Off-label use


Off-label use

Off-label use is the practice of prescribing pharmaceuticals for an unapproved indication or in an unapproved age group, unapproved dose or unapproved form of administration.[1] In the United States, the Food and Drug Administration Center for Drug Evaluation and Research (CDER) reviews a company's New Drug Application (NDA) for data from clinical trials to see if the results support the drug for a specific use or indication.[2] If satisfied that the drug is safe and effective, the drug's manufacturer and the FDA agree on specific language describing dosage, route of administration, and other information to be included on the drug's label. More detail is included in the drug's package insert.

The FDA approves a drug for prescription use, and will continue to regulate the pharmaceutical industry through the work of the Division for Drug Marketing, Advertisement and Communication (DDMAC).[3] The FDA does not have the legal authority to regulate the practice of the medicine, and the physician may prescribe a drug off label. Contrary to popular notion, it is legal in the United States and in many other countries to use drugs off label, including controlled substances such as opiates. Actiq, for example, is commonly prescribed off label even though it is a Schedule II controlled substance. While it would be legal for a physician to independently decide to prescribe a drug such as Actiq off-label, it is illegal for the company to promote off-label uses to prescribers. In fact, Cephalon, the maker of Actiq, was fined for illegal promotion of the drug in September 2008.[4] Under the Food, Drug, and Cosmetic Act (FDAC) at U.S.C. 21 §§301-97, manufacturers are prohibited from directly marketing a drug for a use other than the FDA approved indication. The Food and Drug Administration Modernization Act of 1997 created an exception to the prohibition of off-label marketing. Manufacturers are now able to provide medical practitioners with off-label information in response to an unsolicited request. 21 U.S.C. §360aaa-6.

Contents

Frequency of Off-label use

Off-label use of medications is very common. Generic drugs generally have no sponsor as their indications and use expands, and incentives are limited to initiate new clinical trials to generate additional data for approval agencies to expand indications of proprietary drugs.[1] Up to one-fifth of all drugs are prescribed off label and amongst psychiatric drugs, off-label use rises to 31 %.[5] Among use of antipsychotic medications in the United States, a shift occurred from typical agents in 1995 (84% of all antipsychotic visits) to atypical agents by 2008 (93%). Atypical use has grown far beyond substitution for the now infrequently used typical agents. [6] New drugs are often not tested for safety and efficacy specifically in children and even when they are tested, the results of these trials may not be disseminated to practicing physicians. A 2009 study found that 62% of U.S. pediatric office visits included off-label prescribing, with younger children at higher risk of receiving off-label prescriptions. Specialist physicians also prescribed off-label more frequently than general pediatricians.[7][8]

A study published in 2006 found that off-label use was the most common in cardiac medications and anticonvulsants. This study also found that 73% of off-label use had little or no scientific support [5]

By default use of non-approved drugs is common in obstetrics as, by 2010, during almost five decades of activity the FDA had approved only two drugs for obstetrical indications, namely oxytocin and cervidil.[9] A small market and the high risk of medicolegal action, as exemplified by the Bendectin case, may explain the reluctance to develop drugs for approval.[9]

Some drugs are used more frequently off label than for their original, FDA-approved indications. A 1991 study by the U.S. General Accounting Office found that one-third of all drug administrations to cancer patients were off label, and more than half of cancer patients received at least one drug for an off-label indication. A 1997 survey of 200 cancer doctors by the American Enterprise Institute and the American Cancer Society found that 60% of them prescribed drugs off label.[8][10] In some cases, patients may perceive the efficacy of treatments for off-label purposes to be higher than for their indicated purpose.[11] Frequently, the standard of care for a particular type or stage of cancer involves the off-label use of one or more drugs. An example is the use of tricyclic antidepressants to treat neuropathic pain. This old class of antidepressants is now rarely used for clinical depression due to side effects, but the tricyclics are often effective for treating pain.

Regulations of off-label use in different countries

United States

In the United States, FDA regulations permit physicians and other healthcare practitioners to prescribe approved medications for other than their approved indications. Pharmaceutical companies are not allowed to promote a drug for any other purpose without formal FDA approval. Marketing information for the drug will list one or more indications, that is, illnesses or medical conditions for which the drug has been shown to be both safe and effective.

