Unlicensed and off-label drug use in a Swiss paediatric university hospital

Development of the Swiss Database for dosing medicinal products in pediatrics

In daily paediatrics, drugs are commonly used off-label, as they are not approved for children. Approval is lacking because the required clinical studies were limited to adults in the past. Without clinical studies, evidence-based recommendations for drug use in children are limited. Information on off-label drug dosing in children can be found in different handbooks, databases and scientific publications but the dosing recommendations can differ considerably. To improve safety and efficacy of drugs prescribed to children and to assist the prescribers, stakeholders in Swiss paediatrics started a pilot project, supported by the Federal Office of Public Health, with the aim to create a database, providing healthcare professionals with so called "harmonised" dosage recommendations based on the latest available scientific evidence and best clinical practice. A standardised process for dosage harmonisation between paediatric experts was defined, guided and documented in an electronic tool, developed for this purpose. As proof of principle, a total of 102 dosage recommendations for 30 different drugs have been nationally harmonised in the pilot phase considering the current scientific literature and the approval of the most experienced national experts in the field.Conclusion: This approach paved the way for unified national dosage recommendations for children. Reaching the project's milestones fulfilled the prerequisites for funding and starting regular operation of SwissPedDose in 2018. Since then, the database was extended with recommendations for 100 additional drugs. What is Known: • Prescribing off-label is a common practice among paediatricians, as many drugs are still not authorised for use in children. • Some countries developed national drug formularies providing off-label dosage recommendations. What is New: • Comparison of published dosage recommendations in known drug handbooks and online databases show substantial differences and heterogeneity, revealing the need for harmonisation. • The design of a tool for standardised harmonisation of dosage recommendations, based on information collected on currently applied dosages, latest scientific evidence and the approval of experts.

Description of a clinical decision support tool with integrated dose calculator for paediatrics

Medication errors, especially dosing errors are a leading cause of preventable harm in paediatric patients. The paediatric patient population is particularly vulnerable to dosing errors due to immaturity of metabolising organs and developmental changes. Moreover, the lack of clinical trial data or suitable drug forms, and the need for weight-based dosing, does not simplify drug dosing in paediatric or neonatal patients. Consequently, paediatric pharmacotherapy often requires unlicensed and off-label use including manipulation of adult dosage forms. In practice, this results in the need to calculate individual dosages which in turn increases the likelihood of dosing errors. In the age of digitalisation, clinical decision support (CDS) tools can support healthcare professionals in their daily work. CDS tools are currently amongst the gold standards in reducing preventable errors. In this publication, we describe the development and core functionalities of the CDS tool PEDeDose, a Class IIa medical device software certified according to the European Medical Device Regulation. The CDS tool provides a drug dosing formulary with an integrated calculator to determine individual dosages for paediatric, neonatal, and preterm patients. Even a technical interface is part of the CDS tool to facilitate integration into primary systems. This enables the support of the paediatrician directly during the prescribing process without changing the user interface.Conclusion: PEDeDose is a state-of-the-art CDS tool for individualised paediatric drug dosing that includes a certified calculator. What is Known: • Dosing errors are the most common type of medication errors in paediatric patients. • Clinical decision support tools can reduce medication errors effectively. Integration into the practitioner's workflow improves usability and user acceptance. What is New: • A clinical decision support tool with a certified integrated dosing calculator for paediatric drug dosing. • The tool was designed to facilitate integration into clinical information systems to directly support the prescribing process. Any clinical information system available can interoperate with the PEDeDose web service.

Switzerland's Narcotics Regulation Jungle: Off-Label Use, Counterfoil Prescriptions, and Opioid Agonist Therapy in the French-Speaking Cantons

The word "narcotic" is often first associated with "illicit drugs". Yet, many "narcotic" and psychotropic substances are, in fact, medicines. Controlled medicines (CM) are products that meet the legal definition of both a "narcotic" under the Swiss Narcotics Act and of a medicine under the Therapeutic Products Act. We aim to examine how similar and how different, respectively, the implementation of CM regulations is throughout French-speaking Switzerland. Based on a legal analysis of the cantonal regulations, we conducted semi-structured interviews with cantonal pharmacists and cantonal physicians. We asked them how they perceive and implement the federal legal requirements. We find that some of these requirements have fallen into disuse, notably the federal duty to notify off-label use of CM. We observe that counterfoil prescriptions in their current paper format are a veritable data graveyard in the sense that they are not actively used to monitor or supervise the market. Moreover, we detect different conditions for opioid agonist treatment authorization. Some cantons require additional physicians' training or written commitments by the person treated. Our mapping of the CM regulation implementation can serve as a basis for cantons to review their practices.

