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Patient-reported Outcomes as a Source of Evidence in Off-Label Prescribing: Analysis of Data From PatientsLikeMe

Patient-reported Outcomes as a Source of Evidence in Off-Label Prescribing: Analysis of Data From... Background: Evaluating a new use for an existing drug can be expensive and time consuming. Providers and patients must all too often rely upon their own individual-level experience to inform clinical practice, which generates only anecdotal and unstructured data. While academic-led clinical trials are occasionally conducted to test off-label uses of drugs with expired patents, this is relatively rare. In this work, we explored how a patient-centered online research platform could supplement traditional trials to create a richer understanding of medical products postmarket by efficiently aggregating structured patient-reported data. PatientsLikeMe is a tool for patients, researchers, and caregivers (currently 82,000 members across 11 condition-based communities) that helps users make treatment decisions, manage symptoms, and improve outcomes. Members enter demographic information, longitudinal treatment, symptoms, outcome data, and treatment evaluations. These are reflected back as longitudinal health profiles and aggregated reports. Over the last 3 years, patients have entered treatment histories and evaluations on thousands of medical products. These data may aid in evaluating the effectiveness and safety of some treatments more efficiently and over a longer period of time course than is feasible through traditional trials. Objective: The objective of our study was to examine the illustrative cases of amitriptyline and modafinil – drugs commonly used off-label. Methods: We analyzed patient-reported treatment histories and drug evaluations for each drug, examining prevalence, treatment purpose, and evaluations of effectiveness, side effects, and burden. Results: There were 1948 treatment histories for modafinil and 1394 treatment reports for amitriptyline reported across five PatientsLikeMe communities (multiple sclerosis, Parkinson's disease, mood conditions, fibromyalgia/chronic fatigue syndrome, and amyotrophic lateral sclerosis). In these reports, the majority of members reported taking the drug for off-label uses. Only 34 of the 1755 (1%) reporting purpose used modafinil for an approved purpose (narcolepsy or sleep apnea). Only 104 out of 1197 members (9%) reported taking amitriptyline for its approved indication, depression. Members taking amitriptyline for off-label purposes rated the drug as more effective than those who were taking it for its approved indication. While dry mouth is a commonly reported side effect of amitriptyline for most patients, 88 of 220 (40%) of people with amyotrophic lateral sclerosis on the drug reported taking advantage of this side effect to treat their symptom of excess saliva. Conclusions: Patient-reported outcomes, like those entered within PatientsLikeMe, offer a unique real-time approach to understand utilization and performance of treatments across many conditions. These patient-reported data can provide a new source of evidence about secondary uses and potentially identify targets for treatments to be studied systematically in traditional efficacy trials. (J Med Internet Res 2011;13(1):e6) doi: 10.2196/jmir.1643 http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 1 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al KEYWORDS Off-label; Internet; research; patient platform; methods; online community publish significant findings than nonsignificant findings. Third, Introduction there are inconsistencies among medical conditions in the number of options available; off-label medication use is Off-label prescribing is a legal and common practice in the frequently the only option for “orphan conditions”[1]; and for United States [1]. When a manufacturer develops a new many medical conditions there is no “approved” treatment. For medication for a particular purpose, the US Food and Drug instance, a study comparing approved drug indications against Administration’s (FDA’s) [2] Center for Drug Evaluation and the Diagnostic and Statistical Manual of Mental Disorders, 4th Research evaluates the drug’s efficacy and utility for that edition, text revision (DSM-IV-TR) found that 89% of all purpose before it is brought to market. However, once the drug psychiatric disorders lack approved medications for their is on the market, health care providers are free to prescribe the treatment [8]. Fourth, the regulations apply only to the most drug for either the FDA-approved purpose (“indication”) or any visible means of promotion, and fail to address continuing other purpose – a practice referred to as “off-label prescribing.” medical education presentations and events, or oral responses Across all major drug categories, it is estimated that 21% of all to physicians’ questions at company-sponsored events, exhibit prescriptions are for off-label purposes [3]. booths, or in “detailing” visits [9]. Finally, it has been noted Off-label prescribing has the potential to be a source of that, as the guidance is not legally binding, enforcement is innovation in medicine. Prescribers can discover novel uses for unlikely. existing medications while monitoring tolerability, safety, and Consequently, there is a need to gather evidence to inform effectiveness. Within their practice they can apply the insight off-label prescribing. Unfortunately, gathering this evidence acquired from treating one person to the next case [4]. However, can be prohibitively expensive. Running a clinical trial, of the prescribers may not have an adequate number of cases to type needed to establish the efficacy of a drug for a new purpose, distinguish between a truly meaningful effect of the drug, and costs US $15,700 for a phase 1 trial and over US $26,000 for either a placebo effect or the tendency for patients to improve a phase 3 trial per patient [10]. If a drug is already being used on their own. widely off-label there may be no incentive for manufacturers Off-label prescribing is often done without supporting medical to evaluate it systematically. evidence [1]. For the estimated 21% of prescriptions given In this paper, we propose a new source of evidence to evaluate off-label, 73% lacked scientific evidence underlying their use off-label use: patient-reported outcomes entered via an online [3]. In many cases, patients may be subject to unnecessary, community. An increasing number of patients are going online ineffective, and even harmful treatments. In the past, millions to access information about their health and talk to other patients of women received prophylactic hormone treatment for the about a shared condition [11]. Many patients share advice and prevention of osteoporosis, for instance. However, systematic details about their treatments and symptoms with one another evaluation revealed no therapeutic benefit and elevated risks of and with researchers. Clinical trial researchers increasingly use cardiac damage [5]. Patients are extremely unlikely to be aware the Internet for recruiting subjects, communicating with that the FDA has not evaluated the safety and efficacy of their participants, and even collecting data [12]. Patient groups like treatment for the purpose for which they are using it. the Life Raft Group for patients with gastrointestinal stromal In 2008 the FDA released a guidance document entitled “Good tumor have successfully mobilized their members to study the Reprint Practices for the Distribution of Medical Journal Articles effectiveness of investigational treatments [13]. In this work, and Medical or Scientific Reference Publications on Unapproved we suggest how patients, entering outcomes within an online New Uses of Approved Drugs and Approved or Cleared Medical community, could inform how drugs are working for off-label Devices” [2]. This guidance provides advice for industry on uses by expanding the available evidence base. circulating journal article reprints that contain information on To