However, once a drug has been approved for sale for one purpose, physicians are free to prescribe it for any other purpose that in their professional judgment is both safe and effective, and are not limited to official, FDA-approved indications. This off-label prescribing is most commonly done with older, generic medications that have found new uses but have not had the formal (and often costly) applications and studies required by the FDA to formally approve the drug for these new indications. However, there is usually extensive medical literature to support the off-label use.

In 1993, the US FDA approved gabapentin, marketed by Pfizer under the name "Neurontin", only for treatment of seizures. Pfizer subsidiary Warner-Lambert used activities not usually associated with sales promotion, including continuing medical education and research, to promote gabapentin, so that within 5 years the drug was being widely used for the off-label treatment of pain and psychiatric conditions. In 2004, Warner-Lambert admitted to charges that it violated FDA regulations by promoting the drug for pain, psychiatric conditions, migraine, and other unapproved uses.[12] The company paid $430 million to the federal government to settle the case.[13]

Access to pharmaceutical industry documents have revealed marketing strategies used to promote drugs for off-label use.[14] The United States federal government is aggressively pursuing criminal and civil cases against pharmaceutical companies and their employees for promoting off-label uses of prescription drugs.[15] Between 2003 and 2008, U.S. federal prosecutors and state attorneys general brought more than a dozen cases against drug makers for off-label marketing and won more than $6 billion in criminal and civil settlements.[16] In September 2009, Pfizer paid $1.3 billion, the largest criminal fine ever imposed in the United States, for the off-label marketing of Bextra and three other drugs. Pfizer paid an additional $1 billion in civil penalties resulting from the same illegal activities.[17]

United Kingdom

Physicians in the United Kingdom can prescribe medications off-label. According to the British General Medical Council, off-label prescriptions must better serve patient needs than alternatives and must be supported by evidence or experience to demonstrate safety and efficacy.[18]

Examples of off-label use (and non-use)

Veterinary medicine

The veterinarian has a much smaller pharmacopeia available than does the human practitioner. Therefore, drugs are more likely to be used "off-label"—typically, this involves the use of a human medication in an animal, where there is no corresponding medication licenced for that species. This problem is compounded in "exotic" species (such as reptiles and rodents) where there are very few, if any licenced medications. In addition, especially in Europe, equine veterinarians are forced to use many drugs off-label, as the horse is classified as a "food-producing animal" and many veterinary drugs are labeled specifically not for use in animals intended for human consumption.

This practice is permitted by the Animal Medicinal Drug Use Clarification Act of 1994 (P.L. 103-396). FDA specifically prohibits extralabel use of a number of antibiotics, anti-inflammatory drugs and hormones in food producing animals. FDA also tightly controls the use of certain veterinary-prescribed drugs when administered in the feed of food-producing animals.[28]

Research relating to off-label use

According to a national random mail survey of 599 primary care physicians and 600 psychiatrists, there is a strong indication between a physician’s belief that a use is FDA-approved and the known evidence supporting that use, although almost half of physicians believed one off-label use that had little or no supporting evidence. This shows that there is a need for informing physicians about the evidence supporting off-label prescriptions, although the FDA only regulates drug marketing not drug prescribing.[29]

See also

Largent EA, Miller FG, Pearson SD. "Going Off-label Without Venturing Off-Course: Evidence and Ethical Off-label Prescribing." Arch Intern Med. 2009;169:1745-1747.

Mortenson LE. "The off-label debate: a threat to the future of cancer care." Cancer Invest. 1991;9:597-599.

