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Population-Based Analysis of Non-Steroidal Anti-Inflammatory

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Population-Based Analysis of Non-Steroidal Anti-Inflammatory Valkhoff et al. BMC Pediatrics 2013, 13:192 http://www.biomedcentral.com/1471-2431/13/192 RESEARCH ARTICLE Open Access Population-based analysis of non-steroidal anti-inflammatory drug use among children in four European countries in the SOS project: what size of data platforms and which study designs do we need to assess safety issues? Vera E Valkhoff1,2, René Schade1*, Geert W ‘t Jong1,3,4, Silvana Romio1,5, Martijn J Schuemie1, Andrea Arfe5, Edeltraut Garbe6, Ron Herings7, Silvia Lucchi8, Gino Picelli9, Tania Schink6, Huub Straatman7, Marco Villa8, Ernst J Kuipers2, Miriam CJM Sturkenboom1,10 and on behalf of the investigators of The Safety of Non-steroidal Anti-inflammatory Drugs (SOS) project Abstract Background: Data on utilization patterns and safety of non-steroidal anti-inflammatory drugs (NSAIDs) in children are scarce. The purpose of this study was to investigate the utilization of NSAIDs among children in four European countries as part of the Safety Of non-Steroidal anti-inflammatory drugs (SOS) project. Methods: We used longitudinal patient data from seven databases (GePaRD, IPCI, OSSIFF, Pedianet, PHARMO, SISR, and THIN) to calculate prevalence rates of NSAID use among children (0–18 years of age) from Germany, Italy, Netherlands, and United Kingdom. All databases contained a representative population sample and recorded demographics, diagnoses, and drug prescriptions. Prevalence rates of NSAID use were stratified by age, sex, and calendar time. The person-time of NSAID exposure was calculated by using the duration of the prescription supply. We calculated incidence rates for serious adverse events of interest. For these adverse events of interest, sample size calculations were conducted (alpha = 0.05; 1-beta = 0.8) to determine the amount of NSAID exposure time that would be required for safety studies in children. Results: The source population comprised 7.7 million children with a total of 29.6 million person-years of observation. Of those, 1.3 million children were exposed to at least one of 45 NSAIDs during observation time. Overall prevalence rates of NSAID use in children differed across countries, ranging from 4.4 (Italy) to 197 (Germany) per 1000 person-years in 2007. For Germany, United Kingdom, and Italian pediatricians, we observed high rates of NSAID use among children aged one to four years. For all four countries, NSAID use increased with older age categories for children older than 11. In this analysis, only for ibuprofen (the most frequently used NSAID), enough exposure was available to detect a weak association (relative risk of 2) between exposure and asthma exacerbation (the most common serious adverse event of interest). (Continued on next page) * Correspondence: [email protected] 1Department of Medical Informatics, Erasmus University Medical Center, Dr. Molewaterplein, Rotterdam, The Netherlands Full list of author information is available at the end of the article © 2013 Valkhoff et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Valkhoff et al. BMC Pediatrics 2013, 13:192 Page 2 of 12 http://www.biomedcentral.com/1471-2431/13/192 (Continued from previous page) Conclusions: Patterns of NSAID use in children were heterogeneous across four European countries. The SOS project platform captures data on more than 1.3 million children who were exposed to NSAIDs. Even larger data platforms and the use of advanced versions of case-only study designs may be needed to conclusively assess the safety of these drugs in children. Keywords: Pharmacoepidemiology, Database, Drug utilization, Health resource utilization, Drug safety, Sample size, Asthma exacerbation, Self-controlled case series design, Case-crossover design Background databases contain a representative sample of the respective Non-steroidal anti-inflammatory drugs (NSAIDs) are fre- populations based on age and sex. This analysis was exclu- quently used for their analgesic, antipyretic, and anti- sively based on routinely collected anonymized data and inflammatory effects, even in children. NSAIDs were adhered to the European Commission’s Directive 95/46/EC the tenth most frequently prescribed drug in the age for data protection. The protocol for this drug-utilization group 2–11years(33users/1000personyears)andthe study was approved by the databases’ scientific and ethical sixth most frequently prescribed drug in age group 12– advisory boards or regulatory agencies where applicable. 