conduct this analysis we examined patient reported outcomes off-label use, such as for the use of modafinil in treating fatigue reported on PatientsLikeMe. PatientsLikeMe is a web-based in multiple sclerosis (MS) or amitriptyline in treating excessive community and research platform where patient members share saliva in amyotrophic lateral sclerosis (ALS). Unfortunately details about their treatments, symptoms, and conditions, with there are a number of limitations to the application of this the intention of improving their outcomes[14,15]. Patients join guidance. First, the quality of the scientific literature and the communities designed specifically for their condition. At the informal benchmark of acceptability vary dramatically between time of writing, there were 11 distinct patient communities and diseases. The most widely cited paper on the use of modafinil over 70,000 patient members. The site synthesizes members’ for the treatment of fatigue in MS, for instance, has been cited data into interactive reports for review. Each member sees a nearly 250 times but contained only 65 patients at its 9-week graphical representation of their own and others’ function, end point and failed to find a dose-response effect [6]. Second, treatments, and symptoms over time and can view reports of the guidance requires industry to provide counterbalancing aggregated data. The site includes an interactive treatment report evidence. Perhaps unsurprisingly, though, there is evidence of for each medication and intervention that patients add to the selective reporting: many off-label trials are not published, system. The report includes dosages taken, time on treatment, particularly when their finding are not significant [7]. This effect and evaluations of the treatment, including perceived efficacy, is surely compounded by publication bias; that is, it is easier to http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 2 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al side effects, and burden. These treatment reports can suggest resulted in warnings and fines from the FDA [2]. A recent usage patterns and effectiveness rates for drugs across different review [19] of the MS literature assessing the use of modafinil purposes. for the treatment of fatigue in MS considered it a “reasonable therapeutic option” but cautioned that trials to date have been We examined patient data for two medications that are widely small (total N of the literature = 308 patients), unblinded, and prescribed off-label and currently being evaluated for new with only short-term follow-up (median follow-up 12 weeks). applications: amitriptyline and modafinil. We documented how There were some adverse events, mostly gastrointestinal, but patients reported using these drugs and how patient reports one-third of studies failed to report adverse events at all. Similar could inform broader understanding of these relatively methodological problems likewise seriously undermine existing well-understood medications. PatientsLikeMe hosts communities off-label studies in other diseases. for patients with ALS, MS, depression, Parkinson's disease, fibromyalgia, and chronic fatigue syndrome. Given the high In this study, we conducted a post hoc analysis of the prevalence levels of fatigue, pain, excess saliva, and depression presented of on-label versus off-label use, dosing, and perceived across these communities, many members of the site could be effectiveness and side effects for these medications. We looked candidates for treatment of these symptoms. at prevalence of use across the site and in specific communities. We documented purposes of use by community and the side Amitriptyline (Elavil; Merck & Company Inc, Whitehouse effects they reported. Lastly, we began to look at how Station, NJ, USA) is a tricyclic antidepressant that was effectiveness varied by purpose to see whether these agents developed by Merck and approved in the United States in 1961. function similarly for on- and off-label indications. It has FDA approval for the treatment of major depression, clinical/endogenous depression, and involutional melancholia, Methods but it is commonly used off-label for other symptoms ranging from chronic pain to bed wetting. Due to the anticholinergic We analyzed the treatment information entered by patient effects of amitriptyline a primary side effect of the drug is dry members about the two drugs of interest, amitriptyline and mouth. There are 14 clinical trials involving amitriptyline that modafinil, across five condition-based communities: MS, are recruiting subjects (on clinicaltrials.gov), reflecting an fibromyalgia/chronic fatigue syndrome, ALS, mood disorders ongoing interest in its use. In neurological conditions such as (depression, bipolar disorder, and anxiety disorders), and ALS, amitriptyline has been reported informally as being used Parkinson's disease. At the time of analysis (May 24, 2010), by neurologists for the treatment of depression, as well as these communities contained 53,928 members. off-label for excessive saliva, emotional lability, urinary Patients complete treatment histories, including start date, the urgency, and insomnia [16], despite an absence of trials purpose for taking the treatment, dosage (with available dosages supporting its use. Even in its indicated use, for depression, according to the Multum database [Cerner Multum, Denver, ALS guidelines state “Concerning pharmacological treatment CO, USA] prompted as the most likely response options), dates of depression in patients with ALS, there is broad consensus of dosage change, and stop date. Members can add more than among clinical experts that [selective serotonin-reuptake one treatment history to indicate repeated trials of a treatment. inhibitors] and [tricyclic antidepressants] are helpful, but there In addition to their treatment history, members may complete have been no controlled clinical studies of these medications evaluations for each treatment, entering side effects, severity in ALS patients” [17]. Antidepressants like amitriptyline have of side effects (none, mild, moderate, or severe), burden been highlighted as an important target for future research into (difficulty of being on treatment: not at all, a little, somewhat, off-label drug use [18]. or very), and perceived effectiveness (can’t tell, none, slight, Modafinil (Provigil; Cephalon, Inc, Frazer, PA, USA) is a moderate, or major). In both the treatment reports and the wakefulness-promoting agent first available in the United States evaluations (See Figure 1), users are prompted to use a curated since 1998 for approved purposes related to sleep disorders, vocabulary of side-effect and purpose terms, but may enter their including narcolepsy, shift-work disorder, and obstructive sleep own natural language if they wish. In order to aggregate data apnea. As a wakefulness-promoting agent, it has also been across the patient-entered vocabulary, patient-generated investigated off-label for the treatment of fatigue in conditions symptom and side-effect symptom terms were coded using the including MS [19], fibromyalgia [20], chronic fatigue syndrome Medical Dictionary for Regulatory Activities (MedDRA MSSO, [21,22], and Parkinson's disease [23-25]. In the past, promotion Chantilly, VA, USA). of the drug for these off-label purposes by the manufacturer has http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 3 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al Figure 1. The treatment report for amitriptyline available on PatientsLikeMe. This treatment report was captured after the date of analysis; therefore, the data featured do not match the data reported. http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 4 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al When purposes were viewed by MedDRA system organ class Results (SOC) terminology, modafinil was most commonly used to treat purposes that fall within “general disorders and Modafinil administration site conditions” (1277/1755, 73%) followed by Across the five communities, there were 1948 treatment