Wong Jenna, Motulsky Aude, Abrahamowicz Michal, Eguale Tewodros, Buckeridge David L, Tamblyn Robyn
Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada
Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Canada.
BMJ. 2017 Feb 21;356:j603. doi: 10.1136/bmj.j603.
To examine off-label indications for antidepressants in primary care and determine the level of scientific support for off-label prescribing. Descriptive study of antidepressant prescriptions written by primary care physicians using an indication based electronic prescribing system. Primary care practices in and around two major urban centres in Quebec, Canada. Patients aged 18 years or older who visited a study physician between 1 January 2003 and 30 September 2015 and were prescribed an antidepressant through the electronic prescribing system. Prevalence of off-label indications for antidepressant prescriptions by class and by individual drug. Among off-label antidepressant prescriptions, the proportion of prescriptions in each of the following categories was measured: strong evidence supporting use of the prescribed drug for the respective indication; no strong evidence for the prescribed drug but strong evidence supporting use of another drug in the same class for the indication; or no strong evidence supporting use of the prescribed drug and all other drugs in the same class for the indication. 106 850 antidepressant prescriptions were written by 174 physicians for 20 920 adults. By class, tricyclic antidepressants had the highest prevalence of off-label indications (81.4%, 95% confidence interval, 77.3% to 85.5%), largely due to a high off-label prescribing rate for amitriptyline (93%, 89.6% to 95.7%). Trazodone use for insomnia was the most common off-label use for antidepressants, accounting for 26.2% (21.9% to 30.4%) of all off-label prescriptions. For only 15.9% (13.0% to 19.3%) of all off-label prescriptions, the prescribed drug had strong scientific evidence for the respective indication. For 39.6% (35.7% to 43.2%) of off-label prescriptions, the prescribed drug did not have strong evidence but another antidepressant in the same class had strong evidence for the respective indication. For the remaining 44.6% (40.2% to 49.0%) of off-label prescriptions, neither the prescribed drug nor any other drugs in the class had strong evidence for the indication. When primary care physicians prescribed antidepressants for off-label indications, these indications were usually not supported by strong scientific evidence, yet often another antidepressant in the same class existed that had strong evidence for the respective indication. There is an important need to generate and provide physicians with evidence on off-label antidepressant use to optimise prescribing decisions.
研究初级保健中抗抑郁药的非标签适应症，并确定非标签处方的科学支持水平。使用基于适应症的电子处方系统对初级保健医生开具的抗抑郁药处方进行描述性研究。加拿大魁北克两个主要城市中心及其周边的初级保健机构。2003年1月1日至2015年9月30日期间就诊于研究医生并通过电子处方系统开具抗抑郁药的18岁及以上患者。按类别和个别药物划分抗抑郁药处方的非标签适应症患病率。在非标签抗抑郁药处方中，测量以下各类处方的比例：有强有力证据支持所开药物用于相应适应症；所开药物没有强有力证据，但同一类别的另一种药物有强有力证据支持用于该适应症；或者所开药物和同一类别的所有其他药物都没有强有力证据支持用于该适应症。174名医生为20920名成年人开具了106850张抗抑郁药处方。按类别划分，三环类抗抑郁药的非标签适应症患病率最高（81.4%，95%置信区间为77.3%至85.5%），这主要是由于阿米替林的非标签处方率很高（93%，89.6%至95.7%）。曲唑酮用于失眠是抗抑郁药最常见的非标签用途，占所有非标签处方的26.2%（21.9%至30.4%）。在所有非标签处方中，只有15.9%（13.0%至19.3%）的所开药物有针对相应适应症的有力科学证据。对于39.6%（35.7%至43.2%）的非标签处方，所开药物没有有力证据，但同一类别的另一种抗抑郁药有针对相应适应症的有力证据。对于其余44.6%（40.2%至49.0%）的非标签处方，所开药物和该类别中的任何其他药物都没有针对该适应症的有力证据。当初级保健医生为非标签适应症开具抗抑郁药时，这些适应症通常没有强有力的科学证据支持，但同一类别的另一种抗抑郁药往往有针对相应适应症的有力证据。迫切需要生成并向医生提供关于抗抑郁药非标签使用的证据，以优化处方决策。
