 DOI: 10.1016/s0034-9356(09)70405-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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