對於藥品之管理，主管機關往往僅著重於新藥的核准，對於藥品上市後之監督即第四階段往往付之闕如，因此許多藥商利用上市後對於藥品之反應，往往變相做為另外新適應症的適用研究，對於主管機關而言，藥品標示外使用原則上是已核准藥品之運用，因此，若非有重大不良反應之回報，否則基本上是漠視。 藥害救濟基金會在西元1999年至西元2015年2月第1～217次審議會之統計資料顯示，其中有1030件申請案，審議會審定結果是不予救濟，進一步分析其不予救濟之理由，名列第二名的原因為「未依藥品許可證所載之適應症或效能而為藥品之使用」，占整體不予救濟給付案件的23%，突顯現行的藥害救濟制度下藥害政策與實際臨床用藥的落差。 本文認為醫療行為之目的，乃在救治病人生命及恢復病人之健康，其過程本就充滿不確定性與高度危險性，醫療行為之歸責，應以可合理期待之安全性為考量。然根據衛生署(民國102年7月改制成衛生福利部)於民國91年之函釋說明藥品標示外使用原則為「應據實告知病人」與「不得違反藥品使用當時，已知的、具公信力的醫學文獻」等。因此，雖藥品標示外使用為醫師治療方式之選項之一，但法令上對於藥品標示外使用，卻未有明確之規範，因此產生許多醫學倫理與法律責任之爭議。 本文主題內容鎖定在藥品標示外使用與醫療過失之探討，且從刑法理論觀點，探討藥品標示外使用之法律性質，其在我國刑法規範體系中之定位，並加以闡釋注意義務，告知後同意，醫療過失，醫師說明義務等概念，並以實際發生的實際案例為例，進行說明。 其中，藥品標示外使用是否成為醫師應說明義務之內容?又其說明義務之基礎如何架構，說明內容又為何? 除此之外，文中將分析醫師注意義務與說明義務在藥品標示外使用時所應該達成的程度為何，結合國內的實務現狀與看法提供立法意見。 / After marketing approval, the labels of on drug packages should outline the indications for use, dosage, administrative directions, and safety information. The use of drug could expand over time. Off-label use, which means prescribing an approved drug for a use that is not claimed in the product information, is common in medical practice, especially for some serious or rare diseases. Since there is no regulation for off-label use , a number of clinical , legal and ethical issues arise. According to Taiwan Drug Relief Foundation for Drug Hazards’ statistics regarding the rejected reasons by foundation from 1030 application cases 1999 to 2015. The 2nd reason for unapproved cases is off-label use which is around 23% of total unapproved cases. This shows current criteria for drug relief is quite not fit in real world practice. Medicine is intended to save patients’ lives and to help patients reach renewed health. During the process of treatment, the risk versus benefit profile beyond the original product approval should first be taken into consideration. In Taiwan, the department of health provides an guidance regarding off-label use, ex: The necessity of informed consent before prescribing off-label products. Do physicians need to follow the duty of informed consent whiling prescribing a drug which is off-label use? There should be a guidance to follow in this regard. This study has established the principles and flow chart of off-label use. We suggest that some amendments to the laws are necessary, including setting up the scope of the duty of disclosure.

Zugl.: Göttingen, Univ., Diss., 2007

Masters of Science / Problem and significance: Off-label use of medicines is not illegal; however, it can be risky and harmful, or beneficial and innovative. The main problem of this practice is the lack of systems for monitoring adverse drug reactions, since the drugs are used in a manner that is not approved by regulatory agencies. For this reason public health protection is not guaranteed. Purpose: To identify the various systems employed in different regions to monitor/manage the risks and benefits of off-label use; and to ascertain their extent of implementation. Method/search strategy: Electronic and manual literature search was done. Articles referring to off-label medicine use were reviewed. The literature included journal articles, national MRA guidelines, international guidelines, etc. The articles were sourced from databases such as Pubmed and Google Scholar. Data was collected from both developed and emerging markets. There was no limit to publication date. Findings: Pharmacovigilance systems for off-label use do exist although the degree of commitment and advancement differs per country. Explicit off-label laws are present in the developed countries but not in the developing ones. Implications of findings: Stakeholder involvement is very important in monitoring off-label use. Reporting of ADRs can be improved by asserting the role of off-label PV in drug repositioning. The regulator is under pressure to maintain public trust through efficient control of off-label use.

