Last month's research roundup provided an overview of articles examining the complex issues encountered when prescribing medication during pregnancy (Robertson, 2023). This month, we will review a range of articles that focus on prescribing medication to a young population. The first article examines antipsychotic prescribing in children and adolescents. The second discusses the use of biologic treatments in managing asthma in children. Finally, we will review a paper that analyses trends in drugs prescribed to pediatric patients by GPs.
Trends in antipsychotic prescribing to children and adolescents in England
This cohort study, published in The Lancet Psychiatry journal, aimed to identify trends in antipsychotic drug prescribing to children and adolescents in England (Radojčić et al, 2023). This was driven by concerns about the level and increase of these drugs being prescribed to this population.
The cohort consisted of children aged 3–18 years identified from the Clinical Practice Research Datalink (CPRD) Aurum database. This database contains records from participating primary care services in England. The data are anonymous but allows for extraction of demographic data, diagnoses, symptoms, prescriptions, testing and referrals.
Antipsychotic use was defined as any anatomical therapeutic chemical of class N05A and included typical and atypical variants listed in the BNF. Lithium and prochlorperazine were excluded. Potential indications were identified from records 6 months prior to the prescription.
Data were collected from January 2000 to December 2019. A total of 7 217 098 children met the main inclusion criteria; some were excluded due to indeterminate gender records. Of the 7 216 791 children included for analysis (48.2% girls; 51.8% boys), the mean age at start of follow-up for prescriptions was 7.3 years with a median follow-up period of 4.1 years and a total of 243 529 antipsychotic prescriptions (92.7% atypical; 7.3% typical). Prevalence increased from 0.057% in 2000 to 0.105% in 2019 – an annual increase of 3.3%.
The most common reasons for prescribing antipsychotics were identified as autistic spectrum disorder, non-affective psychosis, anxiety disorders, ADHD, depression and conduct disorders.
The authors suggest that there is an increasing trend in antipsychotic prescribing for both new and repeat prescriptions. They conclude that this evidence strengthens the need for increased monitoring of trends and potential effects of long-term prescribing from childhood.
Factors to consider in prescribing asthma biologic therapies to children
This article, published in the Journal of Allergy and Clinical Immunology: In Practice, outlines factors to consider when prescribing biologic therapies for children with asthma (Anderson 3rd et al, 2023). The authors acknowledge that evidence supporting the use of this treatment in pediatric patients is limited compared to adults. They note that adolescents are often grouped with adult patients in trials and that evidence for this group is more robust. These drugs are becoming more widely available but can be costly and must be used judiciously. The authors suggest a risk/benefit analysis and have compiled a profile of peadiatric patients who may benefit from biologics as well as specifics for individual biologics and a guide to discontinuation.
The Global Initiative for Asthma suggests considering biologic therapy following diagnosis when there has been a failure to respond to optimal dosing of usual treatment options. The authors outline a stepwise process from confirmation of diagnosis through selection of a biologic, assessment of response and timing of discontinuation if needed. Shared decision-making with the patient, family and prescribing team is central to the process.
The authors conclude that prudent use in a guideline-based approach is appropriate in pediatric populations and provides an exciting opportunity to impact long-term management of severe asthma. They suggest further work is needed to explore the safety of long-term use and any disease-modifying impact.
General practitioner prescribing trends among peadiatric patients in the United Kingdom: 1998–2018
This article, published in the Journal of Pharmacoepidemiology and Drug Safety, describes the prescribing trends of 17 therapeutic drug categories and specific drug classes (systemic antibiotics, analgesics, and antidepressants) in children and adolescents in the UK (Masarwa et al, 2022). The authors used a population-based retrospective cohort study approach to collect data from the CPRD GOLD database. This database contains longitudinal electronic health records from UK primary care practices using specific software. Data is anonymous and includes demographics, diagnoses, symptoms, prescribing incidents, tests, referrals and vaccination history. It is available through the Medicines and Healthcare products Regulatory Agency website. Prescription information is recorded and classified according to the BNF.
The authors retrieved records for patients under 18 years old between November 1998 and June 2018 and identified all prescriptions written by GPs. These were classified into 17 categories based on chapters and corresponding headers in the BNF. The study included 4 075 527 patient records: 32% for children under 2 years old; 12.9% for ages 2–4.9 years; 28.6% for ages 5–12.9; and 23.3% for ages 13–18 years (50.8% male; 49.2% female).
Results showed that drugs for ADHD increased by 15%, drugs for anxiety by 14%, and drugs for oesophageal reflux by 8%. Conversely there was a decrease of 6% for cough preparations and a decrease of 3% for analgesics, while systemic antibiotics remained unchanged.
Other findings included decreases in broad-spectrum penicillins/cephalosporins prescriptions while SSRIs and opioids/migraine drugs increased.
The authors conclude that the main increase in prescribing was for reflux medications and centrally acting drugs. They suggest that longitudinal assessments of national drug utilisation patterns in the paediatric population are limited and that this is an area for development to inform research and clinical practice..
Conclusion
Prescribing in paediatric and adolescent populations can often be challenging due to a lack of clinical trials and robust evidence. Reviewing retrospective data can provide insight into prescribing practices and outcomes. Real-world effectiveness and safety may be improved through post-prescribing surveillance of drug utilisation to inform future use.