Extent, reasons and consequences of off-labeled and unlicensed drug prescription in hospitalized children: a narrative review

BACKGROUND

Off-label and unlicensed prescriptions pose a severe safety concern among the pediatric population. We aimed to summarize the up-to-date evidence on the extent, reasons, and consequences of off-label and unlicensed drugs in hospitalized pediatric patients.

METHODS

We systematically searched PubMed, EMBASE, SCOPUS, Web of Science and Google Scholar between 1990 and 2020 in which the last search was conducted on 12 February 2021. We included studies with the following inclusion criteria: (1) observational studies in design; (2) target population was hospitalized pediatric patients whether admitted in the intensive care unit or in the general ward; (3) study reporting the prevalence of off-label, unlicensed prescriptions or both; and (4) published in English.

RESULTS

A total of 47 studies were eligible for inclusion. The proportion of off-label and unlicensed prescriptions ranged from 7.4% to 99.5% and 0.1% to 74.4%, respectively. The most frequent category of off-label prescriptions was prescription outside the age range, with the most commonly reported reason for off-label prescriptions being the lack of information specifically for pediatrics on the drug information leaflets. The consequences of off-label and unlicensed prescriptions ranged from minor and bearable skin reactions to debilitating renal failure, risking deaths.

CONCLUSIONS

Off-label and unlicensed prescriptions are extensive and require progressively meditative interventions. However, the pediatric population is currently a "therapeutic orphan". Unless adequate pediatric clinical trials and licensed drugs become available, off-label and unlicensed drug prescription should not entirely be banned but rather promoted in an organized manner.

Attitudes, knowledge and views on off-label prescribing in children among healthcare professionals in Malaysia

Background Off-label prescribing in children is associated with several prerequisites such as ensuring sound and scientific evidence and obtaining written consent prior to use of off-label drugs to ensure that protection is provided to patients and healthcare professionals. Adherence to the pre-requisites depends on the attitude, views and knowledge of the pharmacists and doctors involved in this practice. Objective To explore the attitudes, knowledge and views on off-label prescribing in children among hospital-based pharmacists and paediatric doctors. Setting The study was conducted in a 620-bedded general hospital located in the urban area of central Peninsular Malaysia. Method Face to face, semi-structured interviews with 12 pharmacists and 12 paediatric doctors. Interviews were audio-recorded, transcribed and analysed using constant comparison method. Main outcome measure Themes surrounding hospital-based pharmacists' and paediatric doctors' attitude, knowledge and views on off-label prescribing in children. Results Four themes were derived: knowledge on off-label prescribing in children, views on off-label prescribing in children, attitude towards off-label prescribing in children and guidance on off-label prescribing in children. Conclusion There is a need to increase the knowledge of hospital-based pharmacists and paediatric doctors and address several concerns on off-label prescribing in children. The decision to prescribe or dispense off-label drugs involved collective decision-making mechanisms and guidance is required with regards to offlabel prescribing in children.

Stability of prostaglandin E1 solutions stored in polypropylene syringes for continuous intravenous administration to newborns

Objective

We aimed to monitor the physicochemical stability of prostaglandin E₁ (PGE₁) 1.5 and 15 µg/mL in 10% dextrose stored in polypropylene syringes.

Methods

We developed a liquid chromatography-high resolution mass spectrometry (LC-HRMS) method to detect and quantify levels of PGE₁. Method selectivity was performed with a mixture of PGE₁ and its degradation products. Forced degradation tests were performed to determine which degradation products were most likely to form. PGE₁ injection solutions in 10% dextrose were stored in unprotected and shielded-from-light polypropylene syringes in a climatic chamber. Samples were taken immediately after preparation (T₀) and after 24, 48, 72 and 168 hours for analysis. PGE₁ solutions were considered stable if ≥90.0% of the initial concentration was retained.