References

  1. ^ a b Randall S. Stafford. "Regulating Off-Label Drug Use — Rethinking the Role of the FDA". N Engl J Med 2008; 358:1427-1429. http://content.nejm.org/cgi/content/full/358/14/1427. 
  2. ^ http://www.fda.gov/Drugs/DevelopmentApprovalProcess/default.htm
  3. ^ http://www.fda.gov/AboutFDA/CentersOffices/CDER/ucm090142.htm
  4. ^ http://www.usdoj.gov/archive/opa/pr/2008/September/08-civ-860.html
  5. ^ a b David C. Radley; Stan N. Finkelstein; Randall S. Stafford (2006). "Off-label Prescribing Among Office-Based Physicians". Archives of Internal Medicine 166 (9): 1021–1026. doi:10.1001/archinte.166.9.1021. PMID 16682577. http://archinte.ama-assn.org/cgi/content/full/166/9/1021. 
  6. ^ Alexander GC; Gallagher SA; Mascola A; (2011). "Increasing off-label use of antipsychotic medications". Pharmacoepidemiology and Drug Safety 20 (2): 177-184. doi:10.1002/pds.2082. PMID 21254289. http://www.ncbi.nlm.nih.gov/pubmed/21254289. 
  7. ^ Alicia Bazzano MD MPH; Rita Mangione-Smith MD; Matthias Schonlau PhD; Marika Suttorp MS; Robert Brook MD ScD (2009). "Off-label prescribing to children in the United States outpatient setting.". Ambulatory Pediatrics 9: 81–8. 
  8. ^ a b http://www.npr.org/templates/story/story.php?storyId=95985619
  9. ^ a b c d Wing DA, Powers B, Hickok D (2010). "U.S. Food and Drug Administration Drug Approval: Slow Advances in Obstetric Care in the United States". Obstetrics & Gynecology: April 2010 - Volume 115 - Issue 4 - pp 825-833 115 (4): 825–33. doi:10.1097/AOG.0b013e3181d53843. PMID 20308845. 
  10. ^ "Why is off-label use of drugs so common in cancer treatment?". National Cancer Institute. http://www.cancer.gov/clinicaltrials/learning/approval-process-for-cancer-drugs/allpages#Anchor-Wh-36735. Retrieved 2009-07-12. 
  11. ^ Jeana Frost, Sally Okun, Timothy Vaughan, James Heywood, Paul Wicks (2011). "Patient-reported Outcomes as a Source of Evidence in Off-Label Prescribing: Analysis of Data From PatientsLikeMe". Journal of Medical Internet Research 13 (1): e6. doi:10.2196/jmir.1643. PMID 21252034. 
  12. ^ Jane E. Henney, MD (15 August 2006). "Editorial: Safeguarding Patient Welfare: Who's In Charge?". Annals of Internal Medicine 145 (4): 305–307. PMID 16908923. http://www.annals.org/cgi/content/full/145/4/305?etoc. Retrieved 2006-08-14. 
  13. ^ US Department of Justice Press Release: Warner-Lambert to Pay $430 Million to Resolve Criminal & Civil Health Care Liability Relating to Off-Label Promotion, retrieved 14 August 2006
  14. ^ Michael A. Steinman, MD; Lisa A. Bero, PhD; Mary-Margaret Chren, MD; and C. Seth Landefeld, MD (15 August 2006). "Narrative Review: The Promotion of Gabapentin: An Analysis of Internal Industry Documents" (abstract). Annals of Internal Medicine 145 (4): 284–293. PMID 16908919. http://www.annals.org/cgi/content/abstract/145/4/284. Retrieved 2006-08-14. 
  15. ^ Erika Kelton, "Sales tactics, whistleblowers and qui tam lawsuits in the pharmaceutical industry"
  16. ^ Chris Adams (February 1, 2009). "Late move on drugs by Bush FDA could be dangerous". McClatchy Newspapers. http://www.mcclatchydc.com/227/story/61113.html. 
  17. ^ http://www.usdoj.gov/opa/pr/2009/September/09-aag-900.html
  18. ^ http://www.gmc-uk.org/guidance/current/library/prescriptions_faqs.asp#5d
  19. ^ http://www.joepaduda.com/archives/000875.html
  20. ^ Boseley, Sarah (2006-06-17). "Drugs firm blocks cheap blindness cure". The Guardian (London). http://www.guardian.co.uk/medicine/story/0,,1799772,00.html. Retrieved 2010-05-20. 
  21. ^ http://www.naabt.org/documents/The_Buprenorphine_effect_on_Depression.pdf
  22. ^ Bodkin JA. et al. (1995): "Buprenorphine Treatment of Refractory Depression", Journal of Clinical Psychopharmacology 15:49-57. PMID 7714228
  23. ^ http://www.leeheymd.com/charts/dep4_1.html
  24. ^ http://ajp.psychiatryonline.org/cgi/reprint/140/7/957
  25. ^ http://idahodur.isu.edu/leaflets/2004/GABAPENTIN%20EDU%20LEAFLET%202004.pdf
  26. ^ http://drugs.nmihi.com/whd/pregnancy.html
  27. ^ http://www.emedicine.com/med/topic643.htm#section~Medication
  28. ^ CRS Report for Congress: Agriculture: A Glossary of Terms, Programs, and Laws, 2005 Edition - Order Code 97-905
  29. ^ Chen DT, Wynia MK, Moloney RM, Alexander GC. U.S. Physician knowledge of the FDA-approved indications of commonly prescribed drugs: results of a national survey. Pharmacoepidemiology and Drug Safety. 2009;18:1-7 [1]

