The impact of reducing dose frequency on health outcomes

Neurofascialvascular training for the treatment of Raynaud's phenomenon: A case report

Primary Raynaud's phenomenon (PRP) is characterised by episodic, reversible, and disabling vasospasms of the peripheral arteries. In the most severe cases, it can lead to ulceration of the fingers and toes. Neuro fascial VascularTraining (NFVT) is a novel therapeutic approach for treating PRP. NFVT aims to enhance peripheral circulation and stimulate the autonomic nervous system (ANS) by engaging multiple physiological mechanisms simultaneously. This integrated approach works to reduce vasospasms and alleviate associated symptoms through neurodynamic and myofascial interventions. A 54-year-old woman, who has experienced pain and hypoesthesia in her hands for 9 years, received a diagnosis of PRP without systemic sclerosis in 2014. The patient reported daily colour changes in her fingers, along with pain and a temporary decrease in tactile sensitivity. The patient engaged in ten 30-minute exercise sessions, and the clinical outcomes were assessed based on several parameters. These included the frequency and duration of vasospastic attacks, evaluated using the Raynaud Condition Score, as well as pain and tingling, measured through the daily Numeric Rating Scale. The Composite Autonomic Symptom Score (COMPASS 31) was utilised to assess dysautonomia, while the frequency of medication use and the Disabilities of the Arm, Shoulder, and Hand questionnaire were also considered. The results indicated a significant improvement in symptoms. NFVT improved symptoms and motor dysfunction in a patient with Raynaud's syndrome, demonstrating how NFVT can increase peripheral blood flow, stimulate the ANS, and improve symptoms in PRP.

Clinical efficacy and safety of switching from eculizumab to ravulizumab in adult patients with aHUS- real-world data

BACKGROUND

The complement factor 5 (C5)-inhibitor eculizumab has been established as standard-of-care for the treatment of atypical hemolytic uremic syndrome (aHUS). In 2021, the long-acting C5-inhibitor ravulizumab was approved, extending intervals of intravenous treatment from two to eight weeks resulting in improvement of quality of life for patients and lowering direct and indirect therapy associated costs.

METHODS

This multicenter, retrospective data analysis of 32 adult patients with aHUS (including 10 kidney transplant recipients) treated with eculizumab for at least three months and switched to ravulizumab aims to evaluate the safety and efficacy of switching medication in the real-world setting. Hematologic parameters, kidney function, concurrent therapy and aHUS associated events were evaluated three months before and until up to 12 months after switching to ravulizumab.

RESULTS

Mean age (range) at ravulizumab initiation was 41 years (19-78 years) and 59% of the patients were female. Genetic analysis was available for all patients with 72% showing a pathogenic variant. Median time (range) on eculizumab before switching was 20 months (3-120 months). No new events of TMA or worsening of renal function were reported during up to 12 months of follow-up during ravulizumab treatment.

CONCLUSIONS

This is the largest, non-industry derived, multi-center retrospective analysis of adult patients with aHUS switching C5-inhibitor treatment from eculizumab to ravulizumab in the real-world setting. Switching to ravulizumab was safe and efficient resulting in sustained hematological stability and preservation of renal function.

Novel nano-drug delivery system for natural products and their application

The development of natural products for potential new drugs faces obstacles such as unknown mechanisms, poor solubility, and limited bioavailability, which limit the broadened applicability of natural products. Therefore, there is a need for advanced pharmaceutical formulations of active compounds or natural products. In recent years, novel nano-drug delivery systems (NDDS) for natural products, including nanosuspensions, nanoliposomes, micelle, microemulsions/self-microemulsions, nanocapsules, and solid lipid nanoparticles, have been developed to improve solubility, bioavailability, and tissue distribution as well as for prolonged retention and enhanced permeation. Here, we updated the NDDS delivery systems used for natural products with the potential enhancement in therapeutic efficiency observed with nano-delivery systems.

Outcomes of high-dose oral beta-lactam definitive therapy compared to fluoroquinolone or trimethoprim-sulfamethoxazole oral therapy for bacteremia secondary to a urinary tract infection

Objective

Compare outcomes of patients receiving high-dose oral beta-lactam versus standard oral therapy for Enterobacterales bacteremia from a urinary tract infection (UTI).

Design

Retrospective, multicenter, observational cohort.

Setting

Three Michigan community teaching hospitals.

Patients

Adult patients admitted between February 1, 2020, and October 1, 2022, with gram-negative bacteremia from a urinary source were evaluated. Patients receiving active empiric intravenous (IV) antibiotics and transitioned to appropriately dosed oral cephalexin, amoxicillin, fluoroquinolone (FQ), or trimethoprim/sulfamethoxazole (TMP/SMX) were included. Patients receiving less than 72 hours of oral therapy, diagnosed with renal abscess, lobar nephronia, or expired during admission were excluded.

Methods

Standard oral therapy was defined as FQ or TMP/SMX. The primary outcome compared the composite of recurrent bacteremia or mortality within 30 days of therapy between groups. Secondary outcomes compared recurrent UTI, emergency department or hospital readmission, and Clostridioides difficile within 30 days.

Results

194 patients were included (beta-lactam, n = 75 vs standard therapy, n =119). Patients in both groups were treated for a median of 11 days, with 4 days IV and 7 days oral therapy. There was no difference in the primary outcome between groups (beta-lactam 1.3% vs standard therapy 1.7%, OR 1.27 [95% CI 0.11-14.2]). No patients experienced C. difficile in either group (p = 1.0). Infectious disease consultation was independently associated with standard therapy prescribing (OR 4.4 [95% CI 2.24-8.26]).

Conclusion

High-dose oral beta-lactams were as safe and effective as oral FQ or TMP/SMX for the treatment of bacteremia from a urinary source. Most patients received 8-10 days of therapy in both groups.

Disease activity-guided tapering of biologics in patients with inflammatory arthritis: a pragmatic, randomized, open-label, equivalence trial

OBJECTIVE

To evaluate whether disease activity-guided tapering of biologics compared to continuation as usual care enables a substantial dose reduction while disease activity remains equivalent.

METHOD

In this pragmatic, randomized, open-label, equivalence trial, adults with rheumatoid arthritis, psoriatic arthritis, or axial spondyloarthritis in low disease activity on stable-dose biologics for ≥ 12 months were randomized 2:1 into either the tapering group, i.e. disease activity-guided prolongation of the biologic dosing interval until flare or withdrawal, or the control group, i.e. maintaince of baseline biologics with a possible small interval increase at the patients request. The co-primary outcome in the intention-to-treat population was met if superiority in ≥ 50% biologic reduction at 18 months was demonstrated and disease activity was equivalent (equivalence margins ± 0.5).

RESULTS

Ninety-five patients were randomized to tapering and 47 to control, of whom 37% (35/95) versus 2% (1/47) achieved ≥ 50% biologic reduction at 18 months. The risk difference was statistically significant [35%, 95% confidence interval (CI) 24%-45%], while disease activity remained equivalent [mean difference 0.05, 95% CI -0.12-0.29]. A statistically significant flare risk was observed [tapering 41% (39/95) vs control 21% (10/47), risk difference 20%, 95% CI 4%-35%]; but, only 1% (1/95) and 6% (3/47) had persistent flare and needed to switch to another biological drug.

CONCLUSIONS

Disease activity-guided tapering of biologics in patients with inflammatory arthritis enabled one-third to achieve ≥ 50% biologic reduction, while disease activity between groups remained equivalent. Flares were more frequent in the tapering group but were managed with rescue therapy.

Two Times Versus Four Times Daily Cephalexin Dosing for the Treatment of Uncomplicated Urinary Tract Infections in Females

Background

The current treatment guidelines of the Infectious Diseases Society of America recommend β-lactam antibiotics as alternative rather than first-line agents for the treatment of uncomplicated urinary tract infection (uUTI). Cephalexin is a commonly prescribed first-generation cephalosporin with excellent bioavailability and urinary penetration; however, little data exist to support optimal dosing for uUTI.

Methods

This retrospective multicenter cohort study included adult female patients who received 5 to 7 days of cephalexin for symptomatic uUTI with a cefazolin-susceptible urine culture. The primary objective was to compare uUTI treatment failure (eg, continued or recurrent symptoms within 30 days) between patients treated with cephalexin 500 mg twice daily (BID group) and 500 mg 4 times daily (QID group) in the outpatient setting. Secondary outcomes included time to treatment failure, reported adverse events within 7 days of treatment, and occurrence of Clostridioides difficile within 30 days of treatment.

Results

A total of 261 patients were included (BID, n = 173; QID, n = 88). Baseline characteristics were similar between the groups. Escherichia coli was the most commonly isolated pathogen (85.4%). There was no difference in treatment failure observed between the groups (BID 12.7% vs QID 17%, P = .343), including failure while undergoing therapy (BID 2.3% vs QID 5.7%, P = .438) or recurrence within 30 days (BID 10.4% vs QID 11.3%, P = .438). No differences in reported adverse events (BID 4.6% vs QID 5.6%, P = .103) were observed between groups.