Results

The LC-HRMS method was validated in the range of 0.086-0.200µg/mL PGE₁ with trueness values between 98.2% and 100.3%, and repeatability and intermediate precision values of <2.2%and <4.7%, respectively. The quantification and detection limits of the method were 0.086 and 0.026µg/mL, respectively. PGE₁ and its degradation products were resolved chromatographically. PGE₁ injection solutions were≥90.0%stable after 48hours in unprotected from light (UPL) syringes. The solutions remained clear without precipitation, colour or pH modification and subvisible particles within the permitted levels. Prostaglandin A₁ was the sole degradation product observed.

Conclusions

A LC-HRMS method to evaluate PGE₁ stability in a 10% dextrose was developed and validated. PGE₁ 1.5 and 15µg/mL in 10% dextrose solution are stable for 48hours when stored at 30ºC in UPL polypropylene syringes.

Cross-sectional survey of off-label and unlicensed prescribing for inpatients at a paediatric teaching hospital in Western Australia

OBJECTIVES

To evaluate the prevalence of off-label and unlicensed prescribing in inpatients at a major paediatric teaching hospital in Western Australia and to identify which drugs are commonly prescribed off-label or unlicensed, including factors influencing such prescribing.

METHODS

A retrospective cross-sectional study was conducted in June, 2013. Patient and prescribing data were collected from 190 inpatient medication chart records which had been randomly selected from all admissions during the second week of February 2013. Drugs were categorised as licensed, off-label or unlicensed, according to their approved Australian registration product information (PI). All drugs were classified according to the Anatomical Therapeutic Chemical (ATC) code.

RESULTS

There were 120 male and 70 female inpatients. The average age was 6.0 years (± 4.7). The study included 1160 prescribed drugs suitable for analysis. The number of drugs prescribed per patient ranged from 1 to 25 with an average of 6.1 (± 4.3). More than half (54%) were prescribed off-label. Oxycodone, clonidine, parecoxib and midazolam were always prescribed off-label. The most common off-label drugs were ondansetron (18.5%), fentanyl (12.9%), oxycodone (8.8%) and paracetamol (6.1%). Many ATC classifications included high off-label proportions especially the genitourinary system and sex hormones, respiratory system drugs, systemic hormonal preparations and alimentary tract and metabolism drugs.

CONCLUSIONS

This study highlights that prescribing of paediatric drugs needs to be better supported by existing and new evidence. Incentives should be established to foster the conduct of evidence-based studies in the paediatric population. The current level of off-label prescribing raises issues of unexpected toxicity and adverse drug effects in children that are in some cases severely ill.

Pattern and extent of off-label and unlicensed drug use in neonatal intensive care units in Iran

Background

Many newborns may need to be hospitalized and receive drugs during the first days of their lives. These drugs are fundamentally prescribed as off-label and unlicensed. This study aimed to investigate the amount of these kinds of drugs administered in the Neonatal Intensive Care Units (NICUs) of Abuzar and Imam Khomeini Teaching Hospitals in Ahvaz, Iran.

Methods

This was a 3-month descriptive, cross-sectional study with retrospective nature in which 193 hospitalized newborns were studied. Demographic data were extracted from the patients’ files. The drugs were classified as off-label, unlicensed or licensed according to the Pediatric & Neonatal Dosage Handbook (Lexicomp®, 22nd Edition).

Results

In total, 1049 prescriptions were registered for the 193 hospitalized newborns (term and preterm). For each newborn, the mean numbers of prescriptions and drugs received were 5.4 and 4.5, respectively. The mean numbers of prescriptions and drugs were greater for preterm newborns.

Of the total 1049 prescriptions, 38.1% were off-label and 1.9% were unlicensed. Of the 193 newborns, 85% received at least one off-label or unlicensed prescription. Off-label prescriptions were mostly related to dose (44.8%) and dosing interval (36.5%). Most off-label drugs were antibiotics (mainly Gentamicin). Albuterol was used off-label in 100% of the cases.

Conclusions

The results of the present study show that the prescription of off-label and unlicensed drugs in NICUs is as high in Iran as in other countries. This suggests that it is necessary to provide information to neonatologists to decrease the prescription of off-label and unlicensed drugs.