histories “nervous system disorders” (415/1755, 24%). No other category for modafinil: 1316 described current treatment at the time of accounts for more than 1% of responses. analysis; therefore, 1316 of 53,928 (2%) of all members reported There were 726 treatment evaluations written about modafinil currently taking modafinil. at time of analysis and 383 side-effect reports. The most Modafinil use was most prevalent in the MS community, where common side effects reported fell into the MedDRA SOC there were 1565 reports for 17,820 members (6%), followed by “nervous system disorders” (134/383, 35%) and “general Parkinson's disease (75/4789, 1%) and mood communities disorders and administration site conditions” (100/383, 26%). (136/14,483, 1%). Purposes were reported in 1755 of 1948 Looking at individual side effects, jittery feeling (68/383, 18%), (90%) modafinil treatment histories (see Table 1, n = 1755). dry mouth (60/383, 16%), and anxiety (46/383, 12%) were the Overall, only 34 of 1755 (less than 1%) of members reported most commonly reported. taking modafinil for an approved purpose (narcolepsy and In these evaluations, most users (532/726, 72%) rated the excessive daytime sleepiness resulting from sleep apnea; see effectiveness of modafinil in the highest response categories: Figure 1). Rather, the majority of users reported taking modafinil either “major” or “moderate” (see Table 2). These effectiveness to treat other issues, including general fatigue (1201/1755, 68%) ratings did not vary by purpose. There was a slight tendency to and excessive daytime sleepiness or tiredness arising from their rate the drug as more effective for some off-label purposes, such condition (288/1755, 16%); less common purposes included as a treatment of MS, than for sleepiness. There was only one “brain fog” (61/1755, 3%) a patient vocabulary term for having evaluation in the system for an approved purpose, specifically difficulty concentrating, and cognitive impairment (29/1755, narcolepsy. 2%). Table 1. Purposes reported by 10 or more users for modafinil Purpose reported Number reporting (n = 1755) % MedDRA LLT code 10016256 1201 68.43% Fatigue 10015595 262 14.9% Excessive daytime sleepiness Brain fog 10016876 61 4% Mood 10027945 26 2% Sleepiness 10041014 26 2% Cognitive impairment 10009846 29 2% Narcolepsy and sleep apnea 10028713; 10040975 24 1% Problems concentrating 10003729 20 1% Multiple sclerosis 10028245 23 1% Medical Dictionary for Regulatory Activities lower-level term. 68% of users reported taking the drug to treat fatigue and another 14% excessive daytime sleepiness, such that most users appear to have taken the drug for related purposes. Table 2. Effectiveness ratings for modafinil and amitriptyline Effectiveness rating Modafinil (n = 726) Amitriptyline (n = 590) # Reporting % # Reporting % Can’t tell 30 4% 36 6% No effect 23 3% 86 15% Slight 141 19% 167 28% Moderate 268 37% 201 34% Major 264 36% 100 17% http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 5 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al disorders, more broadly, accounted for only 208 (17%) of the Amitriptyline 1197 reported purposes. One purpose of note was in ALS, where There were 1,394 treatment reports for amitriptyline: 865 of the 88 of 220 (40%) patients took the drug for the purpose of total 53,928 patient members reported currently taking the drug treating a symptom of their condition, excess saliva. (2%). Overall, there were 270 side-effect reports of amitriptyline in ALS, although a small community, had the highest rate of use. the system. The most commonly reported side effects were At the time of analysis, 228 of 4060 (6%) ALS patients in the related to feeling sleepy (reported 126 times in 270 reports, community reported having taken the drug and 178 of the 4060 46%), including “grogginess/sleepiness/drowsiness” (reported (4%) ALS patients stated they were currently taking 56 times in 270 reports), “daytime sleepiness” (reported 34 amitriptyline. In 1197 of the 1394 (86%) treatment reports, times), and “feeling groggy” (reported 36 times in 270 reports). patients reported a purpose (see Table 3). Off-label uses were The second most common side effect was dry mouth (reported much more commonly reported than the on-label purpose. In 78 times in 270 reports, 29%) and third was weight gain (60/270, 104 of 1197 reports (9%), patients reported taking amitriptyline 22%). for the approved use of depression; most commonly, patients reported taking it for insomnia and other sleep problems In this example, there were 70 effectiveness ratings for the (321/1197, 27%) or pain (197/1197, 17%). Examining purposes approved purpose of depression and 520 effectiveness ratings at the SOC level found that members reported using for off-label purposes (see Table 2). The ratings for off-label amitriptyline to control complaints in a variety of systems, purposes were higher than for depression: 28 of the 70 (40%) including nervous system disorders (544/1197, 45%), respondents taking it for the prescribed purpose of depression musculoskeletal and connective tissue disorders (115/1197, rated it as having either a major or moderate efficacy in 10%), and gastrointestinal disorders (103/1197, 9%). Psychiatric comparison to 273 of 520 (52%) taking it for off-label uses. Table 3. Most common purposes reported for taking amitriptyline: purposes reported by 10 or more users are listed (n = 1197 purpose reports by 1394 users). The reasons people reported taking the drug vary widely. Purpose reported Number reporting (n = 1197) % MedDRA LLT code Insomnia/sleep problems 10022437 321 26.8% Pain 10033371 197 16.5% Depression 10012378 104 8.7% Fibromyalgia 10048439 90 8% Excess saliva 10021677 88 7% Nerve pain 10029181 83 7% Emotional lability 10014555 37 3% Migraine headaches 10027602 37 3% Anxiety 10002855 36 3% Headaches 10019211 24 2% Mood disorder 10027945 21 2% Muscle pain 10028322 17 1% Restless legs syndrome 10038741 14 1% Migraine 10027599 13 1% Fatigue 10016256 11 1% Amyotrophic lateral sclerosis 10052889 10 1% Stiffness/spasticity 10041416 10 1% Medical Dictionary for Regulatory Activities lower-level term. approved indications. Many patients used some of the most Discussion common side effects reported for amitriptyline, including sleepiness, as their purpose for taking the drug, such as the Using an online patient community, PatientsLikeMe, we treatment of insomnia. identified that only less than 1% of nearly 2000 patients taking modafinil and 9% of nearly 1400 patients taking amitriptyline We were surprised to find that in two relatively well-understood reported taking each drug for purposes approved by the FDA. drugs, the vast majority of uses were off-label. Our analysis In both cases, patients subjectively reported the effectiveness may indicate that off-label prescribing is even more common for off-label uses as either higher than or comparable to in certain patient populations. In terms of patient-reported http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 6 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al effectiveness, the data suggest that amitriptyline could be more issues of consent and coding requirements to ensure privacy. efficacious for off-label uses than for FDA-approved uses. In the meantime we believe that the scale, scope, and cost to Further study of newer, less commonly used for off-label execute such studies outweigh, or at the very least, mitigate, purposes, would provide a more complete understanding of the these limitations. value of patient-reported outcomes in this area. Due to the architecture of the PatientsLikeMe system, we One advantage of collecting treatment information through an included only a handful of medical communities and possibly online community is the ability to reach a large population of incomplete patient experiences. However, plans are underway users at relatively little marginal cost. As the Internet becomes to significantly expand the number of communities and allow more accessible, an increasingly diverse population is online for multiple comorbidities to