Feedback and lessons from the prescription of rimonabant, a drug to be used under strict guidelines, in southeastern France, March 2007 through June 2008

BACKGROUND

To provide feedback on the initial market authorization of rimonabant, a drug to be used under strict guidelines, we conducted a study with information from the National health insurance reimbursements database for southeastern France. The aims of this study were to: (1) describe the characteristics of subjects who have had one rimonabant prescription reimbursed; (2) study the frequency of prescriptions that did not comply with reimbursement criteria; (3) study the frequency of prescriptions for patients simultaneously treated with antidepressants; and (4) analyse the factors associated with both types of prescription (patient and prescriber characteristics).

METHODS

Using the database of drug reimbursements maintained by the southeastern France general health insurance fund, we studied the characteristics of outpatients with at least one reimbursement for rimonabant, compared them to the rest of the population, and analysed compliance with the indications, contraindications, and regulations for rimonabant prescription with multivariate logistic regressions.

RESULTS

A total of 10,510 beneficiaries (0.28%) had at least one rimonabant reimbursement. Among them, 55.7% were treated for diabetes. For at least 62.4% of rimonabant beneficiaries, the reimbursement regulations were not respected: this was significantly more frequent among women less than 57 years old, subjects with no chronic diseases, and when the prescriber was not an endocrinologist; 11.4% of rimonabant beneficiaries also received an antidepressant treatment.

CONCLUSION

Despite the specific status of rimonabant regarding its reimbursement modalities, these results suggest that some prescribers get around reimbursement instructions and that a significant percentage of prescriptions did not respect an important contraindication. Tools to follow up the prescriptions of new drugs with strict guidelines for use should be developed and physicians should be better informed and trained regarding specific prescription regulations.

Triptan use and risk of cardiovascular events: a nested-case-control study from the French health system database

BACKGROUND

The use of triptans (5-HT agonists) in the treatment of migraine is associated with a potential increasing risk of cardiovascular events and raises the question of the relationship between overuse and the occurrence of ischemic events.

OBJECTIVE

The aim of this study was to examine the association between the intensity of triptan use and occurrence of an cardiac event.

METHODS

Using the reimbursed drug prescription database of the National French Health Insurance System in the Midi-Pyrenees area, we identified subjects receiving at least one triptan in the second semester of 2002. From this population, we selected new users and retrieved all reimbursed care data up to 31 December 2003. We estimated the patterns of triptan exposure by calculating the number of defined daily doses (DDD) received per 30-day period. Another reimbursed health care database was used to identify as cases of cardiac outcomes those patients receiving care for the management of a possible heart ischemic event. Each case was randomly matched on age and gender with four controls free of any cardiovascular event before the index date. A conditional logistic regression was performed to assess the relationship between cardiac outcomes and exposure to triptans in the 30 days before the index date.

RESULTS

The cohort of new users of triptans included 8625 subjects, 4414 (51.18%) of whom received only one dispensation for triptans during the follow-up period (median duration: 427 days). For the remaining subjects, the peak of triptans delivery was </=8 DDD for 14.68% of the cohort, between 9 and 14 DDD for 22.17%, between 15 and 29 for 10.04% and >/=30 DDD for 1.92%. Fifty-seven users (0.66%) presented a cardiac history and 1388 patients (16.09%) had cardiovascular risk factors. We identified 155 incident cases of cardiac outcomes during the follow-up and compared these to 620 matched controls. Cases were older and presented more frequently with cardiac history or cardiovascular risk factors than the other users of triptans. The distribution exposure to triptans did not significantly differ between cases and controls with an odds ratio for an exposure </=8 DDD in the last 30 days of 0.74 [95% CI (0.31-1.77)] and that for an exposure >8 DDD equal to 1.14 [95% CI (0.58-2.27)].

CONCLUSION

The proportion of patients showing an overuse of triptans (more than 15 DDD for 30 days) reached 12% in this cohort of new users of triptans. However, we did not find any relationship between the overuse of triptans and cardiac outcomes. This study also shows that some patients with cardiovascular risk factors are actually treated by triptans. These patients are more likely to present a cardiac outcome potentially related to an ischemic event after the introduction of triptan.