A survey of medicine use in children and adolescents in Austria

Aims of this survey were to evaluate prescription patterns for children and adolescents in primary and hospital care settings in Austria and to identify the medicines used most frequently in this population. Prescription data were assessed for the year 2014: for primary care, reimbursement data were obtained from Austrian health insurances; for hospital care, information on medicines dispensed to pediatric wards from hospital pharmacies. Frequencies of medicine use were analyzed by Anatomical Therapeutic Chemical classification system, age groups, and care setting. In primary care, anti-infectives (25%) and medicines for the respiratory system (14%) and for the nervous system (13%); in hospitals, anti-infectives (23%) and medicines for the nervous system (13%) and alimentary tract (12%) were prescribed most frequently. Amoxicillin/beta-lactamase inhibitor, ibuprofen, and paracetamol were the most frequent substances in both primary and hospital care settings. Based on the top 80% prescribed substances, a hit list of 150 pediatric medicines was defined for Austria.

CONCLUSION

This is the first representative and comprehensive survey of medicine use in children and adolescents in Austria, allowing comparison of prescription patterns to other European countries and assessing temporal trends in the future. Moreover, it serves as basis for planned measures to improve rational use of pediatric medicines. What is Known: • Large knowledge gaps exist for medicine use in children and adolescents concerning appropriate dosing, efficacy, and safety aspects. • Off-label medicine use is common in the treatment of children and adolescents. What is New: • We present a comprehensive survey of current prescription patterns for children and adolescents in Austria and define a hit list of pediatric medicines, as basis for developing an evidence-based information platform for health care professionals. • Anti-infectives, medicines for respiratory tract system, and pain medication are most frequently prescribed.

Use of off-label and unlicensed medicines in neonatal intensive care

Purpose

To evaluate the use of off-label and unlicensed medicines in a neonatal intensive care unit (NICU) of a teaching maternity hospital specialized in high risk pregnancy.

Methods

A prospective cohort study was conducted between August 2015 and July 2016. All newborns admitted to the NICU who had at least one medication prescribed and a hospital stay longer than 24 hours were included. The classification of off-label and unlicensed drugs for the neonatal population was done according to the information of Food and Drug Administration.

Results

A total of 17421 medication items were analyzed in 3935 prescriptions of 220 newborns. The proportion of newborns exposed to off-label drugs was 96.4%, and to unlicensed medicines was 66.8%. About one-half (49.3%) of the medication items were off-label and 24.6% were unlicensed. The main reason for off-label and unlicensed classification was, respectively, frequency of administration and the administration of adaptations of pharmaceutical forms.

Conclusions

Although there are actions to encourage the development of pharmacological studies with neonates, this study observed a high rate of prescription and exposure of newborns to off-label and unlicensed drugs in NICUs and pointed out areas of neonatal therapy that require scientific investment.

Unlicensed and off-label use of drugs in pediatric surgical units at tertiary care hospitals of Pakistan

Background Unlicensed and off-label prescribing practice is global dilemma around the world. This pioneering study was designed to determine unlicensed and off-label use of drug in surgical wards of tertiary care hospitals of Pakistan. Objective To assess unlicensed and off-label use of drugs in pediatric surgical unit at three tertiary care hospitals in Peshawar, Pakistan. Setting Two government and one private tertiary care hospitals in Pakistan. Method Drug profiles of 895 patients from three different clinical settings were evaluated for unlicensed and off-label use of drugs using Micromedex DRUGDEX. Main outcome measure Characteristics of the unlicensed and off-label drug prescriptions. Result Total of 3168 prescribed drugs were analyzed in this study. Indication (38.7%) and dose (34.8%) were the most frequent off-label categories. In comparison with the corresponding reference categories, infants and children, male patients and having less than five prescribed drugs were significant predictors of unlicensed prescriptions. In comparison with the corresponding reference categories, significant predictors of off-label drug prescribing were children younger than two year, children between 2-12 years, patient staying at hospital less than 5 days and patients having less than five prescribed drugs. Conclusion The prevalence of unlicensed and off-label drug prescriptions are high at pediatric surgical ward of tertiary care hospitals. More awareness of the efficacy and safety of drugs are required in pediatrics. In addition, new formulations with advanced dosing for children are also required to minimize the risk of adverse outcomes.