Der Weg von der Entwicklung bis zur Zulassung neuer Virostatika ist bis heute mit hohen Kosten und einem großen Zeitaufwand verbunden. Sollten jedoch bereits zugelassene antivirale Medikamente eine Wirkung auf andere virale Infektionen zeigen, könnte dieser Prozess stark verkürzt werden. Daher war es Ziel dieser Arbeit, den Effekt von zugelassenen Medikamenten, gegen HSV-1, mCMV, hCMV, RSV, Parainfluenzavirus-3, DENV-2, CHIKV, Poliovirus, Masernvirus und HIV-1 zu evaluieren. Getestet wurden die Polymeraseinhibitoren ACV, GCV, CDV, sowie das neuere Medikament T-705 und die reversen Transkriptase-Inhibitoren TDF, 3TC, AZT und ABC. Außerdem die Proteaseinhibitoren SMV, GRV, DCV, LDV, ELB, VEL, SOF und DSV. TDF senkte in einer Konzentration von 10 µM die Infektiosität von HSV-1 und mCMV bis zu 1 Größenordnung. Auch ABC senkte die Infektiosität von HSV-1 und mCMV in einer Konzentration von 30 µM um 0,4 bzw. 0,6 Größenordnungen. AZT und ELB senkten die Infektiosität bei Infektionen mit HSV-1 in einer Konzentration von 30 µM um 0,4 Größenordnungen. VEL senkte die Infektiosität von mCMV bis zu einer Konzentration von 2 µM um 0,7 Größenordnungen. Durch die Substanzen ELB und LDV konnte die Replikation von DENV-2 bei einer Konzentration von 10 µM um 0,6 bzw. 0,8 Größenordnungen gesenkt werden. Die Substanzen zeigten jedoch keinen Effekt auf Infektionen mit CHIKV und Poliovirus, sodass für beide Substanzen ein virusspezifischer Effekt anzunehmen ist. Es wurde keine Wirkung der Substanzen gegen Infektionen mit Masernvirus, RSV oder Parainfluenzavirus-3 in den Versuchen beobachtet. Es wurde gezeigt, dass die verwendeten Methoden eine schnelle und effektive Möglichkeit darstellen, neue direkt-antivirale Medikamente zu etablieren. Zudem stellen die gefundenen Wirkstoffe eine gute Grundlage als Leitsubstanzen zur Entwicklung neuer Wirkstoffe dar. Weitere Versuche mit Kombinationen der wirksamen Substanzen sollten zur weiteren Therapiefindung durchgeführt werden. Damit hat die vorgelegte Arbeit eine hohe Relevanz für die weitere Forschung. / To this day, the process from development to approval of new antivirals is associated with high costs and a great deal of time. This process could be greatly shortened, if an effect of approved antiviral drugs on other viral infections could be shown. Therefore, the aim of this study was to evaluate the effect of approved drugs against infections with HSV-1, mCMV, hCMV, RSV, parainfluenza virus-3, DENV-2, CHIKV, poliovirus, measles virus and HIV-1. The polymerase inhibitors ACV, GCV, CDV, as well as the newer drug T-705 and the reverse transcriptase inhibitors TDF, 3TC, AZT and ABC were tested. In addition, the protease inhibitors SMV, GRV, DCV, LDV, ELB, VEL, SOF and DSV were included. TDF reduced the infectivity of HSV-1 and mCMV by up to 1 order of magnitude at a concentration of 10 μM. ABC also reduced the infectivity of HSV-1 and mCMV by 0.4 and 0.6 orders of magnitude, respectively, at a concentration of 30 μM. AZT and ELB reduced infectivity by 0.4 orders of magnitude in HSV-1 infections at a concentration of 30 μM. VEL reduced the infectivity of mCMV by 0.7 orders of magnitude up to a concentration of 2 μM. The substances ELB and LDV reduced the replication of DENV-2 by 0.6 and 0.8 orders of magnitude, respectively, at a concentration of 10 μM. However, the substances had no effect on CHIKV and poliovirus infections, and it was assumed that both substances had a virus-specific effect. No effect of the substances against infections with measles virus, RSV or parainfluenza virus-3 was observed in the trials. The methods used proved to be a fast and effective way to establish new direct antiviral drugs. In addition, the used drugs provide a good basis as lead substances for the development of new antiviral drugs. Further experiments with combinations of the active substances should be carried out in order to find further antiviral therapies. Thus, the submitted work has a high relevance for further research.

