Downloaded from http://adc.bmj.com/ on October 27, 2015 - Published by group.bmj.com
Editorial
Do we prescribe medicines rationally?
Drug therapy
Michael Rieder Drug therapy is one of the cornerstones of care for many common and important child health problems worldwide, as safe and effective pharmacotherapy has been one of the key strategies in improving child health over the past century alongside vaccination, public sanitation and child protection. They are also commonly used— for most children, as monotherapy for acute problems but for children with chronic disease ongoing and frequently complex pharmacotherapy is the rule.1 Prescription drugs are also costly—in 2014 the NHS spent £14 billion on prescription drugs, 40% being in-hospital.2 As well, adverse drug reactions are one of the top four causes of death.1 Consequently, it would be prudent to consider that, when we prescribe medications for children, it is done rationally. An important question in child healthcare and in public policy for children is––Is this true? Dr Bénard-Laribière et al3 describe drug use among a sample of 133 800 children selected from a reimbursement claims database representing 90% of the French population. This is the first study to systematically look at drug use in children in France. Over a 1 year period, 84% of French children had a prescription for at least one drug; drug use was age-dependent, with 97% of children under the age of 2 years having at least one prescription and with the rate of drug use declining significantly with age. The median number of drugs prescribed per child over this year was 5. Of interest, this is very similar to the average annual number of prescriptions per child that we found in a study of more than a million Canadian children 15 years age.1 However, this should not be interpreted as meaning that drug use is similar between these two countries; in fact, there are striking differences between the data in this study and other studies of drug use in children. It is important when comparing studies to recognise differences in study design that make findings different to directly compare with other studies. One key
Correspondence to Dr Michael Rieder, Department of Paediatrics, Children’s Hospital, 800 Commissioner’s Road East, London, Ontario, Canada N6C 2V5; [email protected] 958
difference relates to which medications are captured by the Echantillon Généraliste de Bénéficaires, the database used to evaluate use of the French national healthcare insurance system. These medications include drugs that are also available without prescription, for example paracetamol, which is the most commonly used drug across all ages. It is entirely unsurprising that paracetamol would be widely used in children under the age of 2 nor is the frequent use of lidocaine/prilocaine preparations in this age group surprising, notably as there is solid evidence that these preparations reduce vaccination pain and this is the age range with the highest frequency of vaccination. It is also notable that the lack of these agents in other studies is a direct result of reimbursement policy, not for lack of efficacy. This is an issue acknowledged by the authors. However, while it may not be possible to make direct comparisons with studies in other countries there is data in this study that is worth reflecting on in the broader context of rationale drug use for children. One fact that resonates is the frequency of drug use among French children. Even given the caveat noted above one is struck by the fact that, across all age ranges, 84% of French children received a prescription over the course of a year. The fact of increased use of agedependency in prescription use has been noted in studies in other countries, but the frequency found by Bénard-Laribière and her coinvestigators is much higher than in these other studies. As an example, if one crosses the border to Italy work by Clavenna and Bonati has shown that 61% of children in Italy receive a prescription a year, studies in other areas showing similar or lower rates of prescribing.4 We have shown that children in Canada appear to fall into two populations; the majority of children receive either no or a single prescription a year, but a minority—children with serious or chronic disorders—receive many prescriptions.1 Given that this is the first study to address this issue in France temporal evaluations are problematic, but it of interest to note that, in the USA, there has been a decline in prescribing for children from 2002 to 2010 across a broad number of therapeutic
