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Carter, B. and Albino, C., IMS Health Canada B A c k g R o u N D
WHAt is ADHD?
tReAtmeNt foR ADHD
Attention-deficit/hyperactivity disorder (ADHD) stimulants: Methylphenidate and dextro-
is one of the most common neurobehavioral disor- amphetamine are currently the first-line medica- RAtioNAle foR cAse stuDy:
der affecting school-aged children. It is a condi- tion in the psychopharmacological treatment tion whereby children are unable to control their In 2005, Mr. Bernard Richard, Ombudsman and Child and Youth Advocate behaviour or attention. In many cases, the disor- Nonstimulants: Nonstimulants available
for New Brunswick, contacted IMS to request a report on prescription der persists through adolescence and adulthood.1 for treating ADHD include atomoxetine, alpha- • Prevalence: 3-5% of the population.1,2
adrenergic agents 2 and antidepressants. patterns of stimulant drugs in New Brunswick. In particular, he expressed • etiology: still unclear.1
However, only atomoxetine is approved for concerns about the safety and appropriateness of the use of these drugs • signs and symptoms: Principal characteristics
the treatment of ADHD.2,3
of ADHD are inattention, hyperactivity, and
such as methylphenidate or dextroamphetamine in school-aged children. impulsivity.1 These are typically present during These drugs should be part of an overall program
the preschool period or in the early elementary.2 including psychological, educational or social • Diagnosis: Requirement is that difficulties
This study does not attempt to make any were present at or before age seven and create In addition, as some of these drugs are also determinations on the appropriateness of problems or impairment in at least two areas of used in the treatment of narcolepsy, a compara- therapy, as this is decided at the clinical the child’s life (e.g. at school, at home or in tively rare indication, no guarantee can be given level between physician and patient. that the quoted prescribing data relates solely metHoDology
HyPotHesis
DiscussioN
DAtABAses
There are no differences in drug treatment patterns used for ADHD CDTI shows that majority of the drugs are used for The IMS data used to compile figures in this ADHD as the main indication (approximately 80%).
case study were drawn primarily from Canadian between New Brunswick and the rest of Canada.
The use of ADHD medications has risen over the oBjectiVes
last five years (2002-2006) in the majority of the provinces. In 2006, New Brunswick had Canadian Compuscript Audit estimates the num-
ber of prescriptions dispensed by Canadian retail • To determine the differences, if any, in prescribing patterns of 6 DDD per 1,000 population per day dispensed, which is equal to the Canadian average and ranks pharmacies, projected from data drawn from 5th among Canadian provinces. Nova Scotia had the • To examine treatment patterns of ADHD medications to support highest number of DDD per 1,000 population per day at 8. Other provinces with high DDD rates were Canadian Disease and Therapeutic Index (CDTI)
the efforts of the Ombudsman and Child Youth Advocate.
Manitoba, Quebec and Saskatchewan. Alberta was identifies drug recommendations and treatment • To demonstrate the value of analysing national and provincial the only province to show a decrease (-8%) from patterns of office-based physicians in Canada by drug, diagnoses, physician specialty and prescription databases, such as those held by IMS, to help support patient demographics. Data are collected from research and to inform dialogue about drug treatment issues. Methylphenidate is the most commonly dispensed a representative sample of physicians stratified ADHD medication, although Concerta (an extended by geographic region and representing all major release formulation introduced in 2003), continues to gain popularity and in New Brunswick has risen to about 88% of the level of DDD rates for generic Xponent Database provides estimated prescrip-
Figure 1 ADHD medications:
Figure 2 ADHD medications:
Number of Defined Daily Dosage* (DDD)
Prescriptions dispensed in New Brunswick
tion volumes by aggregated groups of prescribers. per 1,000 population per day
The information is available for six provinces. The Within New Brunswick, RHAs 1303, 1306 and 1301 projection methodology uses geospatial statistics have the highest DDD rates for ADHD medications which takes into account the natural boundaries in 2006 (with 6.78, 6.52 and 5.02 respectively). About 8% of New Brunswick prescribers account for mAPPiNg of NeW BRuNsWick RegioNAl
approximately 50% of the ADHD drug prescriptions HeAltH AutHoRities (RHAs)
Mapping of the RHA used the Forward Sortation dispensed in New Brunswick come from pediatri- Areas (FSAs) from the Canada Post Website 4 and cians followed by family medicine physicians and combined this with the related geographical and population information from the New Brunswick are also the top prescribers followed by general Department of Health Website 5. For RHA 1301, the two RHAs, 1B and 1SE FSAs were combined.