Conclusions

Twice-daily cephalexin is as effective as 4-times-daily dosing for uUTI. A twice-daily dosing strategy may improve patient adherence.

PEGylated Recombinant Adenosine Deaminase Maintains Detoxification and Lymphocyte Counts in Patients with ADA-SCID

PURPOSE

Metabolic detoxification with enzyme replacement therapy (ERT) promotes immune recovery in patients with adenosine deaminase (ADA)-deficient severe combined immunodeficiency (ADA-SCID). Elapegademase is a PEGylated recombinant bovine ADA ERT developed to replace the now-discontinued bovine-derived pegademase. This study was a 1-way crossover from pegademase to elapegademase in 7 patients with ADA-SCID to assess efficacy and safety outcomes for elapegademase.

METHODS

After once-weekly pegademase dosage was adjusted to achieve therapeutic metabolic detoxification and trough ADA activity, patients transitioned to a bioequivalent dose of elapegademase. Maintenance of metabolic detoxification and adequate ADA activity were evaluated periodically.

RESULTS

One patient withdrew after 2 doses of an early elapegademase formulation due to injection-site pain caused by EDTA. The 6 remaining patients completed 71-216 weeks of elapegademase therapy with a formulation that did not contain EDTA. In these patients, elapegademase improved ADA activity compared with pegademase and maintained metabolic detoxification. Total lymphocyte counts increased for all completer patients from between 1.2- and 2.1-fold at the end of study compared with baseline. Elapegademase had a comparable safety profile to pegademase; no patient developed a severe infectious complication. Three patients had transient, non-neutralizing antibodies to pegademase, elapegademase, and/or polyethylene glycol ≤ 47 weeks of treatment without effect on trough plasma ADA activity or trough erythrocyte deoxyadenosine nucleotide levels.

CONCLUSION

Elapegademase was safe, well tolerated, achieved stable trough plasma ADA activity with weekly dosing, was effective in maintaining metabolic detoxification, and was associated with maintenance or improvements in lymphocyte counts compared with pegademase therapy in patients with ADA-SCID.

REFINE-Lung implements a novel multi-arm randomised trial design to address possible immunotherapy overtreatment

Increasing evidence suggests that some immunotherapy dosing regimens for patients with advanced cancer could result in overtreatment. Given the high costs of these agents, and important implications for quality of life and toxicity, new approaches are needed to identify and reduce unnecessary treatment. Conventional two-arm non-inferiority designs are inefficient in this context because they require large numbers of patients to explore a single alternative to the standard of care. Here, we discuss the potential problem of overtreatment with anti-PD-1 directed agents in general and introduce REFINE-Lung (NCT05085028), a UK multicentre phase 3 study of reduced frequency pembrolizumab in advanced non-small-cell lung cancer. REFINE-Lung uses a novel multi-arm multi-stage response over continuous interventions (MAMS-ROCI) design to determine the optimal dose frequency of pembrolizumab. Along with a similarly designed basket study of patients with renal cancer and melanoma, REFINE-Lung and the MAMS-ROCI design could contribute to practice-changing advances in patient care and form a template for future immunotherapy optimisation studies across cancer types and indications. This new trial design is applicable to many new or existing agents for which optimisation of dose, frequency, or duration of therapy is desirable.

Safety and Tolerability of Bilastine 0.6% Ophthalmic Solution: An 8-Weeks Phase III Study

Purpose

The objective of this study was to assess the safety and tolerability of preservative-free bilastine 0.6% ophthalmic solution after 8 weeks of once-daily administration in patients with allergic conjunctivitis (AC).

Patients and Methods

Multi-center, international, randomized, double blind, placebo-controlled, parallel-group, phase III study of adult patients with seasonal or perennial AC. The study was conducted in 26 centers of 5 European countries. Duration of daily treatment with bilastine 0.6% ophthalmic solution or placebo was 8 weeks. Safety was evaluated by analyzing incidence of ocular treatment-emergent adverse events (TEAEs); additionally, and as secondary parameters, ocular tolerability was assessed, in addition efficacy was also assessed by the average daily total eye symptoms score (TESS).

Results

A total of 333 randomized patients with AC were included (bilastine, N=218; placebo, N=115). Mean (SD) age of the patients was 39.9 (13.7) and were 63.7% female. Overall, the percentage of ocular related TEAEs was low, and the percentage of patients with ocular related TEAEs was lower in the bilastine ophthalmic solution group (2.8%) than in the placebo group (4.3%). No severe TEAEs were reported. The ocular symptoms and TESS improved during the trial in both treatment groups. Statistically significant treatment differences were observed at Week 8 for the TESS and all individual ocular symptoms, being significantly better in the bilastine ophthalmic solution group than in placebo group.

Conclusion

Bilastine 0.6% ophthalmic solution revealed no safety concerns in patients with AC after 8 weeks of once-daily administration. Bilastine was effective in reducing ocular symptoms associated with AC in response to both seasonal and perennial allergens.

Efficacy of plain cholecalciferol versus ergocalciferol in raising serum vitamin D level in Thai female healthcare workers

Objectives

To compare the efficacy of cholecalciferol and ergocalciferol in raising 25-hydroxyvitamin D (25(OH)D) level in Thai female healthcare workers.

Methods

A randomized control trial was conducted in healthy female healthcare workers. Randomization allocated the participants into vitamin D2 group (N = 43), receiving ergocalciferol 20,000 IU weekly and vitamin D3 group (N = 40), receiving cholecalciferol 1000 IU daily for 12 months. Venous blood sample was collected at baseline, 6 and 12 months for serum 25(OH)D, parathyroid hormone and calcium. Compliance was also assessed.

Results

The mean age of the participants was 50.6 ± 9.9 and 50.9 ± 8.4 years in vitamin D2 and D3 groups (P = 0.884). The mean 25(OH)D levels were 16.91 ± 6.07 ng/mL and 17.62 ± 4.39 ng/mL (P = 0.547), respectively. Both groups had significant improvement in 25(OH)D level at 6 months (from 16.91 ± 6.07 to 21.67 ± 5.11 ng/mL and 17.62 ± 4.39 to 26.03 ± 6.59 ng/mL in vitamin D2 and D3 group). Improvement was significantly greater with cholecalciferol (P = 0.018). The level plateaued afterwards in both groups. Only cholecalciferol could increase 25(OH)D in participants without vitamin D deficiency (6.88 ± 4.20 ng/mL increment). Compliance was significantly better in vitamin D2 group (P = 0.025).

Conclusions

Daily cholecalciferol supplementation resulted in a larger increase in serum 25(OH)D level during the first 6 months comparing to weekly ergocalciferol. While vitamin D3 could increase serum 25(OH)D level in all participants, vitamin D2 could not do so in participants without vitamin D deficiency.

Evergreened drugs or evergreened profits?

BACKGROUND

Branded drugs contribute disproportionately to high prescription drug spending. Pharmaceutical companies utilize patent extension "evergreening" techniques that contribute to high drug costs.

AIMS

This article describes various patent extension techniques and analyzes the tactic of combining generic drugs with branded drugs, using metformin combinations for diabetes treatment as a case study. It examines the argument that FDCs enhance adherence and compares the cost of several branded fixed-dose combinations with the cost of their individual constituents.

MATERIALS & METHODS

We reviewed literature on patent extension techniques in both medical and marketing literature, supplemented by our own extensive files. We performed a price analysis of several branded pharmaceuticals and generically available equivalents. Prescription drug prices were determined using GoodRx.com, and prices of over-the-counter products were established based on the prices of two chain wholesalers. Patent and formulation information was taken from the FDA Orange Book: Approved Drugs with Therapeutic Equivalence Evaluations database.

RESULTS

"Evergreening" patent extension tactics include the sequential release of different formulations, minor dosing changes, and fixed-dose combinations (FDCs). A "new use" provides an opportunity for a company to re-patent, rebrand, and remarket one drug for multiple indications. It is unclear whether or not FDCs enhance adherence. Branded fixed-dose combinations generally cost far more than their individual constituents. FDCs that combine metformin with other drugs are an exception, often costing the same as the non-metformin component.

DISCUSSION

Patent extension tactics increase drug costs while providing little additional benefit to patients. Minor alterations in formulations or dosing may provide no clinical benefits. Many FDCs are expensive and fail to provide cost-justified improvements in clinical outcomes, compared to equivalent generic drugs that would save money while delivering an equal standard of care. Combining newer hypoglycemic drugs with metformin, a gold-standard, generic, inexpensive drug, does not appear to cost more than individual constituents but offers no clinical advantage over metformin alone.

CONCLUSION

Evergreening tactics should be reined in, as they represent significant cost to the healthcare system and to patients. Physicians and other prescribers should avoid prescribing FDCs, or slightly tweaked "new" drugs. Patented drug combinations generate profit without innovation.