Objetivos: Descrever o uso e determinar a prevalência de medicamentos potencialmente perigosos e de uso off label e não aprovados em prescrições de unidades de pediatria geral de um hospital universitário no sul do Brasil. Método: Estudo transversal, realizado de novembro de 2007 a janeiro de 2008, envolvendo pacientes até 14 anos de idade, com período de internação superior a 24 horas. Pacientes de unidades de terapia intensiva e oncologia pediátrica foram excluídos. A classificação quanto aos critérios de aprovação da Food and Drug Administration foi realizada pela fonte terciária DrugDex-Micromedex e a classificação dos potencialmente perigosos, pelo Institute for Safe Medication Practices. Resultados e discussão: No período de estudo foram analisadas 342 prescrições de 342 pacientes. O sexo masculino foi o mais freqüente (57%) e mais da metade dos pacientes já apresentavam doenças crônicas à internação. Analgésicos foi a classe terapêutica mais prescrita (26,9%) e entre os off label, os antiespasmódicos (31,5%) foram os mais prevalentes. Das prescrições analisadas, aproximadamente 39% tiveram pelo menos um medicamento de uso off label prescrito, principalmente em relação à indicação terapêutica (38,4%) e à idade (21,9 %), e 11,8% dos pacientes fizeram uso de fármacos não aprovados. Do total de itens (2026), cerca de 6% foram classificados como potencialmente perigosos, destacando-se os analgésicos opióides (35%). Não houve relação de associação entre medicamentos de uso off label e os potencialmente perigosos. Conclusão: As frequências encontradas de medicamentos off label e não aprovados estão de acordo com a literatura e podem ser consideradas elevadas. Os potencialmente perigosos, apesar da baixa prevalência, oferecem risco pelos efeitos prejudiciais que possam vir a causar nos pacientes. Assim, os medicamentos em destaque neste estudo representam uma preocupação constante em hospitais. / Objectives: Describe the use and determine the prevalence of high-alert medications, off label use and unlicensed drugs in prescriptions of general pediatric units of a university hospital in southern Brazil. Method: Cross-sectional study, performed from November 2007 to January 2008, involving patients up to 14 years of age, with admission period over 24 hours. Patients of intensive care and pediatric oncology units were excluded. The classification regarding the Food and Drug Administration approval criteria was performed according to the DrugDex-Micromedex tertiary source and the classification of high-alert medications according to the Institute for Safe Medication Practices. Results e discussion: In the study period, 342 prescriptions were analyzed. Males were more frequent (57%) and over half of the patients already presented chronic diseases for admission. Analgesic drugs were the most frequently prescribed therapeutic class of drugs (26.9%) and among the off-label drugs, antispasmodic drugs (31.5%) were the most prevalent. Around 39% of the analyzed prescriptions had at least one off-label use drug, especially in relation to therapeutic indication (38.4%) and age (21.9%), and 11.8% of the patients received unlicensed drugs. About 6% of the total items (2026) were classified as high-alert medications, such as opioid analgesic drugs (35%). No relation of association was observed between off-label use and high-alert medications. Conclusion: The frequency analyses found of off-label and unlicensed drugs are according to the literature and can be considered as high. The high-alert medications, although of low prevalence, offer risks due to negative effects that can occur in patients. Then, the drugs highlighted in this study constitute a constant concern in hospitals.