External references


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  • Off-Label-Use — Dieser Artikel oder Absatz stellt die Situation in Deutschland dar. Hilf mit, die Situation in anderen Ländern zu schildern. Unter zulassungsüberschreitender Anwendung, engl. off label use, versteht man die Verordnung eines zugelassenen… …   Deutsch Wikipedia

  • Off-Label Use — Dieser Artikel oder Absatz stellt die Situation in Deutschland dar. Hilf mit, die Situation in anderen Ländern zu schildern. Unter Off Label Use versteht man die Verordnung eines zugelassenen Fertigarzneimittels außerhalb des in der Zulassung… …   Deutsch Wikipedia

  • Off-label use — Dieser Artikel oder Absatz stellt die Situation in Deutschland dar. Hilf mit, die Situation in anderen Ländern zu schildern. Unter Off Label Use versteht man die Verordnung eines zugelassenen Fertigarzneimittels außerhalb des in der Zulassung… …   Deutsch Wikipedia

  • Off label use — Dieser Artikel oder Absatz stellt die Situation in Deutschland dar. Hilf mit, die Situation in anderen Ländern zu schildern. Unter Off Label Use versteht man die Verordnung eines zugelassenen Fertigarzneimittels außerhalb des in der Zulassung… …   Deutsch Wikipedia

  • off-label use — veterinarinio vaisto naudojimas ne pagal veterinarinio vaisto aprašą statusas Aprobuotas sritis veterinariniai vaistai apibrėžtis Veterinarinio vaisto naudojimas, neatitinkantis veterinarinio vaisto aprašo nuostatų, ypač netinkamas naudojimas ar… …   Lithuanian dictionary (lietuvių žodynas)

  • Off-label use — In the United States, the regulations of the Food and Drug Administration (FDA) permit physicians to prescribe approved medications for other than their intended indications. This practice is known as off label use …   Medical dictionary

  • off label — or off la|bel «AWF LAY buhl, of », adjective. of or having to do with the use of a prescription drug to treat a condition for which the drug is not approved by the U.S. Food and Drug Administration: »A doctor who prescribes medications for an… …   Useful english dictionary

  • off-label — off la·bel .ȯf .lā bəl adj of, relating to, or being an approved drug legally prescribed or a medical device legally used by a physician for a purpose (as the treatment of children or of a certain disease or condition) for which it has not been… …   Medical dictionary

  • Off-label — Dieser Artikel oder Absatz stellt die Situation in Deutschland dar. Hilf mit, die Situation in anderen Ländern zu schildern. Unter Off Label Use versteht man die Verordnung eines zugelassenen Fertigarzneimittels außerhalb des in der Zulassung… …   Deutsch Wikipedia

  • off label — adverb Use of a prescription medication by a physician to treat a condition other than that for which the drug was approved by the Food and Drug Administration (FDA). While the drug is approved for use in treating stomach cancer, many doctors… …   Wiktionary


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