Comparison of Efficacy and Safety of Transdermal Buprenorphine Patch and Conventional Analgesics in Intra-capsular Femur Neck Fracture Post Hemiarthroplasty

BACKGROUND

One of the most common fractures in the elderly population is a fracture of the neck of femur. Effective post-operative analgesia is a major challenge. Age-related co-morbidities restrict the choice of analgesics. The purpose of this study was to compare the efficacy and safety of transdermal buprenorphine [TDB] patch and conventional analgesics following hemiarthroplasty for intra-capsular fracture neck of femur.

MATERIALS AND METHODS

This was a prospective, randomized control study done in 60 patients undergoing hemiarthroplasty for intra-capsular fracture neck of femur over a period of 2 years. Patients were randomized in 2 groups. Group A received a combination of IV paracetamol and tramadol for first 48 h followed by oral formulation. In Group B patients, a transdermal buprenorphine patch of 5 mcg/h was applied at the beginning of surgery and was continued 2 weeks post-operative.Pain score by VAS was observed both at rest and on movement and followed up till 14 days post-operative. Primary target was to maintain a VAS ≤ 4. Rescue analgesic was given if the VAS was ≥ 6. Secondary targets were number of rescue analgesics required, adverse reactions and complications if any.

RESULTS

Group B had significantly lower pain scores at rest and during movement [p value 0.0012 to ≤ 0.0001], so was rescue analgesia requirement. No significant side effects were seen in TDB group.

CONCLUSION

TDB patch is safe and provides superior analgesia and compliance as compared to conventional analgesics in the post-operative period in proximal femur fracture surgeries.

Intraovarian Injection of Recombinant Human Follicle-Stimulating Hormone for Luteal-Phase Ovarian Stimulation during Oocyte Retrieval Is Effective in Women with Impending Ovarian Failure and Diminished Ovarian Reserve

It is a challenge to obtain sufficient eggs during in vitro fertilization (IVF) in women with impending ovarian failure (IOF)/diminished ovarian reserve (DOR). Although studies have suggested that more than one wave of follicle growth exists, the efficacy of controlled ovulation stimulation (COS) in both follicular and luteal phases of the same ovarian cycle (DuoStim) is not established in women with IOF/DOR. We investigated the efficacy of DuoStim using the intraovarian injection of recombinant human follicle-stimulating hormone (rhFSH) during oocyte retrieval in women with DOR. For luteal-phase stimulation, intraovarian (Group A, N = 28) or superficial subcutaneous (Group B, N = 18) injection of 300 IU rhFSH immediately after oocyte retrieval was administered as the first dose, and intermittent superficial subcutaneous addition of gonadotropins was employed accordingly for further COS in both groups. In Group A, significantly lower Gn doses, a shorter duration of COS, a greater number of antral follicle counts, and an increased number of retrieved mature and total oocytes were noted. Compared with the clinical outcomes of luteal-phase COS, the average daily doses of rhFSH used in Group A were significantly lower. In summary, the novel approach using intraovarian rhFSH injection provides an efficient treatment regimen in women with IOF/DOR.

Efficacy and Safety of a New Sustained-release Pregabalin Formulation Compared With Immediate-release Pregabalin in Patients With Peripheral Neuropathic Pain: A Randomized Noninferiority Phase 3 Trial

OBJECTIVE

This study investigated whether a new sustained-release (SR) pregabalin formulation is noninferior to immediate-release (IR) pregabalin in alleviating peripheral neuropathic pain in Korean patients.

MATERIALS AND METHODS

This was a randomized, double-blind, active-controlled phase 3 study of patients with diabetic peripheral neuropathy or postherpetic neuralgia from 41 sites in South Korea in 2017-2018. Eligible patients were randomized (1:1) to receive once-daily SR pregabalin or twice-daily IR pregabalin (150 to 600 mg/d) in a double-dummy manner for 12 weeks according to a stratified permuted block randomization scheme. The primary endpoint was the Daily Pain Rating Scale score at the end of treatment, averaged from the last 7 available scores.

RESULTS

A total of 319 of 371 (86.0%) randomized patients completed the 12-week treatment (SR pregabalin: n=154; IR pregabalin: n=165; per-protocol set: n=296). The least square mean difference between both groups for the primary endpoint was 0.06 (SE 0.19); (95% confidence interval -0.31 to 0.42), with the lower limit of the confidence interval above the pre-specified margin (-0.78; Pnoninferiority<0.0001). Drug-related treatment-emergent adverse events (TEAEs) were comparable between both groups. The incidence of drug-related TEAEs leading to treatment discontinuation was low (SR pregabalin: 2.7%; IR pregabalin: 1.1%). No serious drug-related TEAEs or deaths occurred.

DISCUSSION

The results demonstrate that the new once-daily SR pregabalin formulation is noninferior to twice-daily IR pregabalin in reducing peripheral neuropathic pain and is well tolerated in Korean patients with diabetic peripheral neuropathy or postherpetic neuralgia after 12 weeks of treatment.

Extended Injection Intervals of Gonadotropins by Intradermal Administration in IVF Treatment

CONTEXT

Gonadotropins can be administered every 5 days under intradermal injection in in vitro fertilization (IVF) treatment.

OBJECTIVE

To explore the effectiveness of intradermal injection of recombinant human FSH (rhFSH) for women undergoing IVF.

METHODS

Women who received their first IVF treatment enrolled in this prospective intervention in 2018. All women received a bolus of 900 IU rhFSH intradermally at day 2 of the treatment cycle followed by additional dosage of rhFSH at day 7 and/or day 10. The main outcome measures included the total dose of rhFSH and number of injections required, sequential serum FSH level detected, and number of mature oocytes retrieved.

RESULTS

Seventy women completed the study. On average, 2.31 ± 0.73 injections and 1662 ± 397 IU of rhFSH were administered. While the baseline FSH level was 5.6 ± 2.2 IU/L, the serum concentrations of FSH after rhFSH administration were 35.3 ± 7.0 on the first day (24 hours) and 10.7 ± 3.7 IU/L on the fifth day (120 hours). A total of 10.5 ± 6.6 mature oocytes were retrieved, resulting in 7.3 ± 5.1 pronuclear embryos; 1.8 ± 0.6 embryos were transferred to the uterus. Our findings resulted in 72% fertilization, 91% cleavage, 31% implantation, and 36% live birth rates. Although fewer larger follicles were found, noninferiority results were noted in the mature oocytes retrieved, good embryos available, and clinical pregnancy rate compared with those received conventional daily subcutaneous rhFSH administration.

CONCLUSION

Intradermal administration of rhFSH, with a smaller dose of rhFSH and fewer injections, may achieve the goal of a cost-effective and more patient-friendly regimen.

Risk of flare after tapering or withdrawal of b-/tsDMARDs in patients with RA or axSpA: A systematic review and meta-analysis

OBJECTIVE

To evaluate flare risk when tapering or withdrawing biological or targeted synthetic disease-modifying antirheumatic drugs (b-/tsDMARDs) compared to continuation in patients with inflammatory arthritis (IA) in sustained remission or low disease activity.

METHODS

Articles were identified in Cochrane Library, PubMed, EMBASE and Web of Science. Eligible trials were randomised, controlled trials comparing tapering and/or withdrawal of b- and/or tsDMARDs with standard dose in IA. Random-effects meta-analysis was performed with risk ratio (RR), or Peto's Odds Ratio (POR) for sparse events, and 95% confidence intervals (95%CI).

RESULTS

The meta-analysis comprised 22 trials: 11 assessed tapering and 7 addressed withdrawal (4 assessed both). Only trials with a rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) population were identified. An increased flare risk was demonstrated when b-/tsDMARD tapering was compared to continuation, RR = 1.45 (95%CI: 1.19 to 1.77, I2 = 42.5%), and potentially increased for persistent flare, POR = 1.56 (95%CI: 0.97 to 2.52, I2 = 0%). Comparing tumour necrosis factor inhibitor (TNFi) withdrawal to continuation, a highly increased flare risk (RR = 2.28, 95%CI: 1.78 to 2.93, I2 = 78%) and increased odds of persistent flare (POR = 3.41, 95%CI: 1.91 to 6.09, I2 = 49%) was observed. No clear difference in flare risk between RA or axSpA was observed.

CONCLUSION

A high risk for flare and persistent flare was demonstrated for TNFi withdrawal whereas an increased risk for flare but not for persistent flare was observed for b-/tsDMARD tapering. Thus, tapering seems to be the more favourable approach.

REGISTRATION

PROSPERO (CRD42019136905).

Comparison of ticagrelor with clopidogrel on quality of life in patients with acute coronary syndrome

Background

Ticagrelor has a Class I recommendation for use following percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS). However, ticagrelor needs to be taken twice a day, as compared to clopidogrel. Its adverse effects, such as dyspnea or bleeding, are known to be more common than with clopidogrel. Dyspnea may tend to be uncomfortable and limit activity. Major bleeding often leads to hospitalization or transfusions, and frequent minor bleeding, which might not result in patients seeking medical care, can make ACS patients feel unhealthy. Thus, these characteristics may affect the health-related quality of life (HQOL).