18 years (57 users/1000 person years) in a combined The databases are described as follows. primary care database study conducted in Italy, the Netherlands and the United Kingdom [1]. German pharmacoepidemiological research The Safety of Non-steroidal Anti-inflammatory Drugs database (GePaRD) (SOS) project is a research and development project GePaRD is a claims database and consists of claims data funded by the Health Area of the European Commission from four German statutory health insurance (SHI) pro- under the Seventh Framework Programme, with the aim viders. It covers about 14 million persons throughout to assess the cardiovascular and gastrointestinal safety of Germany who have at any time between 2004 and 2008 NSAIDs, in particular with respect to children [2]. In the been enrolled in one of the four SHIs. The database SOS project, prior to conducting novel observational population represents approximately 17% of the German studies on NSAID safety by linking seven databases from population. Available data contain demographic informa- four European countries, data from published clinical tion and information on hospital discharges, outpatient trials and observational studies have been investigated physician visits, and outpatient dispensing of prescribed by literature review and meta-analysis. This literature medications in the pharmacies. Hospital diagnoses are review revealed that safety of NSAIDs in children has coded according to the German Modification of the not been adequately assessed in clinical trials nor post- International Classification of Diseases, 10th Revision marketing studies since most of these studies were too (ICD-10 GM) with at least 4 digits [4]. Information on small and short to detect infrequent adverse events. In drug prescriptions is linked to a pharmaceutical reference addition, the Paediatric Working Party of the European database providing information on the World Health Medicines Agency (EMA) has identified the need to Organization’s (WHO) anatomical-therapeutic-chemical study safety issues related to specific NSAIDs, such as (ATC) code [5], prescribed quantity (number of packages), diclofenac, ibuprofen, ketoprofen, and naproxen [3]. prescription date, dispensation date, substance, product In this study, as part of the SOS project, we aimed to name, manufacturer, pack size, strength, defined daily investigate NSAID utilization patterns among children dose (DDD), and pharmaceutical formulation. All involved in four European countries and assess statistical power SHIs, the Federal Ministry of Health (for data from to study NSAID safety for ten adverse events of interest. multiple federal states) and the health authority of Bremen (for data from the Federal State of Bremen) approved the Methods use of the data for this study. Data sources Data for this study were obtained from seven longitudinal The Health Improvement Network (THIN) database observational databases from four European countries THIN is a longitudinal database of primary care medical involving medical data from more than 32 million people. records from more than 10 million people in the UK. Three primary care databases and four hospital discharge Some electronic records date back to 1985. Currently, or administrative databases provided data from Germany the database has 3.6 million active patients registered. (DE), Italy (IT), the Netherlands (NL) and the United Data recorded in THIN include demographics, diagnoses, Kingdom (UK) (Table 1). All databases recorded demo- symptoms, prescriptions, life style information such as graphics, diagnoses, and drug prescriptions. Participating smoking or alcohol consumption, test results, height, Valkhoff http://www.biomedcentral.com/1471-2431/13/192 et al. BMC Pediatrics 2013, 13 :192 Table 1 Study population and database characteristics Pediatric source population (Age 0 to 18 years) Database Country Type of database Diagnoses captured with: Drugs captured with: Study period Number of persons Person-years of Number of observation NSAID users GePaRD Germany Claims database ICD-10-GM ATC 2005 - 2008 2,992,087 7,056,919 925,667 THIN United Kingdom General practice database READ BNF/Multilex/ATC 1999 – 2008 1,261,668 5,198,351 227,927 IPCI Netherlands General practice database ICPC and free text ATC 1999 – 2011 250,296 618,479 12,002 PHARMO Netherlands Record linkage system ICD-9-CM ATC 1999 – 2008 594,800 2,914,576 82,233 OSSIFF Italy National Health Services registry (claims) ICD-9-CM ATC 2000 – 2008 675,197 3,671,014 22,760 SISR Italy National Health Services registry (claims) ICD-9-CM ATC 2002 – 2009 1,744,525 9,111,635 34,308 Pedianet* Italy General practice pediatric database ICD-9-CM and free text ATC 2000 – 2010 221,115 1,064,867 34,575 Total 7,739,688 29,635,841 1,339,472 *Pedianet only includes children up to the age of 14 years. ICD-10-GM: International
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