Abstract
The series of studies captured in this thesis have one common source, a prospective, open label, follow-up study to evaluate patterns of use, safety and effectiveness of the PPI lansoprazole in 10,008 naturally occurring patients in the Netherlands
(1994-1998). Clinical record forms and medication histories of this cohort
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have been completed representing in total 35,000
users-months of follow-up. The study was designed and performed according to the SAMM guidelines. Briefly, this means no
additional in- or exclusion criteria with respect to patient enrolment in the study, a modest remuneration for participating
physicians and, most importantly, a separation in time between the moment of prescription of the study drug (i.e. lansoprazole)
and the moment of inclusion of the patient in the study in order to avoid seeding prescriptions. What have we learned from all
this? A primary interest of the study was to evaluate patterns of use of lansoprazole. The drug has been used for a variety of
indications, frequently also beyond the official labelling of peptic ulcer and reflux oesophagitis. The study on the seeding of
prescriptions revealed that in the limited number of cases when seeding was there, this occurred most likely in patients with
relatively minor peptic disorders, including unlicensed indications. One out of five lansoprazole prescriptions was NSAID
related. The use of corticosteroids, anticoagulants, female gender and an age between 45 and 70 years were strongly associated
with NSAIDs induced PPI-use. The medley of prescribed eradication schedules and the large variety in pre- and post-testing of
the existence of H. pylori confirmed the great need of guidelines and protocols to ensure treatment success. It was a peculiar
finding that many patients with H. pylori eradication continued lansoprazole treatment (41.1%). Even one out of three peptic
ulcer patients without GERD and treated with triple or quadruple therapies had continued PPI use after H. pylori eradication
therapy. Regarding safety, we found that 17.4% of all studied patients reported adverse events. No unlabelled events were
detected. The profile and frequency of occurrence were analogous to results of clinical trials and other observational studies.
The reporting rates of adverse effects decreased in time. We found that certain patients had a higher risk to develop adverse
events, namely women, alcohol consumers, OTC-users and patients with co-morbidity. The occurrence of headache was
associated with female gender, a history of analgesics use and the tendency of reporting other adverse events as well. The
onset of diarrhoea during PPI use was related with the reporting of other adverse events, alcohol use and the concomitant use
of antibiotics, an important finding for ensuring treatment compliance with H. pylori eradication schemes including antibiotics.
We found that indication-related complaints disappeared or improved in 90.5% of patients after 8 weeks of lansoprazole use.
The effectiveness was comparable to results found in clinical trials in the registered indications for lansoprazole and high taking
into account the fact that patients were only endoscopically examined in 50.3%, that 29% of the patients had not licensed
indications and that patients with complex morbidity were included. We were able to gain more in depth insight in the patterns
of use of a new drug launched on the Dutch market. Peptic Survey was designed as a field follow-up study bringing data from
various sources together in one research database. This approach is most appealing when prescribing of a new drug is highly
variable at the moment of product launch in the market place and when drug exposure is not covered sufficiently yet by
automated databases. A main concern remains the costs and time burden of building such large cohorts of recipients of a new
drug in the market. Industry will continue to play a major role in funding these studies. A critical appraisal of a possible conflict
of interest remains necessary. The postmarketing project described in this thesis represents certainly no panacea for solving all
problems, but has surely contributed to the knowledge base of conducting sound postmarketing studies of new drugs.
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