Methods

In the PLEIO (comParison of ticagreLor and clopidogrEl on mIcrocirculation in patients with acute cOronary syndrome) trial, we randomized 120 participants to receive ticagrelor 90 mg twice daily or clopidogrel 75 mg once daily for at least 12 months. We carried out an HQOL assessment with the Short Form 36 Health Survey (SF-36) questionnaire on the day of discharge following PCI, as well as six months later.

Results

At discharge, the HQOL measures were similar in the ticagrelor and clopidogrel groups, both having a physical component summary (PCS) and a mental component summary (MCS) score. A six-month HQOL follow-up assessment showed that there were no differences between the two study groups in either the PCS or the MCS scores. In both groups, the PCS scores significantly increased over six months of treatment (both p < 0.01). However, the MCS score did not differ significantly. A baseline MCS score is an independent predictor of better physical and mental health status at six months.

Conclusions

Ticagrelor, as compared to clopidogrel, did not significantly reduce the HQOL during the six months following PCI in patients with ACS.

Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02618733.

The Attitude towards Polypills Questionnaire (APPQ): a phase I-III development and validation study in patients with cerebrovascular disease

Background and purpose

The polypill approach has been proposed to reduce patients’ pill burden, increase medication adherence and lower stroke incidence. However, little is known about patients’ attitudes towards polypills for cerebrovascular medication.

Methods

Based on the European Organization for Research and Treatment of Cancer Quality of Life Group questionnaire development guidelines, a questionnaire to measure patients’ attitudes towards polypills for the secondary prevention of stroke (phase I–III) was developed. In phase I, issues were generated via literature review and interviews with patients and healthcare professionals. The issues were operationalized into items in phase II. In phase III the questionnaire was validated in a large single‐centre sample, and test–retest and internal validity were evaluated.

Results

In phase I, 34 relevant issues were identified through literature search and interviews. Pre‐testing the questionnaire indicated high applicability and comprehensibility. The final Attitudes towards Polypills Questionnaire was tested in N = 260 patients and showed a two‐factor structure. The factors were labelled ‘concerns’ and ‘benefits’. The scales showed acceptable and good internal validity (concerns, Cronbach's α = 0.85; benefits, α = 0.93), but the scales’ test–retest validity was ambiguous. On a 0 to 3 rating scale, concerns were rated lower than benefits (mean 1.07, SD 0.69 vs. mean 1.87, SD 0.89).

Conclusions

The Attitudes towards Polypills Questionnaire showed high comprehensibility and content validity to assess German language patients’ attitudes towards a polypill medication. Our data and questionnaire may aid the implementation of polypill treatments in clinical practice and can be used in the design of future clinical trials on polypill therapy. Further validation of the questionnaire is advised.

The Effect of Regimen Frequency Simplification on Provider Order Generation: A Quasi-Experimental Study in a Korean Hospital

The multiplicity of dosing frequencies that are attached to medication orders poses a challenge to patients regarding adhering to their medication regimens and healthcare professionals in maximizing the efficiencies of health care service delivery. A multidisciplinary team project was performed to simplify medication regimens to improve the computerized physician order entry (CPOE) system to reduce the dosing frequencies for patients who were discharged from the hospital. A 36-month pre-test–post-test study was performed, including 12-month pre-intervention, 12-month intervention, and 12-month post-intervention periods. Two-pronged strategies, including regimen standardization and prioritization, were devised to evaluate the dosing frequencies and prescribing efficiency. The results showed that the standardized menu reduced the dosing frequencies from 4.3 ± 2.2 per day in the pre-intervention period to 3.5 ± 1.8 per day in the post-intervention period (p < 0.001). In addition, the proportion of patients taking medications five or more times per day decreased from 40.8% to 20.7% (p < 0.001). After prioritizing the CPOE dosing regimen, the number of pull-down options that were available reflected an improvement in the prescribing efficiency. Our findings indicate that concerted efforts in improving even a simple change on the CPOE screen via standardization and prioritization simplified the dosing frequencies for patients and improved the physicians’ prescribing process.

The long-acting C5 inhibitor, ravulizumab, is efficacious and safe in pediatric patients with atypical hemolytic uremic syndrome previously treated with eculizumab

BACKGROUND

Atypical hemolytic uremic syndrome (aHUS) is a rare, complement-mediated disease associated with poor outcomes if untreated. Ravulizumab, a long-acting C5 inhibitor developed through minimal, targeted modifications to eculizumab was recently approved for the treatment of aHUS. Here, we report outcomes from a pediatric patient cohort from the ravulizumab clinical trial (NCT03131219) who were switched from chronic eculizumab to ravulizumab treatment.

METHODS

Ten patients received a loading dose of ravulizumab on Day 1, followed by maintenance doses administered initially on Day 15, and then, every 4-8 weeks thereafter, depending on body weight. All patients completed the initial evaluation period of 26 weeks and entered the extension period.

RESULTS

No patients required dialysis at any point throughout the study. The median estimated glomerular filtration rate values remained stable during the trial: 99.8 mL/min/1.73m2 at baseline, 93.5 mL/min/1.73m2 at 26 weeks, and 104 mL/min/1.73m2 at 52 weeks. At last available follow-up, all patients were in the same chronic kidney disease stage as recorded at baseline. Hematologic variables (platelets, lactate dehydrogenase, and hemoglobin) also remained stable throughout the initial evaluation period and up to the last available follow-up. All patients experienced adverse events; the most common were upper respiratory tract infection (40%) and oropharyngeal pain (30%). There were no meningococcal infections reported, no deaths occurred, and no patients discontinued during the study.

CONCLUSIONS

Overall, treatment with ravulizumab in pediatric patients with aHUS who were previously treated with eculizumab resulted in stable kidney and hematologic parameters, with no unexpected safety concerns when administered every 4-8 weeks.

TRIAL REGISTRATION

Trial identifiers: Trial ID: ALXN1210-aHUS-312 Clinical trials.gov : NCT03131219 EudraCT number: 2016-002499-29 Graphical abstract.

Haemophilia A patients' medication adherence to prophylaxis with efmoroctocog alfa

INTRODUCTION

Lightening the injection burden is commonly believed to improve prophylaxis adherence. Efmoroctocog alfa (rFVIIIFc) is the first recombinant FVIII-Fc fusion protein available in France. This clotting factor with an extended half-life could thus improve medication adherence.

AIM

The study primarily aimed to assess the real-life impact on prophylaxis adherence of haemophilia A patients, when switching from a standard to an extended half-life FVIII.

METHODS

This study was an observational, monocentre, non-interventional study aiming at assessing haemophilia A patients' real-life adherence during the first-year post-rFVIIIFc prophylaxis initiation. Medication adherence was assessed using two methods: the medication possession ratio (MPR), which is based on the hospital pharmacy dispensing data, and self-reported VERITAS-Pro^® questionnaire. Patients on rFVIIIFc prophylaxis for at least 12 months, following a 12-month standard FVIII prophylaxis, were eligible for inclusion.

RESULTS

In 2019, 47 male patients were undergoing rFVIIIFc prophylaxis in our Hemophilia Center, among which 36 meeting the inclusion criteria. Switching from standard to extended half-life FVIII prophylaxis resulted in increased mean dosing, while the mean number of weekly prophylactic injections (2.6 ± 0.5 vs 1.8 ± 0.3) decreased. Following rFVIIIFc initiation, a non-significant increase in median MPR occurred and the self-reported VERITAS-Pro^® questionnaire demonstrated improved adherence to rFVIIIFc prophylaxis. Comparing adherent and non-adherent patients revealed age as the only factor likely to impact adherence (p = .07).

CONCLUSION

Our patient cohort exhibited high adherence levels before and after FVIII switching, based on MPR and VERITAS-Pro^® questionnaire. The latter is likely a useful tool to quantity prophylaxis adherence from a patient's perspective in daily use.

Kinetics of Intestinal Presence of Spores Following Oral Administration of Bacillus clausii Formulations: Three Single-Centre, Crossover, Randomised, Open-Label Studies

BACKGROUND AND OBJECTIVE: Probiotics are live microorganisms that may provide benefits including the prevention of gastrointestinal disorders and other diseases. Enterogermina is a probiotic mix of spores from four strains of Bacillus clausii (O/C, T, N/R and SIN), available in several oral formulations. The objective of this analysis was to evaluate and compare the kinetic profiles of different formulations of Enterogermina-vial [E4 once daily (OD) and E2 twice daily (BID)], capsule [EC2 three times daily (TID)], oral powder for suspension (ES6 OD) and oral powder not requiring suspension (E6 OD) from two studies from 2012 (EUDRACT 2010-024497-19 and 2010-023187-41) and one study from 2016 (EUDRACT 2015-003330-27).