be collected, thereby increasing and joining online communities for support with health problems the scope, quality, and representativeness of future studies. [11]. By gathering experiences directly from patients, Finally, when collecting data from patients online, there is the researchers can elicit new types of data not recorded distinct possibility of more egregious misrepresentation – systematically through routine clinical practice, and which namely, that users are not who they appear to be. Patients on would be unlikely to attract funding for traditional clinical trials. the site could be falsifying their identities entirely. While this In fields of study where self-reported data are acceptable, the is always possible, certain Internet platforms may be at higher Internet offers a unique vehicle to collect vast quantities of data risk for these gross inaccuracies than others. In many websites far more effectively than traditional studies permit. This is built specifically to collect medication ratings from patients, particularly true for ongoing monitoring of patient safety and users enter minimal information about themselves before serious adverse events. Toward this end, PatientsLikeMe is entering treatment evaluations, thus lowering the barrier for developing its pharmacovigilance platform to provide a constant misrepresentation. PatientsLikeMe, as a community based on stream of safety data to manufacturers and the FDA, which can ongoing interaction and a reputation built upon a time-based serve as an ongoing phase 4 study of pharmaceutical products. health profile, may be less susceptible to flagrant However, there are significant challenges associated with misrepresentation. collecting patients’ outcome data for post hoc analysis. Members Conclusion of an online community visit the site on their own schedule and There are stated methodologies to evaluate the safety and contingent upon their own needs. While a website may prompt efficacy of drugs for a specific purpose before they are brought users for specific information at timed intervals, members to market. Once approved, these drugs are being used to treat ultimately have the choice of when and whether they will add a wide variety of symptoms and conditions. In many cases, this data. Members may add data only when they feel strongly about is a legitimate and ultimately positive use for an existing agent, a treatment, leading to a substantial reporting bias. In this light, yet all too often there is no way to establish evidence or monitor unblinded studies like ours might consider different outcome patient safety. metrics of primary importance and rely on markers of perceived treatment effectiveness such as discontinuation rates, adherence At the moment, providers often rely on peer-reviewed literature and side effects, rather than self-reported measures of to inform treatment choice. But critics note that “attempting to effectiveness, which can be highly susceptible to placebo effects. use peer-reviewed literature for a purpose for which it is so ill suited is likely not only to fail to adequately regulate off-label Yet there are other limitations. Within the group of registered use but also to degrade the quality of peer-reviewed literature” patients in a community, patients may not report information [26], suggesting there is a need for other ways to evaluate completely. An unknown proportion may be taking the drug off-label prescribing. Online patient platforms, as a repository but fail to report it or its effects. Among those who have taken for patient-reported outcomes, provide an opportunity to create the treatment, only a certain subset completed an evaluation of new methods to study the effect of these drugs after they have the drug, and for the most part they evaluated it at only one reached the market. Evaluating evidence from multiple sources, timepoint. It is hoped that prompts and improved user interface including peer-reviewed literature and online communities, designs, along with more contextual reports and research studies could provide converging evidence about effectiveness. Online (such as this one), will increase the value to patients and in turn communities are in the unique position to capture and present motivate users to enter more information. information of particular relevance to other patients who are In addition, we have a lower level of confidence than in clinical considering taking a drug. trials that a registered “patient” in our system has had a specific Off-label prescribing is a common practice, but outcomes condition diagnosed, that the user is taking the medication as associated with it are routinely understudied, which sometimes prescribed, or that the patient’s experience is tempered by an leads to wasteful treatments and even harmful effects. We unreported comorbidity. There is the potential in the future to propose that patients, sharing their data online, can provide ask clinicians to verify diagnoses and to use records from the relevant, timely information to fill these gaps in knowledge. pharmacies or eHealth technology to validate patient-reported behavior, but this will require significant research to address http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 7 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al Acknowledgments Thank you to the members of PatientsLikeMe who have contributed the experiences and patient reported outcomes that are analyzed in this article. Publishers' Note: This article was the winner of the JMIR Medicine 2.0 Award 2009 at the 2nd Medicine 2.0 World Congress on Social Media and Web 2.0 in Health, Medicine and Biomedical Research. Publication fees were partly sponsored by JMIR Publications. 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[doi: 10.1345/aph.1M705] [Medline: 20442351] http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 8 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al 20. Schwartz TL, Rayancha S, Rashid A, Chlebowksi S, Chilton M, Morell M. Modafinil treatment for fatigue associated with fibromyalgia. J Clin Rheumatol 2007 Feb;13(1):52. [doi: 10.1097/01.rhu.0000255801.32408.6e] [Medline: 17278955] 21. Randall DC, Cafferty FH, Shneerson JM, Smith IE, Llewelyn MB, File SE. Chronic treatment with modafinil may not be beneficial in patients with chronic fatigue syndrome. J Psychopharmacol 2005 Nov;19(6):647-660. [doi: 10.1177/0269881105056531] [Medline: 16272188] 22. Turkington D, Hedwat D, Rider I, Young AH. Recovery from chronic fatigue syndrome with modafinil. Hum Psychopharmacol 2004 Jan;19(1):63-64. [doi: 10.1002/hup.554] [Medline: 14716715] 23. Nieves AV, Lang AE. Treatment of excessive daytime sleepiness in patients with Parkinson's disease with modafinil. Clin Neuropharmacol 2002;25(2):111-114. [Medline: 11981239] 24. Adler CH, Caviness JN, Hentz JG, Lind M, Tiede J. Randomized trial of modafinil for treating subjective daytime sleepiness in patients with Parkinson's disease. Mov Disord 2003 Mar;18(3):287-293. [doi: 10.1002/mds.10390] [Medline: 12621632] 25. Ondo WG, Fayle R, Atassi F, Jankovic J. Modafinil for daytime somnolence in Parkinson's disease: double blind, placebo controlled parallel trial. J Neurol Neurosurg Psychiatry 2005 Dec;76(12):1636-1639 [FREE Full text] [doi: 10.1136/jnnp.2005.065870] [Medline: 16291885] 26. Psaty BM, Ray W. FDA guidance on off-label promotion and the state of the literature from sponsors. JAMA 2008 Apr 23;299(16):1949-1951. [doi: 10.1001/jama.299.16.1949] [Medline: 18430914] Abbreviations ALS: amyotrophic lateral sclerosis DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision FDA: Food and Drug Administration MedDRA: Medical Dictionary for Regulatory Activities MS: multiple sclerosis SOC: system organ class Edited by G Eysenbach; submitted 10.09.10; peer-reviewed by JT Gussinklo, S Hughes; comments to author 01.11.10; revised version received 06.12.10; accepted 20.12.10; published 21.01.11 Please cite as: Frost J, Okun S, Vaughan T, Heywood J, Wicks P J Med Internet Res 2011;13(1):e6 URL: http://www.jmir.org/2011/1/e6/ doi: 10.2196/jmir.1643 PMID: 21252034 ©Jeana Frost, Sally Okun, Timothy Vaughan, James Heywood, Paul Wicks. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.01.2011. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included. http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 9 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Medical Internet Research JMIR Publications

