Off-label guide welcomed

LEADING doctors have backed a new national framework for off-label prescribing which recommends obtaining written patient consent and closely monitoring treatment outcomes.

Developed by the Council of Australian Therapeutic Advisory Groups (CATAG), the framework provides guiding principles for hospital-based doctors to get through the ethical minefield of prescribing drugs for indications not approved by the Therapeutic Goods Administration, or involving non-approved patient groups or routes of administration. (1)

Professor Madlen Gazarian, co-chair of the expert advisory group that wrote the document, told MJA InSight the framework asked prescribers, drug and therapeutics committees and consumers to more rigorously evaluate the benefits and harms of off-label medicines before starting treatment.

“For example, we are asking doctors to see if there is a clearly demonstrated benefit of a new medication over an older one before deciding to prescribe the newer drug off-label. We don’t believe this question is being systematically asked at the moment”, she said.
    
In a letter published in the MJA, Professor Gazarian and coauthor Steve Morris, chair of CATAG, wrote that there were seven overarching guiding principles, including a core principle of systematic evaluation of the evidence base and risk–benefit ratio for proposed off-label uses. (2)

They wrote that applying the principles in routine practice would help address clinical, safety and ethical concerns. “CATAG anticipates undertaking future work to support wider implementation of the guiding principles.”

Professor Gazarian told MJA InSight the framework included a series of questions for doctors to determine what kind of off-label use may be appropriate — “routine use”, “exceptional/individual use”, “conditional use, with evidence development” or “research or investigational use”.

For example, based on current evidence, valproate for migraine would be considered “routine use”, while rituximab for chronic, refractory immune thrombocytopenic purpura in adults would be considered appropriate only for “exceptional/individual use”.

If a proposed off-label use does not fall into one of the four categories, its use is “not recommended”.

Controversially, Professor Gazarian said using proton pump inhibitors in infants to treat gastro-oesophageal reflux would fall into the “not recommended” category, as “currently available evidence indicates they are not effective in this age group and their longer-term safety is unknown ... the overall harm–benefit ratio may be unfavourable”. (3)

In all but “routine” off-label uses of medicine, the framework says written informed patient consent should be obtained.

However, Professor Gazarian said CATAG was concerned about “creating paperwork without adding benefit”. They therefore recommended hospitals develop a generic information leaflet and consent form for prescribers when discussing off-label medicines, and the creation of education and training tools.

CATAG also said further work was needed to build an off-label use of medicines registry to improve pharmacovigilance and a centralised evidence-evaluation process for selected types of off-label uses.

The principles have been applauded by two experts who recently wrote about potential pitfalls of off-label prescribing in the MJA.

In an MJA editorial Professor Ian Hickie, of Sydney’s Brain and Mind Research Institute, raised public and professional concerns about medications not indicated for common mental health conditions often being prescribed. (4)

In a separate MJA editorial, Professor Paul Seale, professor of pharmacology at the University of Sydney, discussed the need to fully inform patients when prescribing off-label. (5)

Professor Hickie told MJA InSight he strongly supported the push for a registry for off-label uses of medicines.

“There are a whole lot of areas of medicine where large-scale studies are never going to be done but there are good reasons for considering use of medicines — particularly geriatrics, paediatrics, complex patients”, Professor Hickie said.

“In these areas, we should be using new e-health-based systems to monitor patient experiences, not just adverse events.”

Professor Mark Nelson, chair of the discipline of general practice at Tasmania’s Menzies Research Institute, said the recommendations to obtain consent and monitor outcomes when prescribing medicines off-label applied to general practice as well as hospitals.

“A typical example would be using paracetamol for osteoarthritis. You might give the patient paracetamol for a week and record their arthritis on a pain scale and then take them off it for a week to see if there’s any difference”, he said. “We should be doing n = 1 trials like this all the time as part of our clinical management of patients.”

1. CATAG 2013; Guiding principles for the quality use of off-label medicines
2. MJA 2014; 200: 637
3. Pediat 2011; 127: 925-935
4. MJA 2014; 200: 65-66
5. MJA 2014; 200: 65