3,4,5,3′,5′-Pentabromo-2-(2′-hydroxybenzoyl)pyrrole: a potential lead compound as anti-Gram-positive and anti-biofilm agent

The activity against Gram-positive bacteria of 3,4,5,3',5'-pentabromo-2-(2'-hydroxybenzoyl)pyrrole I, a synthetic anti-bacterial compound related to pyrrolomycins, was tested in vitro using seven reference bacterial strains and Staphylococcus epidermidis and Staphylococcus aureus preformed biofilms. Compound I was active against all strains tested, with minimum inhibitory concentration (MIC) values ranging from 0.002 to 0.097 mg/l and minimum bactericidal concentrations (MBCs) from 0.37 to 12.5 mg/l. Compound I was also active at low concentrations against preformed S. epidermidis and S. aureus biofilms.

Utilisation du citrate de clomifène en médecine de ville dans la région Midi-Pyrénées : qualité du bilan explorant la stérilité, de la prescription et de la surveillance du traitement

OBJECTIVE

Evaluate the compliance to the national guidelines from ANDEM (1996) and AFSSAPS (2003) concerning the diagnosis of infertility, the prescription of clomiphene and the monitoring of these treatments.

PATIENTS AND METHODS

Retrospective study of female patients from 16 to 50 y.o. having benefited from reimbursement of clomiphene citrate treatment between 1st April 2002 and 30th June 2002. After random sampling stratified on age, data on diagnosis procedures and treatments were extracted from the Social Security reimbursement database. These data were validated and completed by patients' interviews.

RESULTS

A total of 283 women were included. 30% were subject to the basic hormonal tests (FSH, LH, estradiol). The proportion of patients explored by hysterosalpingogram, post-coital test and echography were respectively 50%, 35% and 68%. A semen analysis was found in 60% of the partners. The complete set of recommended tests before start of treatment was realised in 1.5% of women. In 7% of cases, women were treated without prior exploration. The proportion of tests performed was comparable below and above the age of 35. 77% of treatments were initiated after at least one year of waiting for a spontaneous conception. 69% of women were monitored during treatment by other methods than clinical follow-up.

CONCLUSION

Prescription of clomifene citrate is too frequently realised without compliance to guidelines applicable to infertility investigations and therefore without persuasive diagnosis. These practices can lead to loss of childbearing opportunities and complications.

[Maintenance treatment with high-dose buprenorphine: are the recommendations being followed?]

Since February 1996, high-dose buprenorphine has been approved for use in the treatment of opioid dependence. In addition, recommendations concerning indications, patient selection, prescribing information and patient delivery have been addressed to doctors and pharmacists. Between its date of approval for use and late 1996, the medical service of French National Health Insurance followed 149 illicit drug users who received high-dose buprenorphine. They all lived in the Vosges 'département' and were affiliated with French Social Security Health Insurance. In general, the recommendations (consultation with a specialist, psychosocial follow-up and dosage schedules) were not followed by prescribing physicians. Concomitant prescriptions with psychotropic drugs, mainly benzodiazepines, were frequently encountered. This raises considerable concern since there have been recent reports of lethal intoxications with high-dose buprenorphine.

A systematic survey of breast cancer incidence in the Département of Rhône, France

A systematic survey of all centres of diagnosis and care of breast cancer patients in the Rhône "département" of France was carried out to evaluate, for the year 1985, the incidence rate of breast cancer in an urban, industrialised part of France not covered by a cancer registry. Two hundred and fifty seven institutions or individuals were involved, covering the public and private sectors in the Rhône département, but also in neighbouring cities and elsewhere in France, which also enabled a search to be carried out for cases diagnosed or treated outside the département. Altogether, over this 1-year period, 801 new cases were identified (791 women and 10 men). This study demonstrated a high incidence of female breast cancer (80.5 new cases per 100,000 woman-years, standardised to the world population) which was particularly marked among women aged 40-60. This incidence is higher than that described by the cancer registry of the neighbouring département of Isère, but is close to the incidence found in Geneva. Results also concur with the relatively high mortality rate from breast cancer observed in the Rhône département.