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A Multicenter Evaluation of Off-Label Medication Use and Associated Adverse Drug Reactions in Adult Medical ICUs

Smithburger, Pamela L. PharmD, MS, BCPS1; Buckley, Mitchell S. PharmD, FCCM, BCPS2; Culver, Mark A. PharmD, BCPS2; Sokol, Sarah PharmD3; Lat, Ishaq PharmD, BCPS, FCCM4; Handler, Steven M. MD, PhD5,6; Kirisci, Levent PhD7; Kane-Gill, Sandra L. PharmD, MS, FCCM, FCCP1

doi: 10.1097/CCM.0000000000001022
Clinical Investigations
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Objective: Prior research indicates that off-label use is common in the ICU; however, the safety of off-label use has not been assessed. The study objective was to determine the prevalence of adverse drug reactions associated with off-label use and evaluate off-label use as a risk factor for the development of adverse drug reactions in an adult ICU population.

Design: Multicenter, observational study

Setting: Medical ICUs at three academic medical centers.

Patients: Adult patients (age ≥ 18 yr old) receiving medication therapy.

Interventions: All administered medications were evaluated for Food and Drug Administration–approved or off-label use. Patients were assessed daily for the development of an adverse drug reaction through active surveillance. Three adverse drug reaction assessment instruments were used to determine the probability of an adverse drug reaction resulting from drug therapy. Severity and harm of the adverse drug reaction were also assessed. Cox proportional hazard regression was used to identify a set of covariates that influenced the rate of adverse drug reactions.

Measurements and Main Results: Overall, 1,654 patient-days (327 patients) and 16,391 medications were evaluated, with 43% of medications being used off-label. One hundred and sixteen adverse drug reactions were categorized dichotomously (Food and Drug Administration or off-label), with 56% and 44% being associated with Food and Drug Administration–approved and off-label use, respectively. The number of adverse drug reactions for medications administered and the number of harmful and severe adverse drug reactions did not differ for medications used for Food and Drug Administration–approved or off-label use (0.74% vs 0.67%; p = 0.336; 33 vs 31 events, p = 0.567; 24 vs 24 events, p = 0.276). Age, sex, number of high-risk medications, number of off-label medications, and severity of illness score were included in the Cox proportional hazard regression. It was found that the rate of adverse drug reactions increases by 8% for every one additional off-label medication (hazard ratio = 1.08; 95% CI, 1.018–1.154).

Conclusion: Although adverse drug reactions do not occur more frequently with off-label use, adverse drug reaction risk increases with each additional off-label medication used.

1Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA.

2Department of Pharmacy, Banner Good Samaritan Medical Center, Phoenix, AZ.

3Department of Pharmaceutical Services, University of Chicago Medical Center, Chicago, IL.

4Department of Pharmacy, Rush University Medical Center, Chicago, IL.

5Department of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

6Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA.

7Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by a grant through the American Society of Health–System Pharmacists Research and Education Foundation.

Dr. Smithburger received support for article research from the American Society of Health-System Pharmacists Research and Education Foundation. Her institution received grant support from the American Society of Health-System Pharmacists Research and Education Foundation. Dr. Lat received support for the development of educational presentations from the American College of Clinical Pharmacy. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: smithburgerpl@upmc.edu

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