An Update on Pediatric Drug Utilization

Drugs aren’t just for grown ups, but it would appear that kids are being prescribed fewer medications than they used to be back in the day, all the way back in 2002.¹ The data, published online in the journal Pediatrics, and reported on by Reuters news service, was generated through what I am sure was many joyous hours of sifting through large prescription databases. This allowed the FDA researchers access to about half of all the retail prescriptions written in the U.S. between 2002 and 2010. The database included prescriptions paid for with cash, those filled by Medicaid beneficiaries, and those for participants in commercial insurance plans.  According to the authors, this is the first time the prescription drug use of U.S. children has been described in this way in children. It’s important to recognize that this database didn’t (and still doesn’t) take into account over-the-counter (OTC) medications, supplements that don’t require a prescription, and any prescriptions filled by mail. It also doesn’t tell anyone whether or not any of the drugs were actually taken (probably some were, don’t you think?). When all of the fun was through being had, there were a couple of findings for us to note.

More for the Grownups. Less for the Kids.

It makes sense that adults, especially older adults, take more medication than children. As a whole, older adults have more chronic medical problems that require medications for effective management or control. Think diabetes, heart disease, hypertension, and arthritis. Those 4 alone could leave you taking half a dozen or more medications every day. And then if you’re depressed or can’t sleep, add a couple more. Just a few years ago, children (those of you under 17 years old) were a leading source of growth in the pharmaceutical industry. More than 1 in 4 insured children were taking a prescription medication for a chronic condition. This more recent study seems to indicate just the opposite. While prescription drug use by adults between 2002 and 2010 increased by 11%, outpatient prescriptions for children decreased by 9%. We could debate whether this is a good thing or a bad thing – my vote is on good, but that’s what comments are for.

Sometimes Less is Not More

The drug categories that saw significant declines in the study period were:

• allergy medicines, 61% fewer prescriptions
• cough and cold drugs, 42% fewer prescriptions
• antibiotics, 14% fewer prescriptions
• analgesics, 14% fewer prescriptions
• antidepressants, 5% fewer prescriptions

The authors noted that the allergy medications loratidine (Claritin^®) and cetirizine (Zyrtec^®) transitioned from prescription medications to OTC and this could certainly account for the large decrease in this category of prescriptions. The large drop in prescriptions of cough and cold medicines can be attributed to, at least in part, a Cochrane database systematic review in 2004 and subsequent FDA advisory in 2008. Both of these documents take the view that the risks of using these products, both prescription and OTC, outweigh the benefits. The use of antibiotics remains highly prevalent, but has been curtailed to some degree. There is greater awareness among the general public that not every earache, cough, and stuffy head should be treated with antibiotics.

Wait, There’s More…

The biggest increase (93%) was seen in prescriptions for birth control pills. The authors suggest that this is likely to reflect their use for longer durations and for purposes other than preventing pregnancy, such as helping to control acne. They also mention that these drugs were prescribed relatively rarely to people who can’t get into R-rated movies without a grownup back in 2002 and their prescription doesn’t represent a large proportion of the overall number written in 2010. More remarkable is the 46% increase in prescriptions for medication used to treat attention deficit hyperactivity disorder (ADHD). This means that 800,000 more prescriptions were written for these drugs in 2010 than in 2002. Methylphenidate (Ritalin^®) was the most commonly prescribed drug to adolescents 12-17 years old during the entire study period – 4.3 million prescriptions in 2010 – but overall, the rate of prescription of this drug didn’t change much. Prescription patterns for other medications in this group were more variable, based in part on new evidence becoming available and in part on newer drugs becoming the popular kids in class. Prescriptions for amphetamine/dextroamphetamine (Adderall^®) decreased by 15% and dextroamphetamine (Dexedrine SR^®, Procentra^®) by 69%. In contrast, after 2004, prescriptions for dexmethylphenidate (Focalin^®), lisdexamfetamine (Vyvanse^®), and guanfacine (Intuniv^®) all increased. The last member of this group, atomoxetine (Strattera^®) saw an increase between 2002 and 2004 but a significant decrease between 2004 and 2010. Labeling changes in late 2004, including a black box warning and medication guide related to suicidal ideation in children and adolescents taking atomoxetine, could have contributed to the decline in it’s use. Whew – simpler version – compared to 2002, there’s always a lot of Adderall^® out there, more Focalin^®, Vyvase^®, and Intuniv^®, and less dexedrine and Strattera^®. Other drug categories that saw increases include oral corticosteroids (22%), asthma medications (14%), dermal corticosteroids (10%), and seizure medications (10%).

Into the Mouths of Babes

One of the secondary objectives of the study was to examine off-label prescription in pediatric patients. Off-label prescription refers to the use of an FDA-approved medication in a way which has not been FDA-approved. This is in no way illegal (well, I suppose it could be, but most of the time it’s not) and usually occurs when there is at least some evidence supporting the non-approved application. The study authors state that off-label prescribing is fairly common in this population. Turns out they were right, at least in the case of the drug lansoprazole (Prevacid^®). Of the estimated 500,000 or so prescriptions written for this proton-pump inhibitor for children in 2010, 358,000 (70%) were written for infants younger than one year of age. Guess what? Not FDA-approved, all off-label. OK, no big deal, off-label use isn’t illegal. No it’s not, but the label of the drug itself states that in a multicenter, double-blind, placebo controlled study, lansoprazole was not effective in patients younger than 1 year old with symptomatic reflux! So we’ve got no real potential for benefit, but certainly some risk in the form of potential adverse effects, both short- (abdominal discomfort, constipation, diarrhea) and long-term (questions about increased fracture risk with long-term use). The authors have this one pegged exactly correctly, this is a question that needs an answer.

The Envelope, Please

The big winners, the most commonly prescribed medications in each age group, were:

• infants 0-23 months – amoxicillin
• children 2-11 years – amoxicillin
• adolescents 12-17 years – methylphenidate (Ritalin®)

Wait, Where Am I?

This is useful and all, but what’s the point? The point is that it is useful. If you are a physical or occupational therapist working in a pediatric setting, you should have a working understanding of the medications you’ve just been reading about. That way, when you notice that the way a child you’re working with feels, moves, behaves, or communicates has changed, you have a better starting point for considering whether the medications that child is taking could be playing some role in that change. And, as always, if you’re seeing something that doesn’t make sense, ask!

Reference (Back to text)

1. Chai G, Governale L, McMahon AW, Trinidad JP, Staffa J, Murphy D. Trends of outpatient prescription drug utilization in US children 2002-2010, [published online ahead of print June 18, 2012]. Pediatrics. doi:10.1542/peds.2011-2879.