Patient-reported Outcomes as a Source of Evidence in Off-Label Prescribing: Analysis of Data From PatientsLikeMe

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Abstract

Background: Evaluating a new use for an existing drug can be expensive and time consuming. Providers and patients must all too often rely upon their own individual-level experience to inform clinical practice, which generates only anecdotal and unstructured data. While academic-led clinical trials are occasionally conducted to test off-label uses of drugs with expired patents, this is relatively rare. In this work, we explored how a patient-centered online research platform could supplement traditional trials to create a richer understanding of medical products postmarket by efficiently aggregating structured patient-reported data. PatientsLikeMe is a tool for patients, researchers, and caregivers (currently 82,000 members across 11 condition-based communities) that helps users make treatment decisions, manage symptoms, and improve outcomes. Members enter demographic information, longitudinal treatment, symptoms, outcome data, and treatment evaluations. These are reflected back as longitudinal health profiles and aggregated reports. Over the last 3 years, patients have entered treatment histories and evaluations on thousands of medical products. These data may aid in evaluating the effectiveness and safety of some treatments more efficiently and over a longer period of time course than is feasible through traditional trials. Objective: The objective of our study was to examine the illustrative cases of amitriptyline and modafinil – drugs commonly used off-label. Methods: We analyzed patient-reported treatment histories and drug evaluations for each drug, examining prevalence, treatment purpose, and evaluations of effectiveness, side effects, and burden. Results: There were 1948 treatment histories for modafinil and 1394 treatment reports for amitriptyline reported across five PatientsLikeMe communities (multiple sclerosis, Parkinson's disease, mood conditions, fibromyalgia/chronic fatigue syndrome, and amyotrophic lateral sclerosis). In these reports, the majority of members reported taking the drug for off-label uses. Only 34 of the 1755 (1%) reporting purpose used modafinil for an approved purpose (narcolepsy or sleep apnea). Only 104 out of 1197 members (9%) reported taking amitriptyline for its approved indication, depression. Members taking amitriptyline for off-label purposes rated the drug as more effective than those who were taking it for its approved indication. While dry mouth is a commonly reported side effect of amitriptyline for most patients, 88 of 220 (40%) of people with amyotrophic lateral sclerosis on the drug reported taking advantage of this side effect to treat their symptom of excess saliva. Conclusions: Patient-reported outcomes, like those entered within PatientsLikeMe, offer a unique real-time approach to understand utilization and performance of treatments across many conditions. These patient-reported data can provide a new source of evidence about secondary uses and potentially identify targets for treatments to be studied systematically in traditional efficacy trials. (J Med Internet Res 2011;13(1):e6) doi: 10.2196/jmir.1643 http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 1 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al KEYWORDS Off-label; Internet; research; patient platform; methods; online community publish significant findings than nonsignificant findings. Third, Introduction there are inconsistencies among medical conditions in the number of options available; off-label medication use is Off-label prescribing is a legal and common practice in the frequently the only option for “orphan conditions”[1]; and for United States [1]. When a manufacturer develops a new many medical conditions there is no “approved” treatment. For medication for a particular purpose, the US Food and Drug instance, a study comparing approved drug indications against Administration’s (FDA’s) [2] Center for Drug Evaluation and the Diagnostic and Statistical Manual of Mental Disorders, 4th Research evaluates the drug’s efficacy and utility for that edition, text revision (DSM-IV-TR) found that 89% of all purpose before it is brought to market. However, once the drug psychiatric disorders lack approved medications for their is on the market, health care providers are free to prescribe the treatment [8]. Fourth, the regulations apply only to the most drug for either the FDA-approved purpose (“indication”) or any visible means of promotion, and fail to address continuing other purpose – a practice referred to as “off-label prescribing.” medical education presentations and events, or oral responses Across all major drug categories, it is estimated that 21% of all to physicians’ questions at company-sponsored events, exhibit prescriptions are for off-label purposes [3]. booths, or in “detailing” visits [9]. Finally, it has been noted Off-label prescribing has the potential to be a source of that, as the guidance is not legally binding, enforcement is innovation in medicine. Prescribers can discover novel uses for unlikely. existing medications while monitoring tolerability, safety, and Consequently, there is a need to gather evidence to inform effectiveness. Within their practice they can apply the insight off-label prescribing. Unfortunately, gathering this evidence acquired from treating one person to the next case [4]. However, can be prohibitively expensive. Running a clinical trial, of the prescribers may not have an adequate number of cases to type needed to establish the efficacy of a drug for a new purpose, distinguish between a truly meaningful effect of the drug, and costs US $15,700 for a phase 1 trial and over US $26,000 for either a placebo effect or the tendency for patients to improve a phase 3 trial per patient [10]. If a drug is already being used on their own. widely off-label there may be no incentive for manufacturers Off-label prescribing is often done without supporting medical to evaluate it systematically. evidence [1]. For the estimated 21% of prescriptions given In this paper, we propose a new source of evidence to evaluate off-label, 73% lacked scientific evidence underlying their use off-label use: patient-reported outcomes entered via an online [3]. In many cases, patients may be subject to unnecessary, community. An increasing number of patients are going online ineffective, and even harmful treatments. In the past, millions to access information about their health and talk to other patients of women received prophylactic hormone treatment for the about a shared condition [11]. Many patients share advice and prevention of osteoporosis, for instance. However, systematic details about their treatments and symptoms with one another evaluation revealed no therapeutic benefit and elevated risks of and with researchers. Clinical trial researchers increasingly use cardiac damage [5]. Patients are extremely unlikely to be aware the Internet for recruiting subjects, communicating with that the FDA has not evaluated the safety and efficacy of their participants, and even collecting data [12]. Patient groups like treatment for the purpose for which they are using it. the Life Raft Group for patients with gastrointestinal stromal In 2008 the FDA released a guidance document entitled “Good tumor have successfully mobilized their members to study the Reprint Practices for the Distribution of Medical Journal Articles effectiveness of investigational treatments [13]. In this work, and Medical or Scientific Reference Publications on Unapproved we suggest how patients, entering outcomes within an online New Uses of Approved Drugs and Approved