Objetivos: Descrever o uso e determinar a prevalência de medicamentos potencialmente perigosos e de uso off label e não aprovados em prescrições de unidades de pediatria geral de um hospital universitário no sul do Brasil. Método: Estudo transversal, realizado de novembro de 2007 a janeiro de 2008, envolvendo pacientes até 14 anos de idade, com período de internação superior a 24 horas. Pacientes de unidades de terapia intensiva e oncologia pediátrica foram excluídos. A classificação quanto aos critérios de aprovação da Food and Drug Administration foi realizada pela fonte terciária DrugDex-Micromedex e a classificação dos potencialmente perigosos, pelo Institute for Safe Medication Practices. Resultados e discussão: No período de estudo foram analisadas 342 prescrições de 342 pacientes. O sexo masculino foi o mais freqüente (57%) e mais da metade dos pacientes já apresentavam doenças crônicas à internação. Analgésicos foi a classe terapêutica mais prescrita (26,9%) e entre os off label, os antiespasmódicos (31,5%) foram os mais prevalentes. Das prescrições analisadas, aproximadamente 39% tiveram pelo menos um medicamento de uso off label prescrito, principalmente em relação à indicação terapêutica (38,4%) e à idade (21,9 %), e 11,8% dos pacientes fizeram uso de fármacos não aprovados. Do total de itens (2026), cerca de 6% foram classificados como potencialmente perigosos, destacando-se os analgésicos opióides (35%). Não houve relação de associação entre medicamentos de uso off label e os potencialmente perigosos. Conclusão: As frequências encontradas de medicamentos off label e não aprovados estão de acordo com a literatura e podem ser consideradas elevadas. Os potencialmente perigosos, apesar da baixa prevalência, oferecem risco pelos efeitos prejudiciais que possam vir a causar nos pacientes. Assim, os medicamentos em destaque neste estudo representam uma preocupação constante em hospitais. / Objectives: Describe the use and determine the prevalence of high-alert medications, off label use and unlicensed drugs in prescriptions of general pediatric units of a university hospital in southern Brazil. Method: Cross-sectional study, performed from November 2007 to January 2008, involving patients up to 14 years of age, with admission period over 24 hours. Patients of intensive care and pediatric oncology units were excluded. The classification regarding the Food and Drug Administration approval criteria was performed according to the DrugDex-Micromedex tertiary source and the classification of high-alert medications according to the Institute for Safe Medication Practices. Results e discussion: In the study period, 342 prescriptions were analyzed. Males were more frequent (57%) and over half of the patients already presented chronic diseases for admission. Analgesic drugs were the most frequently prescribed therapeutic class of drugs (26.9%) and among the off-label drugs, antispasmodic drugs (31.5%) were the most prevalent. Around 39% of the analyzed prescriptions had at least one off-label use drug, especially in relation to therapeutic indication (38.4%) and age (21.9%), and 11.8% of the patients received unlicensed drugs. About 6% of the total items (2026) were classified as high-alert medications, such as opioid analgesic drugs (35%). No relation of association was observed between off-label use and high-alert medications. Conclusion: The frequency analyses found of off-label and unlicensed drugs are according to the literature and can be considered as high. The high-alert medications, although of low prevalence, offer risks due to negative effects that can occur in patients. Then, the drugs highlighted in this study constitute a constant concern in hospitals.

