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Medical devices are characterized notably by a wide heterogeneity (from tongue depressors to hip prostheses, and from non-implantable to invasive devices), a short life cycle with recurrent incremental innovations (from 18 months to 5 years), and an operator-dependent nature. The objective of the current round table was to develop proposals and recommendations concerning the prerequisites needed in order to meet the French health authorities expectations concerning requests for post-approval studies for medical devices, required in cases where short and long-term consequences are unknown. These studies, which are the responsibility of the manufacturer or the distributor of the medical device, are designed to confirm the role of the medical device in the therapeutic management strategy in a real-life setting. There are currently approximately 150 post-approval studies underway, mainly concerning class III devices, and the majority face difficulties implementing the study or meeting the study objectives. In light of this, the round table endeavored to clearly identify the conditions for implementation of post-approval studies specific to the characteristics of medical devices. Various areas of progress have been envisaged to improve the performance of these studies, and by consequence, the efficiency of reimbursement of medical devices by the national health insurance. These include providing manufacturers with the opportunity to better anticipate post-approval requirements, defining a study-specific primary objective, integrating a phase allowing dialogue between the manufacturer, the health authorities and the scientific committee, and increasing awareness and training of health professionals on the impact of post-approval clinical studies in terms of the reimbursement of medical devices by the national insurance., (© 2014 Société Française de Pharmacologie et de Thérapeutique.)

In France, there are large discrepancies regarding flu between the severe disease described by Health Authorities and the disease that people face, considered as usual and benign. Flu prevention is useful, mainly through vaccination. For a well-established influenza-like illness, both individual measures dedicated to the limitation of the disease propagation and symptomatic treatment are to be initiated. Few clinical data are available regarding the most often used treatments for influenza-like illness (paracetamol, homeopathic and symptomatic treatments). The analysis did not show any decrease in the chances of success for patients with more often used drugs, either being under medical prescription, pharmacist advice or self-medication. In front of an influenza-like illness, the recommendations for daily practice can be based on 2 well-defined clinical situations: a specific management for patients at risk, and the influenza-like illness symptoms relief for the others, using a treatment specific for each patient., (Copyright © 2014. Published by Elsevier Masson SAS.)

Long-term studies of NSAIDs have demonstrated cardiovascular toxicity which poses a general problem of the benefit risk between the relief of the patient's symptoms and the risk of digestive and cardiovascular toxicity. The digestive complications and the risk factors associated with the ingestion of NSAIDs have been defined by numerous studies but the prevention of this digestive toxicity can be attempted. The benefit-risk ratio caused by the digestive and cardiovascular toxicities of the NSAIDs and COX-2 inhibitors must be evaluated for each individual before starting a treatment. For a treatment of short duration in patients with a low risk of digestive and cardiovascular complications, the risk of digestive toxicity must be taken into consideration first and the COX-2 inhibitors are favoured. For a treatment of long duration the risk must be evaluated with the greatest care. In the case of cardiovascular risk factors, the cardiovascular risk must be evaluated and the treatment must be prescribed at the lowest dose for the shortest duration. In patients with very high risk of digestive and cardiovascular complications, since the digestive and cardiovascular extra-mortality associated with the ingestion of NSAIDs or COX-2 inhibitors is high, it is advised to abandon this type of long-term treatment.

Long-term studies of NSAIDs have demonstrated cardiovascular toxicity which poses a general problem of the benefit risk between the relief of the patient's symptoms and the risk of digestive and cardiovascular toxicity. The digestive complications and the risk factors associated with the ingestion of NSAIDs have been defined by numerous studies but the prevention of this digestive toxicity can be attempted. The benefit-risk ratio caused by the digestive and cardiovascular toxicities of the NSAIDs and COX-2 inhibitors must be evaluated for each individual before starting a treatment. For a treatment of short duration in patients with a low risk of digestive and cardiovascular complications, the risk of digestive toxicity must be taken into consideration first and the COX-2 inhibitors are favoured. For a treatment of long duration the risk must be evaluated with the greatest care. In the case of cardiovascular risk factors, the cardiovascular risk must be evaluated and the treatment must be prescribed at the lowest dose for the shortest duration. In patients with very high risk of digestive and cardiovascular complications, since the digestive and cardiovascular extra-mortality associated with the ingestion of NSAIDs or COX-2 inhibitors is high, it is advised to abandon this type of long-term treatment.