*The Defined Daily Dosage (DDD) is the assumed average maintenance dose Source: IMS Health Canada, Canadian Compuscript Audit Mapping of the calculated DDD rates for each per day for a drug used as a main indication in adults. coNclusioNs
of the New Brunswick RHAs used the MapInfo Fig. 2 Trends in ADHD medication prescriptions over time in Source: IMS Health Canada, Canadian Compuscript Audit, WHO-ATC/DDD New Brunswick. Similar patterns where observed in Canada as a whole.
Fig. 1 Canadian and Provincial trends: DDD rates for ADHD medications are 1301 - RHA 1B (Beauséjour) and 1SE (Moncton) Figure 3 ADHD medications:
DDD per 1,000 population per day –
New Brunswick RHAs 2006
cAlculAtioN of Dose iNteNsities
To describe the population use of prescribed ADHD medications, we use the Defined Daily
Dosage (DDD) per 1,000 population per day, as
developed by the World Health organization
The purpose of this case study is not to attempt (WHo). The DDD is defined as the assumed aver-
to explain why the differences occur, or if the dif- age maintenance dose per day for a drug used as a ferences are appropriate. The focus is on accurately main indication in adults. The rate of the number identifying these differences as a starting point of DDDs dispensed to the population per day or in understanding the use of ADHD medications per year is calculated to measure the “therapeutic and whether or not there should be concerns about intensity” in the population. The advantage of this approach is the elimination of problems associated with prescribed items (such as the Source: IMS Health Canada, Xponent Database AckNoWleDgmeNts
variation of the amount prescribed, difference Bernard Richard, New Brunswick Ombudsman Fig. 3 New Brunswick RHAs 1303 and 1306 show the highest DDD rates on in formulations) and gross ingredient cost (price variation over time and price difference between Norman Byrne, Rx Report Developer, Integrate Figure 4 ADHD medications:
Figure 5 ADHD medications:
Variation in prescribing activity in
Prescribing by physician specialty by
To calculate the DDDs per 1,000 population per New Brunswick quartiles by Rx volume – 2006
share of prescriptions – 2006
day, the following method was used: the annual Sue Cavallucci, Manager, Media and Public amount prescribed to the population was deter- Relations, Anne-Maxime Dagenais, Analyst, Public mined by multiplying the total number of tablets (or other solid dosage forms such as capsules) Vice-President, Public Affairs & Government dispensed by the strength of each tablet. These Relations, Anita Fineberg, Corporate Counsel quantities were then summed for each molecule. and Chief Privacy Officer, Sylvie Gaumond, The total DDD for each molecule is then divided Director, Public Affairs & Government Relations, by the WHO ATC/DDD index for that molecule. Lino Pirollo, Manager, Statistical Services, Ultimately, the overall DDD is then divided by Matthew Pucser, Supplier and Trade Relations.
the population (in 000s) and then divided by 365 to express the DDDs per 1,000 population per day.
RefeReNces
1 http://www.nimh.nih.gov/publicat/adhd.cfm 2 Expert Rev. Neurother. 2007 Feb; 7(2):195-201 3 Neuropsychopharmacology. 2006 Nov; 31(11):2376-83 Source: IMS Health Canada, Xponent Database Source: IMS Health Canada, Xponent Database, Canadian Compuscript Fig. 4 Variation in prescribing activity in New Brunswick: majority of the New Brunswick physicians (91.9 %) prescribed about 49.5% of the Fig. 5 Most of the ADHD prescriptions in New Brunswick come from prescriptions for ADHD medications. The other 50.5% of the prescriptions pediatricians followed by family medicine physicians and general for ADHD medications come from about 8% of the total physicians in practitioners. In Canada, the pediatricians are also the top prescribers New Brunswick who prescribed an average of 500 prescriptions per year. followed by general practitioners and by psychiatrists.
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