Off-label and unlicensed medicines to hospitalised children in Norway

Objectives

The aim of this study was to investigate the use of off‐label (OL) and unlicensed (UL) medicines to hospitalised children in Norway, to add to the current knowledge on use of medicines in this vulnerable patient group.

Methods

The study was performed as a cross‐sectional prospective study. Medication was classified as on‐ or off‐label based on the comparison with the SmPC regarding age, indication, dosage, route of administration and handling of the product. UL products were classified as imported or pharmacy produced.

Key findings

More than 90% of children receiving medicines in our study were given OL or UL medicines. More patients received OL (83%) than UL (59%). Route of administration was the most frequently observed OL category. The vast majority of the OL prescriptions were for ‘off‐patent’ products. One‐third of products prescribed were UL.

Conclusions

The study confirms that medicines to children in hospital to a significant degree are being used outside or without authorisation, in spite of recent paediatric regulatory initiatives. More data are still needed on efficacy and safety of medicines used in children, data to be incorporated in the SmPC. In addition, suitable formulations are needed to ensure optimal dosing and adherence without risky manipulations.

Magistral drugs in hospitalized newborns and children

OBJECTIVE

Study the use of magistral oral solutions and suspensions in infants and children at a university hospital.

METHODS

This is a descriptive study based on the analysis of the assessed hospital's magistral drug request forms regarding the patients in the neonatal ICU, Obstetrics, Pediatrics and Pediatric Emergency from January 2012 to December 2013. The frequency of drug requests and dispensation was evaluated and the consumption of each active ingredient of the preparations was expressed as number of "infant defined daily dose" (iDDD) and of iDDD/100 bed-days.

RESULTS

A total of 657 forms were analyzed - a monthly average of 27 pediatric preparations. The neonatal ICU accounted for 69.6% of these requests. Twenty-one drug items were used, of which the most common were folinic acid (88 requests), sulfadiazine (85) and captopril (73). The consumption of the active principle in these preparations varied in number of iDDD, from 7.5 (hydralazine) to 16,520.0 (folic acid), and in number of iDDD/100 bed-days in the neonatal ICU, from 0.1 (zinc sulfate) to 146.1 (folic acid).

CONCLUSIONS

The constant consumption of magistral oral solutions and suspensions by newborns and children of the assessed hospital indicates the need for such preparations as a pediatric therapeutic alternative in this hospital.

A bundle with a preformatted medical order sheet and an introductory course to reduce prescription errors in neonates

The objective of this study was to assess whether the introduction of a new preformatted medical order sheet coupled with an introductory course affected prescription quality and the frequency of errors during the prescription stage in a neonatal intensive care unit (NICU). Two-phase observational study consisting of two consecutive 4-month phases: pre-intervention (phase 0) and post-intervention (phase I) conducted in an 11-bed NICU in a Swiss university hospital. Interventions consisted of the introduction of a new preformatted medical order sheet with explicit information supplied, coupled with a staff introductory course on appropriate prescription and medication errors. The main outcomes measured were formal aspects of prescription and frequency and nature of prescription errors. Eighty-three and 81 patients were included in phase 0 and phase I, respectively. A total of 505 handwritten prescriptions in phase 0 and 525 in phase I were analysed. The rate of prescription errors decreased significantly from 28.9% in phase 0 to 13.5% in phase I (p < 0.05). Compared with phase 0, dose errors, name confusion and errors in frequency and rate of drug administration decreased in phase I, from 5.4 to 2.7% (p < 0.05), 5.9 to 0.2% (p < 0.05), 3.6 to 0.2% (p < 0.05), and 4.7 to 2.1% (p < 0.05), respectively. The rate of incomplete and ambiguous prescriptions decreased from 44.2 to 25.7 and 8.5 to 3.2% (p < 0.05), respectively.

CONCLUSION

Inexpensive and simple interventions can improve the intelligibility of prescriptions and reduce medication errors.

WHAT IS KNOWN

Medication errors are frequent in NICUs and prescription is one of the most critical steps. CPOE reduce prescription errors, but their implementation is not available everywhere.