Objetivos: Descrever o uso e determinar a prevalência de medicamentos potencialmente perigosos e de uso off label e não aprovados em prescrições de unidades de pediatria geral de um hospital universitário no sul do Brasil. Método: Estudo transversal, realizado de novembro de 2007 a janeiro de 2008, envolvendo pacientes até 14 anos de idade, com período de internação superior a 24 horas. Pacientes de unidades de terapia intensiva e oncologia pediátrica foram excluídos. A classificação quanto aos critérios de aprovação da Food and Drug Administration foi realizada pela fonte terciária DrugDex-Micromedex e a classificação dos potencialmente perigosos, pelo Institute for Safe Medication Practices. Resultados e discussão: No período de estudo foram analisadas 342 prescrições de 342 pacientes. O sexo masculino foi o mais freqüente (57%) e mais da metade dos pacientes já apresentavam doenças crônicas à internação. Analgésicos foi a classe terapêutica mais prescrita (26,9%) e entre os off label, os antiespasmódicos (31,5%) foram os mais prevalentes. Das prescrições analisadas, aproximadamente 39% tiveram pelo menos um medicamento de uso off label prescrito, principalmente em relação à indicação terapêutica (38,4%) e à idade (21,9 %), e 11,8% dos pacientes fizeram uso de fármacos não aprovados. Do total de itens (2026), cerca de 6% foram classificados como potencialmente perigosos, destacando-se os analgésicos opióides (35%). Não houve relação de associação entre medicamentos de uso off label e os potencialmente perigosos. Conclusão: As frequências encontradas de medicamentos off label e não aprovados estão de acordo com a literatura e podem ser consideradas elevadas. Os potencialmente perigosos, apesar da baixa prevalência, oferecem risco pelos efeitos prejudiciais que possam vir a causar nos pacientes. Assim, os medicamentos em destaque neste estudo representam uma preocupação constante em hospitais. / Objectives: Describe the use and determine the prevalence of high-alert medications, off label use and unlicensed drugs in prescriptions of general pediatric units of a university hospital in southern Brazil. Method: Cross-sectional study, performed from November 2007 to January 2008, involving patients up to 14 years of age, with admission period over 24 hours. Patients of intensive care and pediatric oncology units were excluded. The classification regarding the Food and Drug Administration approval criteria was performed according to the DrugDex-Micromedex tertiary source and the classification of high-alert medications according to the Institute for Safe Medication Practices. Results e discussion: In the study period, 342 prescriptions were analyzed. Males were more frequent (57%) and over half of the patients already presented chronic diseases for admission. Analgesic drugs were the most frequently prescribed therapeutic class of drugs (26.9%) and among the off-label drugs, antispasmodic drugs (31.5%) were the most prevalent. Around 39% of the analyzed prescriptions had at least one off-label use drug, especially in relation to therapeutic indication (38.4%) and age (21.9%), and 11.8% of the patients received unlicensed drugs. About 6% of the total items (2026) were classified as high-alert medications, such as opioid analgesic drugs (35%). No relation of association was observed between off-label use and high-alert medications. Conclusion: The frequency analyses found of off-label and unlicensed drugs are according to the literature and can be considered as high. The high-alert medications, although of low prevalence, offer risks due to negative effects that can occur in patients. Then, the drugs highlighted in this study constitute a constant concern in hospitals.

Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / nÃo hà / A Flutamida à um medicamento anti-androgÃnico nÃo esterÃide aprovado para o tratamento do cÃncer de prÃstata. Seu efeito hepatotÃxico foi conhecido desde o inÃcio do perÃodo de comercializaÃÃo, hà mais de 10 anos. Em marÃo e junho de 2002, a Unidade de FarmacovigilÃncia da ANVISA recebeu as primeiras comunicaÃÃes de Ãbitos por hepatite fulminante associados ao uso da substÃncia (medicamento manipulado) em jovens do sexo feminino. A literatura mundial nunca registrara caso semelhante. O objetivo deste trabalho foi revisar e acrescentar informaÃÃes a respeito da seguranÃa da Flutamida quando utilizadas por pacientes do sexo feminino para o tratamento de hirsutismo, acne e alopecia androgenÃtica. Foram realizadas pesquisas para conhecer a indicaÃÃo aprovada em outros paÃses e as notificaÃÃes de reaÃÃes adversas graves em mulheres no banco de dados da OMS. AlÃm disso, por meio de busca ativa, tentou-se identificar outros casos no Brasil; rever as informaÃÃes das bulas de todos os medicamentos comercializados e analisar se as informaÃÃes obrigatÃrias e relevantes para diminuir o risco de reaÃÃes hepÃticas graves estavam presentes. Por fim, foi realizada pesquisa com os prescritores, por meio de questionÃrio eletrÃnico, para conhecer as informaÃÃes de que dispunham sobre a utilizaÃÃo do medicamento em mulheres e comparar estas informaÃÃes com uma revisÃo crÃtica da literatura no que tange à seguranÃa e eficÃcia. Os resultados de todas estas estratÃgias mostraram que a substÃncia tambÃm à utilizada off label em mulheres em outros paÃses, e tambÃm causou reaÃÃes adversas graves, mas nenhum Ãbito no sexo feminino fora relatado. Durante o trabalho, outros casos de Ãbito no Brasil foram identificados. Todas as bulas comercializadas no Brasil mencionavam que a substÃncia nÃo devia ser utilizada por mulheres, assim como mencionavam as reaÃÃes hepÃticas graves. As respostas dos prescritores ao questionÃrio permitem afirmar que a Flutamida se constitui em importante arsenal terapÃutico, e que o risco de seu uso vem sendo subestimado. O trabalho permite concluir que a Flutamida mostra-se eficaz para as condiÃÃes em que vem sendo utilizada em mulheres. Entretanto, os riscos evidenciam uma relaÃÃo benefÃcio/risco inaceitÃvel para as condiÃÃes estÃticas em que vem sendo empregada. / Flutamide is a non steroid anti-androgenic drug used to treat prostate cancer patients. When it became commercialized, more than 10 years ago, the hepatotoxic effect of flutamide was already recognized. In March and July 2002, the first cases of deaths in young females caused by fulminant hepatitis associated to off label use of this substance (magistral drug) was reported to the Pharmacovigilance Office/ANVISA. Up to now, similar cases were not described in the international literature. This work aimed to review and add information about the adequate use of flutamide by female patients to treat hirsutism, acne and androgenetic alopecia. To identify the standard prescriptions and the reported serious reactions in females worldwide, an extensive research through data provided by OMS was conducted. Moreover, using active search we looked for new local cases and review the information from package insert of all commercialized drugs in Brazil to analyze if the required and relevant information warning patients against the serious hepatic risks were provided. Finally, a survey with the prescribers was carried on through the web to identify the available information about the use of this drug in females and to make comparisons with data from the literature about the safety and efficacy of the use of this substance. The results showed that this substance is also used off label by women from other countries, who also presented serious adverse reactions. However, it was not reported any case of female death. Over the study, new cases of obituary occurred in Brazil, despite all analyzed package insert explain that this substance should not be used by females and mention serious hepatic reactions. The answers of the prescribers to the survey indicated that flutamide is an important therapeutic arsenal and that the risk of the use of this substance seem to have been underestimated. We concluded that flutamide is effective for the women treatment which it has been used. However, the threats of this drug point to the unacceptable use of this drug when applied for the esthetic finality.