METHODS

B. clausii spores were counted in homogenised faecal samples (results expressed as counts per gram) or after culture at 37 °C for 24-36 h (results expressed as colony-forming units). Kinetics were assessed by area under the concentration-time curve (AUC), maximum concentration (C_max), time to maximum concentration (T_max) and spore presence/persistence.

RESULTS

In total, 22 subjects in each of the 2012 studies and 30 subjects in the 2016 study were randomised (mean age 25.0-33.8 years across studies). The mean (±SD) absolute faecal spore counts (in millions) expressed as AUC per hour were 270.7 ± 147.7 (E2 BID) and 213.8 ± 60.2 (E4 OD) in 2012 EGKINETIC4, 312.7 ± 218.0 (EC2 TID) and 319.0 ± 221.1 (ES6 OD) in 2012 EGKINETIC6, and 212.6 ± 118.0 (E6 OD) and 293.2 ± 247.2 (ES6 OD) in 2016 EGKINETIC6OP. The kinetic profiles of the different formulations of Enterogermina were similar, with superimposable AUC and daily curve profiles in each study up to the 8th day post dose. B. clausii spore presence/persistence in the intestine of healthy volunteers did not differ between the two formulations within each of the three studies. Enterogermina was well tolerated across all formulations and studies.

CONCLUSION

These results show different formulations of Enterogermina had similar kinetic profiles within each study; however, they also showed that probiotics could be associated with high variability. The European Medicines Agency guidelines are the current bioequivalence reference, although only the T_max parameter is used for high variability drugs. Due to the specific kinetics of probiotics, new parameters of bioequivalence could be necessary, considering, for example, variability via a parameter such as AUC.

TRIAL REGISTRATION

EUDRACT 2010-024497-19, 2010-023187-41 and 2015-003330-27.

The long-acting C5 inhibitor, ravulizumab, is effective and safe in pediatric patients with atypical hemolytic uremic syndrome naïve to complement inhibitor treatment

Ravulizumab, a long-acting complement C5 inhibitor engineered from eculizumab, allows extending maintenance dosing from every 2-3 weeks to every 4-8 weeks depending on bodyweight. Here, we evaluated the efficacy and safety of ravulizumab in complement inhibitor-naïve children (under 18 years) with atypical hemolytic uremic syndrome. In this phase III, single-arm trial, ravulizumab was administered every eight weeks in patients 20 kg and over, and four weeks in patients under 20 kg. The primary endpoint was a complete thrombotic microangiopathy response (normalization of platelet count and lactate dehydrogenase, and a 25% or more improvement in serum creatinine) through 26 weeks. Secondary endpoints included change in hematologic parameters and kidney function. 18 patients with a median age of 5.2 years were evaluated. At baseline, symptoms of atypical hemolytic uremic syndrome outside the kidney were present in 72.2% of patients and 38.9% had been in intensive care. Baseline estimated glomerular filtration rate was 22 mL/min/1.73 m². By week 26, 77.8% of patients achieved a complete thrombotic microangiopathy response; 94.4%, 88.9% and 83.3% of patients achieved platelet normalization, lactate dehydrogenase normalization and a 25% or more improvement in serum creatinine, respectively. By week 50, 94.4% patients had achieved a complete thrombotic microangiopathy response. Median improvement in platelet count was 246 and 213 x10⁹/L through week 26 and week 50, respectively. The median increase above baseline in estimated glomerular filtration rate was 80 and 94 mL/min/1.73m² through week 26 and week 50, respectively. No unexpected adverse events, deaths, or meningococcal infections occurred. Thus, ravulizumab rapidly improved hematologic and kidney parameters with no unexpected safety concerns in complement inhibitor-naïve children with atypical hemolytic uremic syndrome.

Microgel encapsulated nanoparticles for glucose-responsive insulin delivery

An insulin delivery system that self-regulates blood glucose levels has the potential to limit hypoglycemic events and improve glycemic control. Glucose-responsive insulin delivery systems have been developed by coupling glucose oxidase with a stimuli-responsive biomaterial. However, the challenge of achieving desirable release kinetics (i.e., insulin release within minutes after glucose elevation and duration of release on the order of weeks) still remains. Here, we develop a glucose-responsive delivery system using encapsulated glucose-responsive, acetalated-dextran nanoparticles in porous alginate microgels. The nanoparticles respond rapidly to changes in glucose concentrations while the microgels provide them with protection and stability, allowing for extended glucose-responsive insulin release. This system reduces blood sugar in a diabetic mouse model at a rate similar to naked insulin and responds to a glucose challenge 3 days after administration similarly to a healthy animal. With 2 doses of microgels containing 60 IU/kg insulin each, we are able to achieve extended glycemic control in diabetic mice for 22 days.

Rituximab versus natalizumab, fingolimod, and dimethyl fumarate in multiple sclerosis treatment

Introduction

Limited comparative effectiveness data for rituximab (RTX) versus natalizumab (NTZ), fingolimod (FTY), and dimethyl fumarate (DMF) for the treatment of multiple sclerosis (MS) exist.

Methods

Clinician‐reported data on patients prescribed RTX, NTZ, FTY, or DMF for the treatment of MS at the Rocky Mountain MS Center at the University of Colorado were retrospectively collected. Outcomes included a composite effectiveness measure consisting of clinical relapse, contrast‐enhancing lesions, and/or new T2 lesions, individual effectiveness outcomes, and discontinuation. Logistic regression was used on patients matched by propensity scores and using average treatment effect on treated doubly robust weighting estimator.

Results

A total of 182, 451, 271, and 342 patients initiated RTX, NTZ, FTY, and DMF and were followed for 2 years. Before and after adjustment, the odds of experiencing disease activity was significantly higher for FTY [adjusted OR (aOR) = 3.17 (95% CI: 1.81–5.55), P < 0.001].and DMF [aOR = 2.68 (95% CI:1.67–4.29), P < 0.001], and similar for NTZ [aOR = 1.36 (95% CI:0.83–2.23), P = 0.216] versus RTX. When examining months 6–24, NTZ demonstrated higher odds of disease activity compared to RTX [aOR = 2.21 (95% CI: 1.20–4.06), P = 0.007]. Similar odds of discontinuation were seen between NTZ and RTX [aOR = 1.39 (95% CI: 0.88–2.20), P = 0.157]; however, FTY [aOR = 2.02 (95% CI: 1.24–3.30), P = 0.005] and DMF [aOR = 3.27 (95% CI: 2.15–4.97), P < 0.001] had greater odds of discontinuation than RTX.

Interpretation

RTX demonstrated superior effectiveness and discontinuation outcomes compared to FTY and DMF. Although RTX demonstrated similar effectiveness and discontinuation compared to NTZ, RTX had superior effectiveness during months 6–24 and fewer discontinuations when excluding discontinuations due to insurance issues. Results suggest superiority of RTX in reducing disease activity and maintaining long‐term treatment in a real‐world MS cohort.

The long-acting C5 inhibitor, Ravulizumab, is effective and safe in adult patients with atypical hemolytic uremic syndrome naïve to complement inhibitor treatment

Ravulizumab is a long-acting C5 inhibitor engineered from eculizumab with increased elimination half-life, allowing an extended dosing interval from two to eight weeks. Here we evaluate the efficacy and safety of ravulizumab in adults with atypical hemolytic uremic syndrome presenting with thrombotic microangiopathy. In this global, phase 3, single arm study in complement inhibitor-naïve adults (18 years and older) who fulfilled diagnostic criteria for atypical hemolytic uremic syndrome, enrolled patients received ravulizumab through a 26-week initial evaluation period. The primary endpoint was complete thrombotic microangiopathy response defined as normalization of platelet count and lactate dehydrogenase and 25% or more improvement in serum creatinine. Secondary endpoints included changes in hematologic variables and renal function. Safety was also evaluated. Ravulizumab treatment resulted in an immediate, complete, and sustained C5 inhibition in all patients. Complete thrombotic microangiopathy response was achieved in 53.6% of patients. Normalization of platelet count, lactate dehydrogenase and 25% or more improvement in serum creatinine was achieved in 83.9%, 76.8% and 58.9% of patients, respectively. Improvement in estimated glomerular filtration rate by one or more stage was achieved in 68.1% of patients by day 183. No unexpected adverse events were reported across a safety analysis set of 58 patients. Four deaths occurred (three within one month of study initiation, including one in a patient excluded based on eligibility criteria after the first dose) with none considered treatment-related by the study investigator. Thus, treatment with ravulizumab once every eight weeks resulted in rapidly improved hematologic and renal endpoints with no unexpected adverse events in adults with atypical hemolytic uremic syndrome.

Assessing Preferences for Rare Disease Treatment: Qualitative Development of the Paroxysmal Nocturnal Hemoglobinuria Patient Preference Questionnaire (PNH-PPQ©)

PURPOSE

To develop a patient preference questionnaire (PPQ) assessing eculizumab and ravulizumab treatment for paroxysmal nocturnal hemoglobinuria (PNH).