or Cleared Medical community, could inform how drugs are working for off-label Devices” [2]. This guidance provides advice for industry on uses by expanding the available evidence base. circulating journal article reprints that contain information on To conduct this analysis we examined patient reported outcomes off-label use, such as for the use of modafinil in treating fatigue reported on PatientsLikeMe. PatientsLikeMe is a web-based in multiple sclerosis (MS) or amitriptyline in treating excessive community and research platform where patient members share saliva in amyotrophic lateral sclerosis (ALS). Unfortunately details about their treatments, symptoms, and conditions, with there are a number of limitations to the application of this the intention of improving their outcomes[14,15]. Patients join guidance. First, the quality of the scientific literature and the communities designed specifically for their condition. At the informal benchmark of acceptability vary dramatically between time of writing, there were 11 distinct patient communities and diseases. The most widely cited paper on the use of modafinil over 70,000 patient members. The site synthesizes members’ for the treatment of fatigue in MS, for instance, has been cited data into interactive reports for review. Each member sees a nearly 250 times but contained only 65 patients at its 9-week graphical representation of their own and others’ function, end point and failed to find a dose-response effect [6]. Second, treatments, and symptoms over time and can view reports of the guidance requires industry to provide counterbalancing aggregated data. The site includes an interactive treatment report evidence. Perhaps unsurprisingly, though, there is evidence of for each medication and intervention that patients add to the selective reporting: many off-label trials are not published, system. The report includes dosages taken, time on treatment, particularly when their finding are not significant [7]. This effect and evaluations of the treatment, including perceived efficacy, is surely compounded by publication bias; that is, it is easier to http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 2 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al side effects, and burden. These treatment reports can suggest resulted in warnings and fines from the FDA [2]. A recent usage patterns and effectiveness rates for drugs across different review [19] of the MS literature assessing the use of modafinil purposes. for the treatment of fatigue in MS considered it a “reasonable therapeutic option” but cautioned that trials to date have been We examined patient data for two medications that are widely small (total N of the literature = 308 patients), unblinded, and prescribed off-label and currently being evaluated for new with only short-term follow-up (median follow-up 12 weeks). applications: amitriptyline and modafinil. We documented how There were some adverse events, mostly gastrointestinal, but patients reported using these drugs and how patient reports one-third of studies failed to report adverse events at all. Similar could inform broader understanding of these relatively methodological problems likewise seriously undermine existing well-understood medications. PatientsLikeMe hosts communities off-label studies in other diseases. for patients with ALS, MS, depression, Parkinson's disease, fibromyalgia, and chronic fatigue syndrome. Given the high In this study, we conducted a post hoc analysis of the prevalence levels of fatigue, pain, excess saliva, and depression presented of on-label versus off-label use, dosing, and perceived across these communities, many members of the site could be effectiveness and side effects for these medications. We looked candidates for treatment of these symptoms. at prevalence of use across the site and in specific communities. We documented purposes of use by community and the side Amitriptyline (Elavil; Merck & Company Inc, Whitehouse effects they reported. Lastly, we began to look at how Station, NJ, USA) is a tricyclic antidepressant that was effectiveness varied by purpose to see whether these agents developed by Merck and approved in the United States in 1961. function similarly for on- and off-label indications. It has FDA approval for the treatment of major depression, clinical/endogenous depression, and involutional melancholia, Methods but it is commonly used off-label for other symptoms ranging from chronic pain to bed wetting. Due to the anticholinergic We analyzed the treatment information entered by patient effects of amitriptyline a primary side effect of the drug is dry members about the two drugs of interest, amitriptyline and mouth. There are 14 clinical trials involving amitriptyline that modafinil, across five condition-based communities: MS, are recruiting subjects (on clinicaltrials.gov), reflecting an fibromyalgia/chronic fatigue syndrome, ALS, mood disorders ongoing interest in its use. In neurological conditions such as (depression, bipolar disorder, and anxiety disorders), and ALS, amitriptyline has been reported informally as being used Parkinson's disease. At the time of analysis (May 24, 2010), by neurologists for the treatment of depression, as well as these communities contained 53,928 members. off-label for excessive saliva, emotional lability, urinary Patients complete treatment histories, including start date, the urgency, and insomnia [16], despite an absence of trials purpose for taking the treatment, dosage (with available dosages supporting its use. Even in its indicated use, for depression, according to the Multum database [Cerner Multum, Denver, ALS guidelines state “Concerning pharmacological treatment CO, USA] prompted as the most likely response options), dates of depression in patients with ALS, there is broad consensus of dosage change, and stop date. Members can add more than among clinical experts that [selective serotonin-reuptake one treatment history to indicate repeated trials of a treatment. inhibitors] and [tricyclic antidepressants] are helpful, but there In addition to their treatment history, members may complete have been no controlled clinical studies of these medications evaluations for each treatment, entering side effects, severity in ALS patients” [17]. Antidepressants like amitriptyline have of side effects (none, mild, moderate, or severe), burden been highlighted as an important target for future research into (difficulty of being on treatment: not at all, a little, somewhat, off-label drug use [18]. or very), and perceived effectiveness (can’t tell, none, slight, Modafinil (Provigil; Cephalon, Inc, Frazer, PA, USA) is a moderate, or major). In both the treatment reports and the wakefulness-promoting agent first available in the United States evaluations (See Figure 1), users are prompted to use a curated since 1998 for approved purposes related to sleep disorders, vocabulary of side-effect and purpose terms, but may enter their including narcolepsy, shift-work disorder, and obstructive sleep own natural language if they wish. In order to aggregate data apnea. As a wakefulness-promoting agent, it has also been across the patient-entered vocabulary, patient-generated investigated off-label for the treatment of fatigue in conditions symptom and side-effect symptom terms were coded using the including MS [19], fibromyalgia [20], chronic fatigue syndrome Medical Dictionary for Regulatory Activities (MedDRA MSSO, [21,22], and Parkinson's disease [23-25]. In the past, promotion Chantilly, VA, USA). of the drug for these off-label purposes by the manufacturer has http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 3 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al Figure 1. The treatment report for amitriptyline available on PatientsLikeMe. This treatment report was captured after the date of analysis; therefore, the data featured do not match the data reported. http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 4 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al When purposes were viewed by MedDRA system