areas with some increased prescribing for focused therapeutic indications.5 The second issue that resonates relates to therapeutic choices. In a number of studies, antibiotics have been identified as the most commonly prescribed drugs for children. As an example, in the Italian and American studies noted above the most commonly prescribed drugs were antibiotics, the use of which was noted in the American study to be declining over time. In contrast, Bénard-Laribière et al3 found that central nervous system drugs followed by respiratory drugs were the most commonly used medications. Of note, the corticosteroid tixocortol was the second most commonly used for children under age 5 following paracetamol, and was the fourth most commonly used drug overall.3 What are we to learn from this study? First, this study confirms that drug use among children is common and involves drugs from a broad range of therapeutic areas. Second, this study confirms that drug use in children frequently does not follow the evidence as to what might constitute best practice but is driven by societal, cultural and economic issues. The authors note a relatively high rate of antibiotic use and a very high rate of use of other preparations—such as corticosteroids, nasal decongestants and domperidone—for which there are both safety and efficacy concerns. This is not unique to France; for example, Clavenna et al4 noted that the most commonly prescribed antibiotic to Italian children was amoxicillin and clavulanic acid despite guidelines quite clearly stating that amoxicillin monotherapy was the first choice for many common infections in children. Similarly, they found that 40% of antibiotic use was for drugs commonly considered to be secondline agents, suggesting that factors other than safety and efficacy were driving prescribing. In the longitudinal study of prescribing for children in the USA it was noted that lansoprazole use—an off-label indication in children and a drug for which safety issues have been noted in adults—increased significantly over the time of the study.5 Taken together this study and others point to an important issue and a clear direction for future research. The factors that drive prescribing for children are clearly complex and while efficacy and safety are central to prescribing decisions it is clear that other factors—cultural, economic and perceptional—drive prescribing in a manner that we have yet to fully understand. How these factors evolve and
Rieder M. Arch Dis Child October 2015 Vol 100 No 10
Downloaded from http://adc.bmj.com/ on October 27, 2015 - Published by group.bmj.com
Editorial change over time is also an area that needs dialogue and exploration. Thoughtful research into the role of these factors and other influences such as the influence of reimbursement, the local academic environment and the role of key opinion leaders is urgently needed to inform educators, policy makers and the broader community of patients and families, so that therapeutic decisions can be made that are clearly in line with the common goal of better drug therapy for children. Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed. To cite Rieder M. Arch Dis Child 2015;100:958–959. Received 20 April 2015 Revised 14 May 2015 Accepted 17 May 2015 Published Online First 4 June 2015
REFERENCES 1 2
3
4
▸ http://dx.doi.org/10.1136/archdischild-2014-307224 5
Arch Dis Child 2015;100:958–959. doi:10.1136/archdischild-2015-308428
Rieder MJ. If children ruled the pharmaceutical industry. Drug News Perspect 2010;23:458–64. Croft K, Prescribing Team, Health and Social Care Information Centre. Hospital Prescribing: England 2013– 14. Health & Social Information Centre, Government Statistical Service, 2015. ISBN: 978-1-78383-236-8. Bénard-Laribière A, Jové J, Lassalle R, et al. Drug use in French children: a population based reimbursement study. Arch Dis Child 2015;100: 960–5. Clavenna A, Berti A, Gualandi L, et al. Drug utilization in the Italian paediatric population. Eur J Pediatr 2009;168:173–80. Chai G, Governale L, McMahon AW, et al. Trends of outpatient prescription drug utilization in US children, 2002–2010. Pediatrics 2012;130:23–31.
Drug therapy
Rieder M. Arch Dis Child October 2015 Vol 100 No 10
959
Downloaded from http://adc.bmj.com/ on October 27, 2015 - Published by group.bmj.com
Do we prescribe medicines rationally? Michael Rieder Arch Dis Child 2015 100: 958-959 originally published online June 4, 2015
doi: 10.1136/archdischild-2015-308428 Updated information and services can be found at: http://adc.bmj.com/content/100/10/958
These include:
References Email alerting service
Topic Collections
This article cites 4 articles, 2 of which you can access for free at: http://adc.bmj.com/content/100/10/958#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections ADC Drug Therapy (116) Drugs: infectious diseases (926) Immunology (including allergy) (1955) Vaccination / immunisation (324) Child health (3808) Child and adolescent psychiatry (paedatrics) (667) Unwanted effects / adverse reactions (115) Pain (neurology) (569)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Editorial
Do we prescribe medicines rationally?