PATIENTS AND METHODS

The development of the PNH-PPQ^© was consistent with Food and Drug Administration guidelines for patient-reported outcome measure development, and included 1) a targeted literature review; 2) PNH expert clinician input on treatment preferences; 3) review of existing qualitative data on the PNH treatment and disease experience; 4) concept elicitation interviews with 8 PNH patients who received eculizumab and/or ravulizumab; 5) translatability review; and 6) cognitive debriefing with 5 patients. Interview participants were recruited through a United Kingdom PNH patient advocacy group and a Canadian clinical site involved in clinical trial ALXN1210-PNH-302.

RESULTS

Six themes were identified as most relevant to the PNH treatment experience from the concept elicitation interviews: disease symptoms (n=8/8); treatment frequency (n=7/8); quality of life impact of treatment/disease (n=7/8); treatment burden (n=7/8); treatment efficacy (n=5/8); and treatment side effects (n=5/8). An initial list of 88 preference questions was reduced to 11 highly relevant and non-redundant questions reflecting the 6 themes. Cognitive interview participants unanimously agreed that the PNH-PPQ instructions were clear; response options were understandable, easy to use, and provided enough choices; and the questions captured the factors that inform treatment preferences.

DISCUSSION

When new drugs have similar efficacy to existing medications, documenting patient preferences is important for confirming patient benefit from the new medication. Understanding what matters most to patients is essential for delivering patient-centered care and may play a particularly significant role in treatment decision making. The availability of such a tool may be especially important as new orphan drugs are developed and patients with rare diseases have more than one treatment option to consider.

CONCLUSION

The PNH-PPQ provides a patient-centered approach for evaluating preferences for the treatment of PNH. The PNH-PPQ has subsequently assessed patient preference in the clinical trial sub-study ALXN1210-PNH-302s.

The Association Between Use of Hypofractionation and Treatment Completion Among Recipients of Radiation Therapy Post-Mastectomy

PURPOSE

Although there is some evidence to support the use of hypofractionated (HF) radiation therapy (RT) postmastectomy, it is not currently the standard of care. RT noncompletion and delayed completion have been shown to lead to inferior outcomes. This study assesses the association between the choice of an HF versus conventionally fractionated regimen and completion.

METHODS AND MATERIALS

RT orders placed in 2016 and 2017 for patients with a national health plan, along with the associated claims, were extracted. Each order was assigned a target date for timely completion, as well as a date 30 days after the target, which was used to assess delayed completion. Univariate analyses and logistic regressions were conducted to test for an association between regimen and completion. A Poisson regression was used to examine the association between regimen and length of treatment delay among patients completing RT.

RESULTS

Of the 743 orders meeting inclusion criteria, 56 (7.5%) were for HF. Unadjusted analyses found that the timely and delayed completion rates were significantly (P < .001) higher for patients receiving HF. The adjusted odds ratios (HF order versus CF order) were 3.96 (95% confidence interval, 2.23-7.01) for timely completion and 2.64 (95% confidence interval, 1.43-5.15) for completion within 30 days of the target. Among completers, an order for HF was significantly (P < .001) associated with less delay.

CONCLUSIONS

When an HF regimen was ordered, patients were more likely to complete therapy without a delay, to complete therapy overall, and, if experiencing a delay, to experience a shorter delay.

Bimodal Release Ondansetron for Acute Gastroenteritis Among Adolescents and Adults: A Randomized Clinical Trial

IMPORTANCE

Vomiting resulting from acute gastroenteritis is commonly treated with intravenous antiemetics in acute care settings. If oral treatment were beneficial, patients might not need intravenous administered hydration or medication. Furthermore, a long-acting treatment could provide sustained relief from nausea and vomiting.

OBJECTIVE

To determine whether an experimental long-acting bimodal release ondansetron tablet decreases gastroenteritis-related vomiting and eliminates the need for intravenous therapy for 24 hours after administration.

DESIGN, SETTING, AND PARTICIPANTS

This placebo-controlled, double-blind, randomized clinical trial included patients from 19 emergency departments and 2 urgent care centers in the United States from December 8, 2014, to February 17, 2017. Patients 12 years and older with at least 2 vomiting episodes from presumed gastroenteritis in the previous 4 hours and symptoms with less than 36 hours' duration were randomized using a 3:2 active to placebo ratio. Analyses were performed on an intent-to-treat basis and conducted from June 1, 2017, to November 1, 2017.

INTERVENTION

Bimodal release ondansetron tablet containing 6 mg of immediate release ondansetron and 18 mg of a 24-hour release matrix for a total of 24 mg of ondansetron.

MAIN OUTCOMES AND MEASURES

Treatment success was defined as no further vomiting, no need for rescue medication, and no intravenous hydration for 24 hours after bimodal release ondansetron administration.

RESULTS

Analysis included 321 patients (mean [SD] age, 29.0 [11.1] years; 195 [60.7%] women), with 192 patients in the bimodal release ondansetron group and 129 patients in the placebo group. Treatment successes were observed in 126 patients in the bimodal release ondansetron group (65.6%) compared with 70 patients in the placebo group (54.3%), with an 11.4% (95% CI, 0.3%-22.4%) absolute probability difference. The proportion of treatment success was 21% higher among patients who received bimodal release ondansetron compared with those who received a placebo (relative risk, 1.21; 95% CI, 1.00-1.46; P = .04). In an analysis including only patients with a discharge diagnosis of acute gastroenteritis and no major protocol violations, there were 123 treatment successes (69.5%) in the bimodal release ondansetron group compared with 67 treatment successes (54.9%) in the placebo group (relative risk, 1.27; 95% CI, 1.05-1.53; P = .01). Adverse effects were infrequent and similar to the known safety profile of ondansetron.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that a long-acting bimodal release oral ondansetron tablet was an effective antiemetic among adolescents and adults with moderate to severe vomiting from acute gastroenteritis. The drug benefits extended to 24 hours after administration. Bimodal release ondansetron may decrease the need for intravenous access and emergency department care to manage acute gastroenteritis.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02246439.

Modified- versus immediate-release tofacitinib in Japanese rheumatoid arthritis patients: a randomized, phase III, non-inferiority study

Objective

Tofacitinib is an oral Janus kinase inhibitor for treatment of RA. We compared tofacitinib modified-release (MR) 11 mg once daily (QD) with tofacitinib immediate-release (IR) 5 mg twice daily (BID) in Japanese patients with RA and inadequate response to MTX.

Methods

Phase III, randomized, double-blind, double-dummy, 12-week study. Patients were randomized to tofacitinib MR 11 mg QD (n = 104) or IR 5 mg BID (n = 105), with stable MTX. Compliance was based on returned pill counts. The primary objective was to demonstrate non-inferiority of MR 11 mg QD to IR 5 mg BID. Non-inferiority was declared if the upper bound of the two-sided 95% CI for the difference in change from baseline in DAS28-4(CRP) at week 12 was <0.6.

Results

At week 12, with tofacitinib MR 11 mg QD and IR 5 mg BID, respectively, the change from baseline in least squares mean DAS28-4(CRP) was −2.43 and −2.85; the mean difference was 0.43 (95% CI 0.17, 0.69). Non-inferiority of MR 11 mg QD to IR 5 mg BID was not met. Improvement of DAS28-4(CRP) ⩾1.2 was observed in 89 and 85% of patients, respectively, corresponding to a clinically important, significant change in both groups. The frequency of adverse events (52.9 and 51.4%, respectively) and serious adverse events (4.8 and 3.8%, respectively) was generally similar between treatments. No deaths were reported.

Conclusion

Non-inferiority of MR 11 mg QD to IR 5 mg BID was not met in this study. However, clinically meaningful improvements in RA were observed with both tofacitinib formulations in Japanese patients. The safety profile was similar with both formulations.

Trial registration

ClinicalTrials.gov, http://clinicaltrials.gov, NCT02281552.

Medication Regimen Complexity In 8 Australian Residential Aged Care Facilities: Impact Of Age, Length Of Stay, Comorbidity, Frailty, And Dependence In Activities Of Daily Living

Objective

To explore variation in medication regimen complexity in residential aged care facilities (RACFs) according to resident age, length of stay, comorbidity, dementia severity, frailty, and dependence in activities of daily living (ADLs), and compare number of daily administration times and Medication Regimen Complexity Index (MRCI) as measures of regimen complexity.

Methods

This study was a cross-sectional analysis of baseline data from the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial. The SIMPLER study recruited 242 residents with at least one medication charted for regular administration from 8 RACFs in South Australia. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Dementia severity was assessed using the Dementia Severity Rating Scale. Frailty was assessed using the FRAIL-NH scale. Dependence in ADLs was assessed using the Katz ADL scale.