organ class Results (SOC) terminology, modafinil was most commonly used to treat purposes that fall within “general disorders and Modafinil administration site conditions” (1277/1755, 73%) followed by Across the five communities, there were 1948 treatment histories “nervous system disorders” (415/1755, 24%). No other category for modafinil: 1316 described current treatment at the time of accounts for more than 1% of responses. analysis; therefore, 1316 of 53,928 (2%) of all members reported There were 726 treatment evaluations written about modafinil currently taking modafinil. at time of analysis and 383 side-effect reports. The most Modafinil use was most prevalent in the MS community, where common side effects reported fell into the MedDRA SOC there were 1565 reports for 17,820 members (6%), followed by “nervous system disorders” (134/383, 35%) and “general Parkinson's disease (75/4789, 1%) and mood communities disorders and administration site conditions” (100/383, 26%). (136/14,483, 1%). Purposes were reported in 1755 of 1948 Looking at individual side effects, jittery feeling (68/383, 18%), (90%) modafinil treatment histories (see Table 1, n = 1755). dry mouth (60/383, 16%), and anxiety (46/383, 12%) were the Overall, only 34 of 1755 (less than 1%) of members reported most commonly reported. taking modafinil for an approved purpose (narcolepsy and In these evaluations, most users (532/726, 72%) rated the excessive daytime sleepiness resulting from sleep apnea; see effectiveness of modafinil in the highest response categories: Figure 1). Rather, the majority of users reported taking modafinil either “major” or “moderate” (see Table 2). These effectiveness to treat other issues, including general fatigue (1201/1755, 68%) ratings did not vary by purpose. There was a slight tendency to and excessive daytime sleepiness or tiredness arising from their rate the drug as more effective for some off-label purposes, such condition (288/1755, 16%); less common purposes included as a treatment of MS, than for sleepiness. There was only one “brain fog” (61/1755, 3%) a patient vocabulary term for having evaluation in the system for an approved purpose, specifically difficulty concentrating, and cognitive impairment (29/1755, narcolepsy. 2%). Table 1. Purposes reported by 10 or more users for modafinil Purpose reported Number reporting (n = 1755) % MedDRA LLT code 10016256 1201 68.43% Fatigue 10015595 262 14.9% Excessive daytime sleepiness Brain fog 10016876 61 4% Mood 10027945 26 2% Sleepiness 10041014 26 2% Cognitive impairment 10009846 29 2% Narcolepsy and sleep apnea 10028713; 10040975 24 1% Problems concentrating 10003729 20 1% Multiple sclerosis 10028245 23 1% Medical Dictionary for Regulatory Activities lower-level term. 68% of users reported taking the drug to treat fatigue and another 14% excessive daytime sleepiness, such that most users appear to have taken the drug for related purposes. Table 2. Effectiveness ratings for modafinil and amitriptyline Effectiveness rating Modafinil (n = 726) Amitriptyline (n = 590) # Reporting % # Reporting % Can’t tell 30 4% 36 6% No effect 23 3% 86 15% Slight 141 19% 167 28% Moderate 268 37% 201 34% Major 264 36% 100 17% http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 5 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al disorders, more broadly, accounted for only 208 (17%) of the Amitriptyline 1197 reported purposes. One purpose of note was in ALS, where There were 1,394 treatment reports for amitriptyline: 865 of the 88 of 220 (40%) patients took the drug for the purpose of total 53,928 patient members reported currently taking the drug treating a symptom of their condition, excess saliva. (2%). Overall, there were 270 side-effect reports of amitriptyline in ALS, although a small community, had the highest rate of use. the system. The most commonly reported side effects were At the time of analysis, 228 of 4060 (6%) ALS patients in the related to feeling sleepy (reported 126 times in 270 reports, community reported having taken the drug and 178 of the 4060 46%), including “grogginess/sleepiness/drowsiness” (reported (4%) ALS patients stated they were currently taking 56 times in 270 reports), “daytime sleepiness” (reported 34 amitriptyline. In 1197 of the 1394 (86%) treatment reports, times), and “feeling groggy” (reported 36 times in 270 reports). patients reported a purpose (see Table 3). Off-label uses were The second most common side effect was dry mouth (reported much more commonly reported than the on-label purpose. In 78 times in 270 reports, 29%) and third was weight gain (60/270, 104 of 1197 reports (9%), patients reported taking amitriptyline 22%). for the approved use of depression; most commonly, patients reported taking it for insomnia and other sleep problems In this example, there were 70 effectiveness ratings for the (321/1197, 27%) or pain (197/1197, 17%). Examining purposes approved purpose of depression and 520 effectiveness ratings at the SOC level found that members reported using for off-label purposes (see Table 2). The ratings for off-label amitriptyline to control complaints in a variety of systems, purposes were higher than for depression: 28 of the 70 (40%) including nervous system disorders (544/1197, 45%), respondents taking it for the prescribed purpose of depression musculoskeletal and connective tissue disorders (115/1197, rated it as having either a major or moderate efficacy in 10%), and gastrointestinal disorders (103/1197, 9%). Psychiatric comparison to 273 of 520 (52%) taking it for off-label uses. Table 3. Most common purposes reported for taking amitriptyline: purposes reported by 10 or more users are listed (n = 1197 purpose reports by 1394 users). The reasons people reported taking the drug vary widely. Purpose reported Number reporting (n = 1197) % MedDRA LLT code Insomnia/sleep problems 10022437 321 26.8% Pain 10033371 197 16.5% Depression 10012378 104 8.7% Fibromyalgia 10048439 90 8% Excess saliva 10021677 88 7% Nerve pain 10029181 83 7% Emotional lability 10014555 37 3% Migraine headaches 10027602 37 3% Anxiety 10002855 36 3% Headaches 10019211 24 2% Mood disorder 10027945 21 2% Muscle pain 10028322 17 1% Restless legs syndrome 10038741 14 1% Migraine 10027599 13 1% Fatigue 10016256 11 1% Amyotrophic lateral sclerosis 10052889 10 1% Stiffness/spasticity 10041416 10 1% Medical Dictionary for Regulatory Activities lower-level term. approved indications. Many patients used some of the most Discussion common side effects reported for amitriptyline, including sleepiness, as their purpose for taking the drug, such as the Using an online patient community, PatientsLikeMe, we treatment of insomnia. identified that only less than 1% of nearly 2000 patients taking modafinil and 9% of nearly 1400 patients taking amitriptyline We were surprised to find that in two relatively well-understood reported taking each drug for purposes approved by the FDA. drugs, the vast majority of uses were off-label. Our analysis In both cases, patients subjectively reported the effectiveness may indicate that off-label prescribing is even more common for off-label uses as either higher than or comparable to in certain patient populations. In terms of patient-reported http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 6 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al effectiveness, the data suggest that amitriptyline could be more issues of consent and coding requirements to ensure privacy. efficacious for off-label uses than for FDA-approved uses. In the meantime we believe that the scale, scope, and cost to Further study of newer, less commonly used for off-label execute such studies outweigh, or at the very least, mitigate, purposes, would provide a more complete understanding of the these limitations. value of patient-reported outcomes in this area. Due to the architecture of the PatientsLikeMe system, we One advantage of collecting treatment information through an included only a handful of medical communities and possibly online community is the ability to reach a large population of incomplete patient