Unlabelled: IN THEORY: Combination use of a coxib with a gastro-protective agent does not appear justified since results of studies conducted on patients of all types demonstrated that the upper-digestive tract safety and tolerability profile of coxibs is good., In Summary: On the other hand, prescription-related descriptive data demonstrate that in real-life situations such a combination occurs in approximately 25% of cases. Two cases should be differentiated: in about half of cases, patients are receiving long-term therapy with a proton pump inhibitor (PPI) (for reflux oesophagitis, oesophagitis or dyspepsia) and when an NSAID is necessary, the prescribing physician logically turns to a coxib; in the other half of cases, it involves a true simultaneous co-prescription of a coxib and a gastro-protective agent (most often by far a PPI). Thus, it is only in 10-15% of patients that prescription of a coxib leads to prescription of a PPI. A SAFETY ATTITUDE: This approach can be justified by the physician's desire to be as cautious as possible in dealing a patient at high risk of GI disorders (elderly patients, previous history of digestive bleeding, co-prescription of aspirin and/or a steroid, co-morbidity) or in patients for whom the occurrence of GI bleeding would be very serious (i.e. a patient in poor condition due to multiple disorders, treatment with an oral anti-coagulant or heparin). In both cases, if the prescription of an NSAID cannot be avoided, it is therefore logical first to choose a coxib and second to prescribe simultaneously a gastro-protective agent.

Platelet Inhibition: Conventional NSAIDs and aspirin have platelet-inhibiting properties via platelet cyclo-oxygenase-1 (Cox-1) isoenzyme inhibition. Among the NSAIDs which induce reversible inhibition of Cox-1, naproxen seems to have a potent platelet-inhibiting action associated with a decrease in cardiovascular clinical events in secondary prevention. Flurbiprofen is indicated in the secondary prevention after myocardial infarction. Conversely, no conventional NSAID is indicated and none have demonstrated efficacy in primary prevention. GI BLEEDING: The platelet-inhibiting action of conventional NSAIDs and aspirin is a key factor in explaining the increased risk of bleeding reported with these medicinal products. Digestive system bleeding is the main risk. Few data are available regarding bleeding other than gastro-intestinal. COX-2 SPECIFIC INHIBITION PROPERTIES: Conversely, Cox-2 specific inhibitors have no platelet-inhibiting properties: the pharmacological profile of Cox-2 SI is therefore different from that of conventional NSAIDs. These medicinal products are anti-inflammatory, analgesic, platelet-inhibiting agents which are not harmful to the GI mucosa and which probably induce less bronchospasms. In patients with cardiovascular risks, Cox-2 SI can and should be used in combination with platelet-inhibiting agents, in particular aspirin, because they do not alter the aspirin effect on platelets, contrary to what is observed with conventional NSAIDs. PRESCRIPTION WITH ANTI-COAGULANTS: The concomitant prescription of conventional NSAIDs with anti-coagulants is not recommended because, in addition to the possible potentiation of oral anti-coagulants, NSAIDs increase the risk of serious bleeding adverse events due to their irritative effect on the GI mucosa and their platelet-inhibiting effect. This risk might be lower with Cox-2 specific inhibitors.

Osteoporosis is a general disorder of the skeleton characterised by a decrease in bone mass, with damage to the microarchitecture leading to an increase in bone fragility and fracture risk. The incidence of this illness will increase in the future because of the aging of the population and increasing risk factors. Many guidelines have been proposed by qualified authorities--those of the European Agency for the Evaluation of Medicinal Products (EMEA) being the latest published. The aim of treatment of the osteoporosis is to increase, maintain or improve bone mass as well as its strength, with a view to decreasing the incidence of bone fractures. With regard to preclinical studies, in vitro studies--such as those using osteoblast or osteoclast cultures--allow a better understanding of the mechanism of action of drug treatment. The evaluation of bone quality should be performed in two species, such as the ovariectomised female rat model and larger animals (ewe, sow, primate etc.). Phase I studies are designed to enable determinations of pharmacokinetic profiles and bone diffusion and to offer indications of the putative clinical relevance of the dosages. For phase II studies (double-blind controlled studies versus placebo, ideally with a duration of 24 or sometimes 12 months), tests of three dosages are recommended, and the bone mass is considered as a relevant substitution criterion. The aim of secondary osteoporosis prevention studies (randomised double-blind and comparative controlled design versus placebo) is to avoid the occurrence of new bone fractures, and the main evaluation criterion is the number of patients with new fractures. The study length should not be less than 3 years. For evaluation of primary osteoporosis prevention, efficacy in the prevention of bone fracture is the prerequisite--before the use of bone mass as the main evaluation criterion. This criterion can be evaluated by alterations in bone mineral density at the rachis level. Reference drugs such as estrogens can be an alternative to placebo comparison. The tolerability of drugs for the treatment of osteoporosis requires evaluation in long-term studies and the collection of postmarketing data. The International Conference on Harmonisation (ICH) could lead to uniform guidelines for the US, Europe and Japan.