Off-label use of recombinant factor VIIa in U.S. hospitals: analysis of hospital records

Abstract

Background: Recombinant factor VIIa (rFVIIa) is approved for treatment of bleeding in patients who have hemophilia with inhibitors but has been applied to a wide range of off-label indications.

Objective: To estimate patterns of off-label rFVIIa use in U.S. hospitals.

Design: Retrospective database analysis.

Setting: Data were extracted from the Premier Perspectives database (Premier, Charlotte, North Carolina), which contains discharge records from a sample of academic and nonacademic U.S. hospitals.

Patients: 12 644 hospitalizations for patients who received rFVIIa during a hospital stay.

Measurements: Hospital diagnoses and patient dispositions from 1 January 2000 to 31 December 2008. Statistical weights for each hospital were used to provide national estimates of rFVIIa use.

Results: From 2000 to 2008, off-label use of rFVIIa in hospitals increased more than 140-fold, such that in 2008, 97% (95% CI, 96% to 98%) of 18 311 in-hospital uses were off-label. In contrast, in-hospital use for hemophilia increased less than 4-fold and accounted for 2.7% (CI, 1.9% to 3.5%) of use in 2008. Adult and pediatric cardiovascular surgery (29% [CI, 21% to 33%]), body and brain trauma (29% [CI, 19% to 38%]), and intracranial hemorrhage (11% [CI, 7.7% to 14%]) were the most common indications for rFVIIa use. Across all indications, in-hospital mortality was 27% (CI, 19% to 34%) and 43% (CI, 26% to 59%) of patients were discharged to home.

Limitation: Accuracy and completeness of the discharge diagnoses and patient medication records in the database sample cannot be verified.

Conclusion: Off-label use of rFVIIa in the hospital setting far exceeds use for approved indications. These patterns raise concern about the application of rFVIIa to conditions for which strong supporting evidence is lacking.

Figure 1

Estimated Annual In-Hospital Cases* of rFVIIa Use for Hemophilia and Off-Label Indications. * Cases signify the number of hospitalizations during which rFVIIa was used. The graph depicts all cases for each year. The width of each segment represents the number of cases for each category as indicated by differential shading. Hemophilia = Hemophilia A and B; ICH = Non-Traumatic Intracranial Hemorrhage; Trauma = Body and Brain Trauma; CV = Cardiovascular.

Figure 2

Use of rFVIIa at Academic and Non-Academic Institutions During 2000–2008.

Appendix Figure 1

A, Estimated Annual In-Hospital Cases Using rFVIIa for Cardiovascular Surgery in the Adult and Pediatric Populations. B, Annual Use for Trauma and Intracranial Hemorrhage.