experiences. However, plans are underway users at relatively little marginal cost. As the Internet becomes to significantly expand the number of communities and allow more accessible, an increasingly diverse population is online for multiple comorbidities to be collected, thereby increasing and joining online communities for support with health problems the scope, quality, and representativeness of future studies. [11]. By gathering experiences directly from patients, Finally, when collecting data from patients online, there is the researchers can elicit new types of data not recorded distinct possibility of more egregious misrepresentation – systematically through routine clinical practice, and which namely, that users are not who they appear to be. Patients on would be unlikely to attract funding for traditional clinical trials. the site could be falsifying their identities entirely. While this In fields of study where self-reported data are acceptable, the is always possible, certain Internet platforms may be at higher Internet offers a unique vehicle to collect vast quantities of data risk for these gross inaccuracies than others. In many websites far more effectively than traditional studies permit. This is built specifically to collect medication ratings from patients, particularly true for ongoing monitoring of patient safety and users enter minimal information about themselves before serious adverse events. Toward this end, PatientsLikeMe is entering treatment evaluations, thus lowering the barrier for developing its pharmacovigilance platform to provide a constant misrepresentation. PatientsLikeMe, as a community based on stream of safety data to manufacturers and the FDA, which can ongoing interaction and a reputation built upon a time-based serve as an ongoing phase 4 study of pharmaceutical products. health profile, may be less susceptible to flagrant However, there are significant challenges associated with misrepresentation. collecting patients’ outcome data for post hoc analysis. Members Conclusion of an online community visit the site on their own schedule and There are stated methodologies to evaluate the safety and contingent upon their own needs. While a website may prompt efficacy of drugs for a specific purpose before they are brought users for specific information at timed intervals, members to market. Once approved, these drugs are being used to treat ultimately have the choice of when and whether they will add a wide variety of symptoms and conditions. In many cases, this data. Members may add data only when they feel strongly about is a legitimate and ultimately positive use for an existing agent, a treatment, leading to a substantial reporting bias. In this light, yet all too often there is no way to establish evidence or monitor unblinded studies like ours might consider different outcome patient safety. metrics of primary importance and rely on markers of perceived treatment effectiveness such as discontinuation rates, adherence At the moment, providers often rely on peer-reviewed literature and side effects, rather than self-reported measures of to inform treatment choice. But critics note that “attempting to effectiveness, which can be highly susceptible to placebo effects. use peer-reviewed literature for a purpose for which it is so ill suited is likely not only to fail to adequately regulate off-label Yet there are other limitations. Within the group of registered use but also to degrade the quality of peer-reviewed literature” patients in a community, patients may not report information [26], suggesting there is a need for other ways to evaluate completely. An unknown proportion may be taking the drug off-label prescribing. Online patient platforms, as a repository but fail to report it or its effects. Among those who have taken for patient-reported outcomes, provide an opportunity to create the treatment, only a certain subset completed an evaluation of new methods to study the effect of these drugs after they have the drug, and for the most part they evaluated it at only one reached the market. Evaluating evidence from multiple sources, timepoint. It is hoped that prompts and improved user interface including peer-reviewed literature and online communities, designs, along with more contextual reports and research studies could provide converging evidence about effectiveness. Online (such as this one), will increase the value to patients and in turn communities are in the unique position to capture and present motivate users to enter more information. information of particular relevance to other patients who are In addition, we have a lower level of confidence than in clinical considering taking a drug. trials that a registered “patient” in our system has had a specific Off-label prescribing is a common practice, but outcomes condition diagnosed, that the user is taking the medication as associated with it are routinely understudied, which sometimes prescribed, or that the patient’s experience is tempered by an leads to wasteful treatments and even harmful effects. We unreported comorbidity. There is the potential in the future to propose that patients, sharing their data online, can provide ask clinicians to verify diagnoses and to use records from the relevant, timely information to fill these gaps in knowledge. pharmacies or eHealth technology to validate patient-reported behavior, but this will require significant research to address http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 7 (page number not for citation purposes) XSL FO RenderX JOURNAL OF MEDICAL INTERNET RESEARCH Frost et al Acknowledgments Thank you to the members of PatientsLikeMe who have contributed the experiences and patient reported outcomes that are analyzed in this article. Publishers' Note: This article was the winner of the JMIR Medicine 2.0 Award 2009 at the 2nd Medicine 2.0 World Congress on Social Media and Web 2.0 in Health, Medicine and Biomedical Research. Publication fees were partly sponsored by JMIR Publications. 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Treatment of excessive daytime sleepiness in patients with Parkinson's disease with modafinil. Clin Neuropharmacol 2002;25(2):111-114. [Medline: 11981239] 24. Adler CH, Caviness JN, Hentz JG, Lind M, Tiede J. Randomized trial of modafinil for treating subjective daytime sleepiness in patients with Parkinson's disease. Mov Disord 2003 Mar;18(3):287-293. [doi: 10.1002/mds.10390] [Medline: 12621632] 25. Ondo WG, Fayle R, Atassi F, Jankovic J. Modafinil for daytime somnolence in Parkinson's disease: double blind, placebo controlled parallel trial. J Neurol Neurosurg Psychiatry 2005 Dec;76(12):1636-1639 [FREE Full text] [doi: 10.1136/jnnp.2005.065870] [Medline: 16291885] 26. Psaty BM, Ray W. FDA guidance on off-label promotion and the state of the literature from sponsors. JAMA 2008 Apr 23;299(16):1949-1951. [doi: 10.1001/jama.299.16.1949] [Medline: 18430914] Abbreviations ALS: amyotrophic lateral sclerosis DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision FDA: Food and Drug Administration MedDRA: Medical Dictionary for Regulatory Activities MS: multiple sclerosis SOC: system organ class Edited by G Eysenbach; submitted 10.09.10; peer-reviewed by JT Gussinklo, S Hughes; comments to author 01.11.10; revised version received 06.12.10; accepted 20.12.10; published 21.01.11 Please cite as: Frost J, Okun S, Vaughan T, Heywood J, Wicks P J Med Internet Res 2011;13(1):e6 URL: http://www.jmir.org/2011/1/e6/ doi: 10.2196/jmir.1643 PMID: 21252034 ©Jeana Frost, Sally Okun, Timothy Vaughan, James Heywood, Paul Wicks. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.01.2011. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included. http://www.jmir.org/2011/1/e6/ J Med Internet Res 2011 | vol. 13 | iss. 1 | e6 | p. 9 (page number not for citation purposes) XSL FO RenderX

Journal

Journal of Medical Internet Research – JMIR Publications

Published: Jan 21, 2011

Keywords: Off-label; Internet; research; patient platform; methods; online community;

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