WHAT IS NEW

Preformatted medical order sheet coupled with an introductory course decrease medication errors in a NICU. Preformatted medical order sheet is an inexpensive and readily implemented alternative to CPOE.

Drug information leaflets improve parental knowledge of their child's treatment at paediatric emergency department discharge

Background

Hospital discharge is a complex multidisciplinary process that can lead to non-compliance and drugs-related problems. Crucial issue for children is parental knowledge of discharge treatments, especially in the time-limited and stressful environment of an emergency department (ED).

Objective

To compare parental correct knowledge of treatment with and without supply of customised drug information leaflets for the 10 most commonly prescribed drugs.

Method

Inclusion criteria: paediatric patients (0-16 years) with French-speaking parents discharged from ED of the paediatric department of Geneva University Hospitals before (phase A) and after (phase B) intervention.

Intervention

Supply and brief comment of drug information leaflets focusing on specific information not available in official drugs information documents. Follow-up Semi-structured phone interview within 72 h after discharge to evaluate the percentage of parents with correct knowledge of dose, frequency, duration and indication of drugs. Multivariate analysis to identify factors associated with correct knowledge (phases A/B, drugs collection at usual pharmacy, drugs categories).

Results

125 patients were included (phase A: 56; phase B: 69). Drug information leaflets were given to 63/69 ED patients (91%), covering 96/138 prescribed drugs (70%). Parental knowledge was significantly improved in phase B (dose: 62.3% to 89.1%; frequency: 57.9% to 85.5%; duration: 34.2% to 66.7%; indication: 70.2% to 94.9%; p<0.0001). Phase B and collection of drugs at usual pharmacy were significant factors associated with correct knowledge.

Conclusions

Drug information leaflets significantly improved treatment knowledge of French-speaking parents after paediatric ED discharge. Leaflets are now available online for general population.

Analysis of medication prescribing errors in critically ill children

Medication prescribing errors (MPE) can result in serious consequences for patients. In order to reduce errors, we need to know more about the frequency, the type and the severity of such errors. We therefore performed a prospective observational study to determine the number and type of medication prescribing errors in critically ill children in a paediatric intensive care unit (PICU). Prescribing errors were prospectively identified by a clinical pharmacist. A total of 1129 medication orders were analysed. There were 151 prescribing errors, giving an overall error rate of 14 % (95 % CI 11 to 16). The medication groups with the highest proportion of MPEs were antihypertensives, antimycotics and drugs for nasal preparation with error rates of each 50 %, followed by antiasthmatic drugs (25 %), antibiotics (15 %) and analgesics (14 %). One hundred four errors (70 %) were classified as MPEs which required interventions and/or resulted in patient harm equivalent to 9 % of all medication orders (95 % CI 6.5 to 14.4). Forty-five MPEs (30 %) did not result in patient harm.

CONCLUSION

With a view to reduce MPEs and to improve patient safety, our data may help to prevent errors before they occur.

WHAT IS KNOWN

• Prescribing errors may be the most frequent medication errors. • In paediatric populations, the incidence of prescribing errors is higher than in adults. What is New: • Several risk factors for medication prescribing errors, such as medication groups, long PICU stay, and mechanical ventilation could be presented. • Analysing the combination of the most frequent prescribing errors and the severity of these errors.

Unlicensed and Off-Label Drug Use in Children Before and After Pediatric Governmental Initiatives

OBJECTIVES

Governmental agencies (US Food and Drug Administration and European Medicines Agency) implemented initiatives to improve pediatric clinical research, starting in 1997 and 2007, respectively. The aim of this review was to quantify the unlicensed and off-label drug uses in children before and after these implementations.

METHODS

Literature review of unlicensed and off-label drug uses was performed on PubMed and Google-Scholar from 1985 to 2014. Relevant titles/abstracts were reviewed, and articles were included if evaluating unlicensed/off-label drug uses, with a clear description of health care setting and studied population. Included articles were divided into 3 groups: studies conducted in United States (before/after 2007), in Europe (before/after 2007), and in other countries.

