From: Subject: =?Windows-1252?Q?Pharmazeutische_Zeitung_online:_Projektarbeit:_Sichere_A?= =?Windows-1252?Q?rzneimittel_f=FCr_Kinder?= Date: Mon, 24 Jan 2011 09:28:16 +0100 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01CBBBA9.07870F30" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3350 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01CBBBA9.07870F30 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.pharmazeutische-zeitung.de/index.php?id=36002 Pharmazeutische Zeitung online: Projektarbeit: = Sichere Arzneimittel f=FCr Kinder
3D"Pharmazeutische
 3D"Sunstar

ORIGINALIA

Projektarbeit
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Sichere Arzneimittel f=FCr=20 Kinder


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Von = Anna=20 Flegel / Auf = Initiative der=20 PharmHuman Stiftung entstand im Jahr 2007 das Projekt = =BBSichere=20 Arzneimittel f=FCr Kinder=AB, welches einen Beitrag zur = Sicherheit im=20 Einsatz mit Arzneimitteln auf p=E4diatrischen Stationen des=20 St=E4dtischen Klinikums Braunschweig gGmbH leistet. Nachdem = in den=20 vergangenen Jahren die Kinderonkologie und die = neonatologische=20 Intensivstation Untersuchungsobjekte des Projektes waren, = ist es im=20 Jahr 2010 eine Allgemeinstation, die eine Vielzahl an = Kindern=20 unterschiedlicher Erkrankungen=20 betreut.


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Ziel = des Projektes=20 ist es, die h=E4ufigsten Indikationen einer Kinderstation = systematisch=20 zu erfassen und die hier angewendeten Arzneimittel auf die = Datenlage=20 zur Anwendung bei Kindern und Jugendlichen zu =FCberpr=FCfen = und zu=20 klassifizieren.


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PZ-Originalia
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In der Rubrik=20 Originalia werden wissen­schaftliche = Untersuchungen und=20 Studien ver=F6ffentlicht. Eingereichte Beitr=E4ge = sollten in der=20 Regel den Umfang von zwei Druckseiten nicht = =FCberschreiten und=20 per E-Mail geschickt werden. Die PZ beh=E4lt sich vor, = eingereichte Manuskripte abzulehnen. Die = ver=F6ffentlichten=20 Beitr=E4ge geben nicht grunds=E4tzlich die Meinung der = Redaktion=20 = wieder.



Dazu = werden t=E4glich=20 alle verordneten Medikamente dokumentiert und anschlie=DFend = nach=20 ihrem Zulassungsstatus klassifiziert. Besonderes Interesse = liegt=20 dabei auf Arzneimitteln, die unlicensed oder off label, = sprich=20 au=DFerhalb der Zulassung eingesetzt = werden.



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F=FCr kranke Kinder gibt = es l=E4ngst=20 nicht so viele Therapieoptionen wie f=FCr kranke = Erwachsene.=20 Jedoch bessert sich die Situation bei den f=FCr Kinder = zugelassenen Arzneimitteln.

Foto: DAK/Wigger


Die = Bewertung des=20 Zulassungsstatus erfolgt mithilfe der vom=20 Arzneimittel­her­steller verfassten = Fachinformatio­nen,=20 in denen Parameter wie Alter, Dosis und Indikation des=20 Arzneimit­tels klar definiert sind. Entspricht das = verordnete=20 Arzneimittel in einem der drei genannten Kriterien nicht der = Fachinformation, so wird es als Off-Label-Use gewertet. =

 

Anlass = zu diesem=20 Projekt bietet die Tatsache, dass viele auf dem=20 Arznei­mittelmarkt befindliche Medikamente lediglich = eine=20 Zulassung f=FCr Erwach­sene aufweisen, jedoch seltener = f=FCr Kinder,=20 wie schon in zwei vorange­gangenen Projektarbeiten=20 dokumen­tiert wurde. Dies f=FChrt dazu, dass viele = Therapien an=20 Kindern auf, zumeist von Klinik=E4rzten, gesammelten = Erfahrungswerten=20 basieren und nur so die Sicherheit des Arzneimitteleinsatzes = ohne=20 gr=F6=DFere Komplikationen garantiert werden kann. =

 

Die = beschriebene=20 Problematik ist bekannt und dennoch steht vor Beginn einer = jeden=20 klinischen Studie mit p=E4diatrischen Studienteilnehmern die = Frage der=20 ethischen Vertretbarkeit im Raum.