Results

The median age of participants was 87 years (interquartile range 81–92). Over one-third of participants (n=86, 36%) had 5 or more daily medication administration times. The number of daily administration times and MRCI scores were positively correlated with resident length of stay (r_s=0.19; 0.27), FRAIL-NH score (r_s=0.23; 0.34) and dependence in ADLs (r_s=−0.21; −0.33) (all p<0.01). MRCI was weakly negatively correlated with CCI score (r_s=−0.16; p=0.013). Neither number of daily administration times nor MRCI score were correlated with age or dementia severity. In multivariate analysis, frailty was associated with number of daily administration times (OR: 1.13, 95% CI: 1.03–1.24) and MRCI score (OR: 1.26, 95% CI: 1.13–1.41). Dementia severity was inversely associated with both multiple medication administration times (OR: 0.97, 95% CI: 0.94–0.99) and high MRCI score (OR: 0.95, 95% CI: 0.92–0.98).

Conclusion

Residents with longer lengths of stay, more dependent in ADLs and most frail had the most complex medication regimens and, therefore, may benefit from targeted strategies to reduce medication regimen complexity.

Methotrexate withdrawal in patients with rheumatoid arthritis who achieve low disease activity with tofacitinib modified-release 11 mg once daily plus methotrexate (ORAL Shift): a randomised, phase 3b/4, non-inferiority trial

BACKGROUND

Tofacitinib is an oral Janus kinase (JAK) inhibitor used for the treatment of rheumatoid arthritis. We assessed the efficacy and safety of tofacitinib after methotrexate withdrawal in patients who achieved low disease activity (LDA) with tofacitinib in combination with methotrexate.

METHODS

ORAL Shift was a phase 3b/4 non-inferiority trial in patients aged at least 18 years with moderate-to-severe rheumatoid arthritis and an inadequate response to methotrexate done in 109 centres across 16 countries. After 24 weeks of open-label tofacitinib modified-release 11 mg once daily plus methotrexate, patients who achieved LDA (clinical disease activity index [CDAI] ≤10) were randomly assigned 1:1 via an automated web-based response system to receive tofacitinib plus placebo (tofacitinib monotherapy; ie, masked methotrexate withdrawal) or continue tofacitinib plus methotrexate for 24 weeks in a double-blind manner. The primary endpoint was the least squares mean change from week 24 to week 48 in disease activity score in 28 joints with four variables, including erythrocyte sedimentation rate (DAS28-4[ESR]). The primary analysis was done in all patients who received at least one dose of study treatment in both phases, and safety was assessed in all patients who received at least one dose of study treatment since enrolment. Non-inferiority of tofacitinib monotherapy versus tofacitinib plus methotrexate was declared if the upper bound of the 95% CI for the difference in change in DAS28-4(ESR) between treatment groups was less than 0·6. Safety was assessed in both phases. The trial is registered with ClinicalTrials.gov, NCT02831855, and is complete.

FINDINGS

Between Sept 1, 2016, and Nov 1, 2017, 694 patients were enrolled in the open-label phase and 623 received study treatment for 24 weeks. 533 achieved CDAI-defined LDA and were randomly assigned into the double-blind phase (267 in the tofacitinib monotherapy group and 266 in the tofacitinib plus methotrexate group). Three participants in the monotherapy group did not start treatment so were not included in the primary analysis. Non-inferiority was demonstrated (difference 0·30 [95% CI 0·12-0·48]). 107 (41%) of 264 patients in the tofacitinib monotherapy group and 109 (41%) of 266 in the tofacitinib plus methotrexate group had adverse events; five patients from each group discontinued because of adverse events; two patients died in the tofacitinib plus methotrexate group. No new safety findings were reported up to 48 weeks.

INTERPRETATION

Patients with rheumatoid arthritis who achieve LDA with a combination of tofacitinib plus methotrexate may consider withdrawing methotrexate without significant worsening of disease activity or unexpected safety issues.

FUNDING

Pfizer.

Multimorbidity and medication complexity: New challenges in heart transplantation

INTRODUCTION

Multimorbidity and therapeutic complexity are a recognized problem in the heart transplant (HTx) population. However, little is known about how best to quantify this complexity or the strategies that could reduce its burden.

METHODS

This single-center, observational study included adult heart transplant recipients (HTxR) >1.5 years from transplant. We assessed multimorbidity (>2 comorbidities) and the patient-level Medication Regimen Complexity Index Spanish version (pMRCI-S) score. We also analyzed the independent predictors of pMRCI-S and the impact of the index score on specific clinical variables.

RESULTS

We included 135 chronic-stage HTxR. Comorbidities significantly increased after HTx (6 ± 3 vs 2 ± 2, P-value < .001). Patients took 12 ± 3 chronic drugs/d, 58% of them to treat comorbidities. The mean total pMRCI-S score was 42 ± 11, higher than in several other chronic diseases. The medication category drugs to treat comorbidities predicted a higher total pMRCI-S score (OR = 3.12, 95% CI 2.8-3.43, P-value < .001). Therapeutic complexity after HTx had an impact on solid malignancies (OR = 1.1, 95% CI 1.02-1.18, P-value = .02) and renal function (OR=-0.81, 95% CI -1.21-(-0.42), P-value < .001).

CONCLUSIONS

The multimorbidity and pMRCI-S scores obtained in HTx population were worrisomely high. The pMRCI score is a sensitive method that allows identification of the factors determining therapeutic complexity after HTx and selection of strategies to reduce pMRCI-S values.

Ravulizumab (ALXN1210) in patients with paroxysmal nocturnal hemoglobinuria: results of 2 phase 1b/2 studies

Ravulizumab (ALXN1210), a humanized monoclonal antibody to complement component C5, was engineered from eculizumab to have a substantially longer terminal half-life, permitting longer dosing intervals for paroxysmal nocturnal hemoglobinuria (PNH) treatment. Two phase 1b/2 multicenter open-label studies evaluated efficacy and safety of multiple doses and regimens of ravulizumab in PNH patients naive to complement-inhibitor treatment. Patients in study 103 (n = 13) received ravulizumab 900 mg (lower trough exposure) or 1800 mg every 4 weeks (higher trough exposure); those in study 201 (n = 26) received 1000 mg every 4, 1600 mg every 6, 2400 mg every 8, or 5400 mg every 12 weeks. Trough exposure levels with study 201 dosing regimens were similar to the study 103 900-mg every-4-weeks regimen. Rapid sustained reduction of plasma lactate dehydrogenase (LDH) occurred across all cohorts (73%-90% at end point vs baseline). A greater proportion of patients had normalized LDH (<234 U/L) at least once from days 29 to 253 in the higher- (85.7%) vs lower-trough-exposure (50.0%-83.3%) cohorts; the weighted average of the proportion of instances of LDH normalization from days 29 to 253 was highest in higher- vs lower-trough-exposure cohorts (62.3% vs 31.4%-54.5%). No patients in the higher-trough-exposure cohort, but 1 to 2 patients in all lower-trough-exposure cohorts, experienced breakthrough hemolysis. Ravulizumab improved quality of life (QoL) measures in all cohorts. Two patients experienced meningococcal infections; both recovered and continued in the study. In summary, ravulizumab provided rapid and sustained reduction in complement-mediated hemolysis and improved QoL at dosing intervals up to 12 weeks. This trial was registered at www.clinicaltrials.gov as #NCT02598583 (study 103) and NCT02605993 (study 201).

Medication Burden for Patients With Bacterial Keratitis

PURPOSE

To understand medication use and patient burden for treatment of bacterial keratitis (BK).

METHODS

A retrospective study was conducted examining medical records of adult patients with BK in an academic cornea practice. Data collected included medications used in the treatment of BK, dosing of medications, and the number and total duration of clinical encounters. Costs of medications were estimated using the average wholesale pharmacy price. Linear regression analysis was used to investigate associations of medication use with patient demographics and corneal culture results and reported with beta estimates (β) and 95% confidence intervals (95% CIs).

RESULTS

Forty-eight patients with BK (56% female) were studied. Patients were treated for a median of 54 days with 10 visits, 5 unique medications, 587 drops, and 7 prescriptions. The estimated median medication cost was $933 (interquartile range: $457-$1422) US dollars. Positive bacterial growth was significantly associated with more visits (β: 6.16, 95% CI: 1.75-10.6, P = 0.007), more days of treatment (β: 86.8, 95% CI: 10.8-163, P = 0.026), more prescribed medications (β: 2.86, 95% CI: 1.04-4.67, P = 0.003), and more doses of medications (β: 796, 95% CI: 818-1412, P = 0.012) compared with patients who did not undergo corneal scraping. Patients were prescribed 132 more drops of medication for every 10 years of older age (β: 132, 95% CI: 18.2-246, P = 0.024). Sex and income were not associated with medication burden or treatment length.

CONCLUSIONS

Older patients and those with positive cultures incur the most medication burden in treatment of BK. Providers should be aware of medication usage and cost burden as it may affect compliance with treatment.