RESULTS

Of the 48 articles reviewed, 27 were included. Before implementation of pediatric initiatives, global unlicensed drug use rate in Europe was found to be 0.2% to 36% for inpatients and 0.3% to 16.6% for outpatients. After implementation, it marginally decreased to 11.4% and 1.26% to 6.7%, respectively. Concerning off-label drug use rates, it was found to be 18% to 66% for inpatients and 10.5% to 37.5% for outpatients before the implementation. After implementation, it decreased marginally to 33.2% to 46.5% and to 3.3% to 13.5%, respectively. In other countries, unlicensed and off-label drug use rates were found to be, respectively, 8% to 27.3% and 11% to 47%.

CONCLUSIONS

Governmental initiatives to improve clinical research conducted in children seem to have had a marginal effect to decrease the unlicensed and off-label drug uses prevalence in Europe.

Clinical setting influences off-label and unlicensed prescribing in a paediatric teaching hospital

PURPOSE

To estimate the prevalence of off-label and unlicensed prescribing during 2008 at a major paediatric teaching hospital in Western Australia.

METHODS

A 12-month retrospective study was conducted at Princess Margaret Hospital using medication chart records randomly selected from 145,550 patient encounters from the Emergency Department, Inpatient Wards and Outpatient Clinics. Patient and prescribing data were collected. Drugs were classified as off-label or unlicensed based on Australian registration data. A hierarchical system of age, indication, route of administration and dosage was used. Drugs were classified according to the Anatomical Therapeutic Chemical Code.

RESULTS

A total of 1,037 paediatric patients were selected where 2,654 prescriptions for 330 different drugs were prescribed to 699 patients (67.4%). Most off-label drugs (n = 295; 43.3%) were from the nervous system; a majority of unlicensed drugs were systemic hormonal preparations excluding sex hormones (n = 22, 32.4%). Inpatients were prescribed more off-label drugs than outpatients or Emergency Department patients (p < 0.0001). Most off-label prescribing occurred in infants and children (31.7% and 35.9% respectively) and the highest percentage of unlicensed prescribing (7.2%) occurred in infants (p < 0.0001). There were 25.7% of off-label and 2.6% of unlicensed medications prescribed across all three settings. Common reasons for off-label prescribing were dosage (47.4%) and age (43.2%).

CONCLUSION

This study confirmed off-label and unlicensed use of drugs remains common. Further, that prevalence of both is influenced by the clinical setting, which has implications in regards to medication misadventure, and the need to have systems in place to minimise medication errors. Further, there remains a need for changes in the regulatory system in Australia to ensure that manufacturers incorporate, as it becomes available, evidence regarding efficacy and safety of their drugs in children in the official product information.

Evaluation of unlicensed and off-label antiepileptic drugs prescribed to children: Brazilian Regulatory Agency versus FDA

BACKGROUND

Epileptic seizures are neurological disorders common in children; 4 to 10% of under 16-year olds have suffered at least one seizure. Antiepileptic drugs represent the basis of treatment for the majority of patients, but many of the drugs prescribed to pediatrics are used unlicensed and off-label.

OBJECTIVE

To analyze the prevalence of use of unlicensed and off-label antiepileptic drugs, by the pediatric population, according to the Food and Drug Administration and the Brazilian National Health Surveillance Agency. Setting General Hospital of the Faculty of Medicine at Ribeirão Preto, Brazil.

METHODS

A cross-sectional, retrospective and observational study was carried out. The daily prescriptions of children up to 12 years of age were collected for the analysis of antiepileptic drug use. Data of the registration number, sex, age, reason hospitalized, unit where hospitalized, drug prescribed, dosage, route and administration frequency were collected.

MAIN OUTCOME MEASURE

Antiepileptic drugs prescribed for children were classified as unlicensed and off-label according to the term of the product's license registered in the Food and Drug Administration and the Brazilian National Health Surveillance Agency.

RESULTS

Of the 6,637 pediatric patients identified during the study period, 583 (9.0%) received at least one antiepileptic drug. The most used antiepileptic drugs were phenobarbital, phenytoin, carbamazepine, valproic acid and clonazepam. As expected, the number of pharmaceutical dosage form classified as unlicensed or off-label was high in both agencies, but distinct between the two. The number of patients (n = 287) using unlicensed drugs was similar in the two agencies, but the use of off-label drugs was higher according to the analysis carried out by the North American agency (40.5%).