 

Um dem = Prozess des=20 fortw=E4hrenden Off-Label-Use entgegenzusteuern, sind die=20 Arzneimittelhersteller seit Erlass der EU-Verordnung f=FCr=20 Kinderarzneimittel im Januar 2007 (EG Nr. 1901/2006) dazu=20 verpflichtet, f=FCr das p=E4diatrische Patientenkollektiv = Pr=FCfkonzepte=20 zu formulieren. Geschieht dies nicht, so erh=E4lt das = Arzneimittel=20 auch keine Zulassung f=FCr Erwachsene.

 

Ergebnisse

 

=DCber = einen Zeitraum=20 von zw=F6lf Wochen wurden auf der Station K2 der Kinder- und = Jugendklinik des St=E4dtischen Klinikums Braunschweig gGmbH = 97=20 Patienten im Alter von wenigen Tagen bis hin zu jungen = Erwachsenen=20 station=E4r behandelt.

 

Der = Schwerpunkt der=20 Station liegt in der Behandlung infekti=F6ser Erkrankungen. = So trifft=20 man neben den Virusinfektionen verursacht durch Rotaviren = oder dem=20 Eppstein-Barr-Virus, besser bekannt als das Pfeiffersche=20 Dr=FCsenfieber, Patienten mit bakteriellen Infekten an wie = Bronchitis,=20 Tonsillitis oder Harnwegsinfektionen.

 

Es = ergibt sich als=20 Ergebnis der Analyse der h=E4ufigsten Erkrankungen eine = H=E4ufung im=20 Bereich der bakteriell bedingten Atemwegserkrankungen wie=20 Bronchitis, Tonsillitis oder Pneumonie.

 

Dementsprechend ist=20 das Verordnungsvolumen an Antiinfektiva mit einem Anteil von = 65=20 Prozent sehr hoch (Abbildung 1), best=E4tigt aber den=20 Behandlungsschwerpunkt der Station K2. Neben Antiinfektiva = werden=20 verst=E4rkt Analgetika und Vitaminpr=E4parate verordnet. Der = Analgetika-Einsatz korreliert mit dem Verordnungsvolumen der = Antiinfek­tiva, da viele bakterielle Infektionen Fieber=20 hervorrufen, die eine Verordnung von antipyre­tisch = wirkenden=20 Analgetika wie Paracetamol oder Ibuprofen=20 begr=FCnden.


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Abbildung 1: Prozentuale = Verteilung der eingesetzten Arzneimittel, bezogen auf = die=20 Anzahl der Patienten



Erfreulich ist, dass=20 knapp 80 Prozent der Verordnungen zugelassen sind und 52 der = 97=20 beobachteten Kinder weder mit einer Unlicensed noch mit = einer=20 Off-LabelVerordnung behandelt wurden, sondern nur = zugelassene=20 Arzneimittel erhalten haben. Die restlichen 20 Prozent des = gesamten=20 Verordnungsvolumens unterteilen sich in 2 Prozent unlicensed = use und=20 18 Prozent nicht zugelassenen Verschreibungen (Abbildung=20 2).