Drug therapy
Michael Rieder Drug therapy is one of the cornerstones of care for many common and important child health problems worldwide, as safe and effective pharmacotherapy has been one of the key strategies in improving child health over the past century alongside vaccination, public sanitation and child protection. They are also commonly used— for most children, as monotherapy for acute problems but for children with chronic disease ongoing and frequently complex pharmacotherapy is the rule.1 Prescription drugs are also costly—in 2014 the NHS spent £14 billion on prescription drugs, 40% being in-hospital.2 As well, adverse drug reactions are one of the top four causes of death.1 Consequently, it would be prudent to consider that, when we prescribe medications for children, it is done rationally. An important question in child healthcare and in public policy for children is––Is this true? Dr Bénard-Laribière et al3 describe drug use among a sample of 133 800 children selected from a reimbursement claims database representing 90% of the French population. This is the first study to systematically look at drug use in children in France. Over a 1 year period, 84% of French children had a prescription for at least one drug; drug use was age-dependent, with 97% of children under the age of 2 years having at least one prescription and with the rate of drug use declining significantly with age. The median number of drugs prescribed per child over this year was 5. Of interest, this is very similar to the average annual number of prescriptions per child that we found in a study of more than a million Canadian children 15 years age.1 However, this should not be interpreted as meaning that drug use is similar between these two countries; in fact, there are striking differences between the data in this study and other studies of drug use in children. It is important when comparing studies to recognise differences in study design that make findings different to directly compare with other studies. One key
Correspondence to Dr Michael Rieder, Department of Paediatrics, Children’s Hospital, 800 Commissioner’s Road East, London, Ontario, Canada N6C 2V5; [email protected] 958
difference relates to which medications are captured by the Echantillon Généraliste de Bénéficaires, the database used to evaluate use of the French national healthcare insurance system. These medications include drugs that are also available without prescription, for example paracetamol, which is the most commonly used drug across all ages. It is entirely unsurprising that paracetamol would be widely used in children under the age of 2 nor is the frequent use of lidocaine/prilocaine preparations in this age group surprising, notably as there is solid evidence that these preparations reduce vaccination pain and this is the age range with the highest frequency of vaccination. It is also notable that the lack of these agents in other studies is a direct result of reimbursement policy, not for lack of efficacy. This is an issue acknowledged by the authors. However, while it may not be possible to make direct comparisons with studies in other countries there is data in this study that is worth reflecting on in the broader context of rationale drug use for children. One fact that resonates is the frequency of drug use among French children. Even given the caveat noted above one is struck by the fact that, across all age ranges, 84% of French children received a prescription over the course of a year. The fact of increased use of agedependency in prescription use has been noted in studies in other countries, but the frequency found by Bénard-Laribière and her coinvestigators is much higher than in these other studies. As an example, if one crosses the border to Italy work by Clavenna and Bonati has shown that 61% of children in Italy receive a prescription a year, studies in other areas showing similar or lower rates of prescribing.4 We have shown that children in Canada appear to fall into two populations; the majority of children receive either no or a single prescription a year, but a minority—children with serious or chronic disorders—receive many prescriptions.1 Given that this is the first study to address this issue in France temporal evaluations are problematic, but it of interest to note that, in the USA, there has been a decline in prescribing for children from 2002 to 2010 across a broad number of therapeutic