CONCLUSIONS

Old-generation antiepileptic drugs are widely prescribed to children. The results found for the use of off-label drugs demonstrate the absence of uniformity in action between the agencies and a lack of integration between the studies carried out. Although legislation on the licensing of drugs aims to protect the patients from drugs that have not been scientifically evaluated, the scarcity of data about the safety of the therapeutic resources obliges the doctors to prescribe unlicensed and off-label antiepileptic drugs to the pediatric population.

Paediatric drug use with focus on off-label prescriptions at Swedish hospitals - a nationwide study

AIM

To perform a nationwide investigation of paediatric drug use at Swedish hospitals, including an analysis of off-label drug use.

METHODS

All paediatric hospitals in Sweden were invited to register all prescriptions to children, aged between 0 and 18, during two separate 2-day-periods in 2008. Data were reported and analysed with respect to licence status and proportion of and reasons for off-label drug use.

RESULTS

Data on 11,294 prescriptions to 2947 paediatric patients were received. Drugs associated with pain relief, infection, prematurity, nutrition and surgery or anaesthesia were most commonly used. Paracetamol was the most frequently used drug on-label and also among the most commonly used off-label drugs. Nearly half (49%) of all administered prescriptions concerned unlicensed drugs, off-label drugs or extemporaneously prepared drugs. The corresponding rate among neonates was 69%. Lack of paediatric information in the Summary of Product Characteristics was the main reason for off-label classification.

CONCLUSIONS

Paediatric off-label drug use is common at Swedish hospitals, and nearly half of all prescriptions were not documented for use in children. The findings emphasize a need for paediatric clinical studies as well as compilation of existing clinical experience and scattered evidence, particularly for drug treatment in infants and neonates.

Drug treatments in a neonatal setting: focus on the off-label use in the first month of life

OBJECTIVE

The purpose of this work was to analyse drugs prescribed in the first month of life among a group of newborns admitted to the Neonatal Intensive Care Unit and Neonatal Pathology of Cagliari University Hospital.

METHOD

This pilot study was prospectively conducted during a 1-month period and involved all newborns admitted to our hospital that received a pharmacotherapy. After obtaining written parental consent, data collected from each newborn included date of birth, sex, gestational age and weight. Also, diagnosis and information about each drug administered during the first month of life: dose, frequency, route of administration, and indication for use was collected.

RESULTS

Among the 79 newborn infants admitted to our hospital during the study period, 38 received a pharmacotherapy and were enrolled in our study. A total of 88 treatments were given: 41 (47%) followed the terms of the product license, 47 (53%) were used in an unlicensed or off-label manner.

CONCLUSION

Our results confirm this trend of drug use in the neonatological field and suggest the need to update information contained in the data sheets of medicines.

Off-label and unlicensed drug utilization in hospitalized children in Fortaleza, Brazil

OBJECTIVES

To investigate the use of drugs, the extent and pattern of unlicensed and off-label use, and the potential relationship between off-label drug use and adverse drug reactions in northeastern Brazil.

METHODS

A follow-up study of drug utilization in a general ward of a pediatric reference hospital, involving patients hospitalized for more than 24 h. Prescriptions and medical records were reviewed daily from August to December 2001. Drug licensing status of all prescriptions given to these patients was determined.

RESULTS

A total of 272 patients were admitted during the study, 265 (97.4%) of whom received one or more drugs. The median number of drugs/patient was 6 (1-18), and the most frequent diagnosis was pneumonia (29.4% of patients). The therapeutic class most prescribed was anti-infectives for systemic use (68.8% of all children). In all, 82.6% of children received at least one unlicensed or off-label drug, and 17% received both an unlicensed and an off-label drug. Dose/frequency was the most common form of off-label drug use. Off-label drug use was significantly associated with adverse drug reactions (relative risk 2.44; 95% CI 2.12, 2.89).

CONCLUSIONS

Although off-label drug use is a complex issue and is not synonymous with inappropriate drug use, a high rate of unlicensed/off-label drug use was found and was also associated with an increased risk of adverse drug reactions. More efforts are needed to increase rational drug use in children.