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Abbildung 2: Anteile an = off label,=20 unlicensed und zugelassenen Arzneimitteln



51 = Prozent der=20 Off-Label-Verordnungen haben ein zu geringes Patientenalter = als=20 Ursache (Abbildung 3). Beispielhaft hierf=FCr steht der = Wirkstoff=20 Enoxaparin-Natrium, ein niedermolekulares Heparinderivat zur = Thromboseprophylaxe, der nicht f=FCr p=E4diatrische = Patienten zugelassen=20 ist. Auf der Station K2 des St=E4dtischen Klinikums = Braunschweig gGmbH=20 werden Patienten nach chirugischen Eingriffen bis zur = Entlassung=20 betreut. Ist ein Patient in seiner Mobilit=E4t = eingeschr=E4nkt, so=20 bekommt dieser den genannten Wirkstoff subkutan zur=20 Thromboseprohphylaxe injiziert. Diese Verordnung wird dann = als off=20 label gewertet, wenn der Patient j=FCnger als 18 Jahre=20 ist.


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Abbildung 3: Gr=FCnde = f=FCr=20 Off-Label-Use


Weitere = 34 Prozent=20 des Verord­nungs­volumens geh=F6ren in die Gruppe = der nicht=20 zulassungs­kon­formen Dosierungen, sprich=20 =DCber­dosierungen. Letzteres betrifft beson­ders = den=20 Wirkstoff Salbutamol, der in 90 Prozent der=20 Salbutamolverord­nungen =FCberdosiert wurde. Oftmals ist = lediglich=20 die maximale Einzeldo­sis von acht Tropfen, um ein bis = zwei=20 Tropfen =FCberschritten beziehungs­weise die Frequenz = der=20 Inhalation ist zu hoch.

 

Salbutamol als=20 Sympathomimetikum wird inhalativ angewendet, f=FChrt zu = einer Weitung=20 der Bronchien, zur Verbesserung der mukozilli=E4ren = Clearence und=20 damit zu einer erleichterten Atmung. In Kombination mit = Salbutamol=20 wird auf der Station das Parasympatholytikum = Ipratropiumbromid=20 inhalativ verabreicht, welches zu einer Relaxation = obstruktiv=20 verkrampfter Atemwegsmuskulatur f=FChrt. Beide Wirkstoffe = z=E4hlen zu=20 den verordnungsst=E4rksten Medikamenten, weil sie auf der = Station K2=20 zur Standardtherapie jeglicher Erkrankungen der Atemwege = geh=F6ren.=20

 

Die = restlichen 15=20 Prozent der Off-Label-Anwendungen sind durch Indikationen = bedingt.=20 In diese Gruppe z=E4hlen unter anderem die Verordnungen des = Wirkstoffs=20 Propranolol f=FCr die H=E4mangiom-Therapie. Dabei ist zu = bedenken, dass=20 Propranolol bewusst off label eingesetzt wird, obwohl es = f=FCr diese=20 Art der Therapie keine Zulassung besitzt. Erfolgreiche = Erfahrungen=20 anderer Kliniken begr=FCnden den Einsatz. Die Eltern werden = vor Beginn=20 der Therapie mit den Risiken vertraut gemacht und stimmen = einer=20 Therapie schriftlich zu.


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PharmHuman=20 Stiftung
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Die im=20 Jahr 2005 gegr=FCndete PharmHuman Stiftung (http://www.pharmhuman.de/) = hat es sich=20 zum Ziel gesetzt, Pharmazie mit humanit=E4rer=20 Verantwortung zu verkn=FCpfen. Sie initiiert und = unterst=FCtzt Projekte zur = Gesundheitsf=F6rderung und zum=20 Informations- und Erfahrungsaustausch im In- und = Ausland.

 

Durch den=20 Einsatz der PharmHuman Stiftung sowie der = Apotheke des=20 Klinikums Braunschweig und die Mitfinanzierung = durch die=20 Kroschke Stiftung f=FCr Kinder kann mit der = Projektarbeit=20 =BBSichere Arzneimittel f=FCr Kinder=AB ein = wichtiger Beitrag=20 zur Arzneimittelsicherheit bei Kindern geleistet = = werden.