areas with some increased prescribing for focused therapeutic indications.5 The second issue that resonates relates to therapeutic choices. In a number of studies, antibiotics have been identified as the most commonly prescribed drugs for children. As an example, in the Italian and American studies noted above the most commonly prescribed drugs were antibiotics, the use of which was noted in the American study to be declining over time. In contrast, Bénard-Laribière et al3 found that central nervous system drugs followed by respiratory drugs were the most commonly used medications. Of note, the corticosteroid tixocortol was the second most commonly used for children under age 5 following paracetamol, and was the fourth most commonly used drug overall.3 What are we to learn from this study? First, this study confirms that drug use among children is common and involves drugs from a broad range of therapeutic areas. Second, this study confirms that drug use in children frequently does not follow the evidence as to what might constitute best practice but is driven by societal, cultural and economic issues. The authors note a relatively high rate of antibiotic use and a very high rate of use of other preparations—such as corticosteroids, nasal decongestants and domperidone—for which there are both safety and efficacy concerns. This is not unique to France; for example, Clavenna et al4 noted that the most commonly prescribed antibiotic to Italian children was amoxicillin and clavulanic acid despite guidelines quite clearly stating that amoxicillin monotherapy was the first choice for many common infections in children. Similarly, they found that 40% of antibiotic use was for drugs commonly considered to be secondline agents, suggesting that factors other than safety and efficacy were driving prescribing. In the longitudinal study of prescribing for children in the USA it was noted that lansoprazole use—an off-label indication in children and a drug for which safety issues have been noted in adults—increased significantly over the time of the study.5 Taken together this study and others point to an important issue and a clear direction for future research. The factors that drive prescribing for children are clearly complex and while efficacy and safety are central to prescribing decisions it is clear that other factors—cultural, economic and perceptional—drive prescribing in a manner that we have yet to fully understand. How these factors evolve and
Rieder M. Arch Dis Child October 2015 Vol 100 No 10
Downloaded from http://adc.bmj.com/ on October 27, 2015 - Published by group.bmj.com
Editorial change over time is also an area that needs dialogue and exploration. Thoughtful research into the role of these factors and other influences such as the influence of reimbursement, the local academic environment and the role of key opinion leaders is urgently needed to inform educators, policy makers and the broader community of patients and families, so that therapeutic decisions can be made that are clearly in line with the common goal of better drug therapy for children. Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed. To cite Rieder M. Arch Dis Child 2015;100:958–959. Received 20 April 2015 Revised 14 May 2015 Accepted 17 May 2015 Published Online First 4 June 2015
REFERENCES 1 2
3
4
▸ http://dx.doi.org/10.1136/archdischild-2014-307224 5
Arch Dis Child 2015;100:958–959. doi:10.1136/archdischild-2015-308428
Rieder MJ. If children ruled the pharmaceutical industry. Drug News Perspect 2010;23:458–64. Croft K, Prescribing Team, Health and Social Care Information Centre. Hospital Prescribing: England 2013– 14. Health & Social Information Centre, Government Statistical Service, 2015. ISBN: 978-1-78383-236-8. Bénard-Laribière A, Jové J, Lassalle R, et al. Drug use in French children: a population based reimbursement study. Arch Dis Child 2015;100: 960–5. Clavenna A, Berti A, Gualandi L, et al. Drug utilization in the Italian paediatric population. Eur J Pediatr 2009;168:173–80. Chai G, Governale L, McMahon AW, et al. Trends of outpatient prescription drug utilization in US children, 2002–2010. Pediatrics 2012;130:23–31.
Drug therapy
Rieder M. Arch Dis Child October 2015 Vol 100 No 10
959
Downloaded from http://adc.bmj.com/ on October 27, 2015 - Published by group.bmj.com
Do we prescribe medicines rationally? Michael Rieder Arch Dis Child 2015 100: 958-959 originally published online June 4, 2015
doi: 10.1136/archdischild-2015-308428 Updated information and services can be found at: http://adc.bmj.com/content/100/10/958
These include:
References Email alerting service
Topic Collections
This article cites 4 articles, 2 of which you can access for free at: http://adc.bmj.com/content/100/10/958#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections ADC Drug Therapy (116) Drugs: infectious diseases (926) Immunology (including allergy) (1955) Vaccination / immunisation (324) Child health (3808) Child and adolescent psychiatry (paedatrics) (667) Unwanted effects / adverse reactions (115) Pain (neurology) (569)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