Paracetamol är ett vanligt använt läkemedel med analgesisk och antipyretisk effekt. Läkemedlet finns tillgängligt i ett flertal beredningsformer och doseringsstyrkor för användning både receptfritt och i sjukhusvården. Syftet med detta projekt var att undersöka påverkan av alternativ, off-label, dosering av paracetamol i pediatrisk vård, med hjälp av fysiologiskt baserad farmakokinetisk (PBPK) modellering. Modellen utvecklades först för en vuxen population genom integrering av in vitro, in vivo och in silico data för paracetamol. Efter detta extrapolerades concentrationskurvor till en pediatrisk population med hjälp av ontogeni-information. Modellen validerades i både vuxna och barn, och var tillförlitlig för både peroral och intravenös dosering. Efter valideringen utfördes simuleringar för nio olika åldersgrupper baserat på rekommenderade doseringsprotokoll i Sverige. Simuleringarna visade att perorala tablettdoseringen var jämförbar med formulering i lösningsform, med snarlika maximumkoncentrationer och area-under-kurvan (AUC) för exponering. Hastigheten av magtömning influerade maximumkoncentrationer men inte AUC. Ytterligare testades modellens förmåga att prediktera plasmakoncentrationer i blodet efter överdosering med paracetamol. Dessa prediktioner fungerade bättre när läkemedelsmetaboliserande enzymer lämnades oförändrade, eller ökade något i aktivitet. Slutligen, den utvecklade PBPK-modellen kan användas för att säkert undersöka olika doseringsprotokoll och för design av pediatriska kliniska studier. / Paracetamol, a widely used analgesic and antipyretic drug, can be found in various formulations and doses for both home and hospital use. The aim of this study was to investigate the impact of off-label dosing of paracetamol in pediatric clinical practice using physiologically based pharmacokinetic (PBPK) modeling. The model was initially developed for adults by integrating relevant in vitro, in vivo and in silico data of paracetamol, after which the model was extrapolated for pediatrics by adding ontogeny information. The model was successfully validated in both adult and pediatric populations, and it showed accuracy for both oral and intravenous administration routes. After validation, simulations were conducted across nine different age groups following the recommended doses in Sweden. These simulations showed that tablet dose is comparable to solution dosing, resulting in nearly identical maximum concentrations and area under the curve (AUC) values. Furthermore, it was observed that gastric emptying time, which reflects the fed state of individuals, significantly influences the maximum concentration, with longer gastric emptying times resulting in lower and delayed peak concentrations. However, the gastric emptying time had no effect on the AUC values. Lastly, the model’s performance on overdose data was evaluated, and it turned out that it performs better when liver enzymes were not affected, or they were only slightly elevated. Finally, the developed PBPK model can be further used for safe and effective way of exploring dose banding and designing clinical trials in pediatrics.

The American Medical Association (AMA) has estimated that as many as 40 percent of all prescriptions are issued for off-label use. Off-label prescribing is considered to be clinically beneficial and rational in certain life-threatening situations. However, off-label use can pose risks to patients in terms of adverse drug events as well as contribute to rising pharmaceutical costs. The anti-anemic drugs erythropoietin and darbepoetin are costly, and there are significant off-label uses for these drugs some of which are not supported with clinical evidence, hence were selected as study drugs. Our study goals included quantification of the prevalence rate and appropriateness of off-label use of erythropoietin and darbepoetin across U.S. hospitals, and identification of possible predictors of off-label use from the domains of patient characteristics, physician specialty, hospital characteristics and drug characteristics. To address the research questions we performed a retrospective review of 464,834 discharged patients across 515 hospitals who have received erythropoietin and darbepoetin from the time periods between 2001and 2004. The data was supplied by Solucient®. The uses of the two drugs have been categorized using an evidence-based medicine framework that classifies them into: a) on-label use (approved by the FDA), b) off-label use supported (use not approved by FDA but there is strong clinical evidence supporting off-label use), and c) off-label use unsupported (lack of clinical evidence). A multinomial logistic regression model clustered by hospitals was conducted to determine predictors of off-label use. The results of this study revealed that more than half of the utilization of the two erythropoietic drugs is for off-label purposes, the majority of which is supported with evidence. Among the covariates, physician specialty, patient age group, race, drug coverage and length of hospital stay were significant (0.05 level) predictors of off-label use (supported and unsupported) relative to on-label. It is useful to understand the extent and appropriateness of off-label utilization in order to ensure safe and cost-effective use in patients. The availability of empirically derived knowledge on the national level could precipitate the promulgation of more meaningful post-marketing surveillance measures.