Des = Weiteren z=E4hlen=20 zu den 15 Prozent durch Indikation bedingte = Off-Label-Verordnungen,=20 jene Medikamente die vor vollst=E4ndig abgekl=E4rter = Diagnose den=20 Kindern verabreicht werden.

 

Fazit

 

Die = Forschung und=20 Entwicklung von kindgerechten Arzneimitteln sind aufgrund = der=20 relativ kleinen Zielgruppe kostenintensiv, da nur circa 15 = Prozent=20 der Bev=F6lkerung Kinder unter 15 Jahren sind. Somit ist der = Bedarf an=20 Arzneimitteln dieser Gruppe gering. Erschwerend kommt hinzu, = dass in=20 der Bev=F6lkerung aus ethischen Aspekten eine kritische = Einstellung=20 gegen=FCber klinischen Pr=FCfungen an Kindern herrscht. = Infolgedessen=20 m=FCssen Medikamente, gepr=FCft an Erwachsenen, auch bei = Kindern=20 angewandt werden, weil nur lediglich 20 Prozent der auf dem=20 Arzneimittelmarkt befindlichen Arzneimittel eine = p=E4diatrische=20 Indikation vorweisen.

 

Um = dieser ernst zu=20 nehmenden Problematik entgegenzuwirken, ist die 2007 in = Kraft=20 getretene EU-Verordnung, die Arzneimittelhersteller zur = Ausarbeitung=20 eines p=E4diatrischen Pr=FCfkon­zeptes verpflichtet, ein = Erfolg f=FCr=20 die P=E4diatrie.

 

Nach = Abschluss des=20 Projektes l=E4sst sich ein generelles Ergebnis formulieren: = Die=20 Situation der f=FCr Kinder zugelassenen Arzneimittel bessert = sich, was=20 durch einen Off-Label-Use unter 20 Prozent auf der = untersuchten=20 Kinderstation klar dokumentiert wird.

 

Zudem = ist=20 festzustellen, dass mit steigendem Alter des Kindes, die = Datenlage=20 besser und der Anteil an Off-Label-Verordnungen geringer = werden.=20

 

Ab = Erreichen des=20 Schulkindalters (6 Jahre) sind 82 Prozent aller eingesetzten = Arzneimittel zugelassen. Dennoch besteht vor allen Dingen = f=FCr die=20 j=FCngeren Patienten Nachholbedarf in Sachen=20 altersgruppenentsprechender Datenerhe­bung f=FCr = Arzneimittel. Es=20 w=E4re w=FCnschenswert, dass generelle Zulassungen f=FCr = Kinder minimiert=20 werden k=F6nnten zugunsten spezifischer Zulassungen f=FCr = die=20 entsprechen Altersgruppen mit entsprechenden Aussagen =FCber = Dosis und=20 Applikationsart.

 

Zurzeit = sind=20 sorgsames Handeln der =C4rzte sowie Erfahrungswerte noch die = wichtigsten Elemente in der Pharmakotherapie von Kindern, da = die=20 Zahl der Neuzulassungen der Arzneimittel f=FCr Kinder erst=20 allm=E4h­lich steigt.

 

Der = Einsatz eines=20 Apothekers, der, vertraut mit den besonderen Anforderungen = einer=20 Kindersta­tion, den =C4rzten und auch dem Pflegepersonal = mit=20 Fachkompetenz beratend bei der Medikation zur Seite zu = stehen=20 k=F6nnte, w=E4re eine sehr hilfreiche Unterst=FCtzung f=FCr = jede=20 Kinderstation. /


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Anschrift der Verfasserin =

 

Anna=20 Flegel

St=E4dtisches Klinikum Braunschweig = gGmbH=20

Celler=20 Stra=DFe 38

38114=20 = Braunschweig



3D"" Au=DFerdem in dieser=20 = Ausgabe...


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