Physician and patient preferences for dosing options in migraine prevention

Background

Adherence to a therapy, though a key factor for successful treatment, is low among patients with chronic conditions such as migraine. Dose frequency plays a major role in adherence. This study evaluated the impact of having flexible dosing options on acceptance of and adherence to a new migraine preventive therapy class among adults with migraine.

Methods

In this observational study, two 20-min online surveys were completed: one by physicians currently treating adult patients with migraine and the other by adults with migraine. Both surveys presented the participants with three scenarios: 1) only monthly, 2) only quarterly, and 3) both dosing options of the new medication are available. Physicians estimated the proportion of their migraine patients who would receive the new medication in each scenario. Patients were asked about their dosing preference when either or both options are available. Respondents were asked to rate the likelihood of their acceptance of and adherence to the therapy.

Results

400 physicians and 417 US adults with migraine completed the surveys. The availability of both dosing options yielded a significant increase in the proportion of patients expected to receive the new medication. The overall proportion of patients favoring monthly dosing (35%) was similar to the proportion favoring quarterly dosing (40%). Among those who preferred monthly dosing (n = 147), a greater proportion indicated they are more likely to fill the prescription (77% vs 56%, P < 0.05) and remain adherent (80% vs 57%, P < 0.05) when only monthly is available versus when only quarterly is available. Similarly, among those who preferred quarterly dosing (n = 166), a greater proportion indicated they are likely to fill (63% vs 55%, P < 0.05) and remain adherent (62% vs 54%, P < 0.05) when only quarterly is available compared with when only monthly is available.

Conclusions

Physicians anticipated that the proportion of patients to receive the new medication would increase when both dosing options are available. Patients stated that they are more likely to fill the prescription and adhere to the new therapy when their preferred dosing regimen is available.

Real-world outcomes post-transition to once-every-3-months paliperidone palmitate in patients with schizophrenia within US commercial plans

OBJECTIVES

To compare comorbidity-related outcomes, adherence to antipsychotics (APs), healthcare resource utilization (HRU), and costs pre- and post-transition to once-every-3-months paliperidone palmitate (PP3M) in commercially-insured patients with schizophrenia.

METHODS

Adults with ≥1 claim for PP3M, ≥2 schizophrenia diagnoses, and adequate treatment with once-monthly paliperidone palmitate (PP1M; i.e. no gap of >45 days in PP1M coverage for ≥4 months, same PP1M dosage for the last two PP1M claims, and appropriate PP1M to PP3M dosing conversion) were selected from the IQVIA PharMetrics Plus database (May 2014-February 2018). Generalized estimating equation models adjusted for repeated measurements were used to compare patient characteristics, adherence to APs, HRU, and costs during the 6-month period pre- vs post-transition to PP3M.

RESULTS

Of 152 included patients, the mean age was 41.0 years and 36.2% were females. Post-PP3M transition, patients were less likely to have a claim with a diagnosis for substance-related and addictive disorders (odds ratio [OR] = 0.57), psychoses (OR = 0.57), diabetes without chronic complication (OR = 0.72), and drug abuse (OR = 0.64; all p < .05). Patients were more likely to be adherent to APs (OR = 2.01, p = .007), compared to the period pre-PP3M transition. There was no significant difference in HRU pre- vs post-transition. All-cause total (mean monthly cost difference [MMCD] = $242), pre-rebate pharmacy (MMCD = $65), and medical costs (MMCD = $176) remained similar pre- vs post-transition (all p > .05).

CONCLUSIONS

Transitioning to PP3M was associated with an improvement in adherence and in comorbidity-related outcomes related to substance-related and addictive disorders, psychoses, diabetes without chronic complication, and drug abuse. These findings suggest PP3M may enhance comorbidity-related outcomes and adherence while remaining cost neutral.

Impact of antiepileptic-drug treatment burden on health-care-resource utilization and costs

Background

Complex titration requirements and dosing of antiepileptic drugs (AEDs) may pose a significant treatment burden for patients with epilepsy. This study evaluated health-care-resource utilization (HCRU) rates and costs by treatment burden, defined as number of daily pills and dosing frequency, among managed-care enrollees with epilepsy who initiated AED monotherapy.

Methods

This retrospective longitudinal study examined administrative HC-claim data in patients aged ≥18 years with two or more pharmacy claims for an AED and two or more medical claims for epilepsy or afebrile convulsion. The number of daily AED pills was estimated at index as the total number of pills dispensed divided by the days supplied, and categorized as more than zero/one, one/two, two/three, and more than three per day. AED-dosing frequency was measured at index and categorized as one, two, three, or four times daily. Postindex 12-month all-cause and epilepsy-related HCRU and costs were estimated using multivariable Poisson regression models and generalized linear models, respectively.

Results

Unadjusted total all-cause and epilepsy-related costs at 12 months postindex averaged US$26,015 per person and US$5,557 per person (2017 values), respectively. Adjusted all-cause and epilepsy-related costs were US$25,918 per person and US$5,602 per person, respectively. A pill burden of more than three a day was associated with a 6.7% increase in total annual HC costs compared with one pill/day. Patients receiving one/two, two/three, and more than three pills per day had 13.3%, 23.9%, and 38.3% higher epilepsy-related costs, respectively, than those receiving one pill per day (P<0.0001). Increase in dosing frequency was associated with greater total HCRU and higher costs, but only patients with twice-daily dosing had significantly higher epilepsy-related costs.

Conclusion

Findings from this study suggest that increased treatment burden is associated with greater HCRU and higher overall and epilepsy-related costs. Reducing treatment burden via selection of AED therapy with reduced pill numbers and dosing frequency should be considered to improve health and economic outcomes.

Amino Acids in the Development of Prodrugs

Although drugs currently used for the various types of diseases (e.g., antiparasitic, antiviral, antibacterial, etc.) are effective, they present several undesirable pharmacological and pharmaceutical properties. Most of the drugs have low bioavailability, lack of sensitivity, and do not target only the damaged cells, thus also affecting normal cells. Moreover, there is the risk of developing resistance against drugs upon chronic treatment. Consequently, their potential clinical applications might be limited and therefore, it is mandatory to find strategies that improve those properties of therapeutic agents. The development of prodrugs using amino acids as moieties has resulted in improvements in several properties, namely increased bioavailability, decreased toxicity of the parent drug, accurate delivery to target tissues or organs, and prevention of fast metabolism. Herein, we provide an overview of models currently in use of prodrug design with amino acids. Furthermore, we review the challenges related to the permeability of poorly absorbed drugs and transport and deliver on target organs.

Development and validation of the Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE)

Background

Residents of aged care facilities use increasingly complex medication regimens. Reducing unnecessary medication regimen complexity (eg, by consolidating the number of administration times or using alternative formulations) may benefit residents and staff.

Objective

To develop and validate an implicit tool to facilitate medication regimen simplification in aged care facilities.

Method

A purposively selected multidisciplinary expert panel used modified nominal group technique to identify and prioritize factors important in determining whether a medication regimen can be simplified. The five prioritized factors were formulated as questions, pilot-tested using non-identifiable medication charts and refined by panel members. The final tool was validated by two clinical pharmacists who independently applied the tool to a random sample of 50 residents of aged care facilities to identify opportunities for medication regimen simplification. Inter-rater agreement was calculated using Cohen’s kappa.

Results

The Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) was developed as an implicit tool comprising of five questions about 1) the resident; 2) regulatory and safety requirements; 3) drug interactions; 4) formulation; and 5) facility and follow-up considerations. Using MRS GRACE, two pharmacists independently simplified medication regimens for 29/50 and 30/50 residents (Cohen’s kappa=0.38, 95% CI 0.12–0.64), respectively. Simplification was possible for all residents with five or more administration times. Changing an administration time comprised 75% of the two pharmacists’ recommendations.

Conclusions

Using MRS GRACE, two clinical pharmacists independently simplified over half of residents’ medication regimens with fair agreement. MRS GRACE is a promising new tool to guide medication regimen simplification in aged care.

Regularity of self-reported daily dosage of mood stabilizers and antipsychotics in patients with bipolar disorder

BACKGROUND

Polypharmacy is often prescribed for bipolar disorder, yet medication non-adherence remains a serious problem. This study investigated the regularity in the daily dosage taken of mood stabilizers and second generation antipsychotics.

METHODS

Daily self-reported data on medications taken and mood were available from 241 patients with a diagnosis of bipolar disorder who received treatment as usual. Patients who took the same mood stabilizer or second generation antipsychotic for ≥ 100 days were included. Approximate entropy was used to determine serial regularity in daily dosage taken. Generalized estimating equations were used to estimate if demographic or clinical variables were associated with regularity.

RESULTS

There were 422 analysis periods available from the 241 patients. Patients took drugs on 84.4% of days. Considerable irregularity was found, mostly due to single-day omissions and dosage changes. Drug holidays (missing 3 or more consecutive days) were found in 35.8% of the analysis periods. Irregularity was associated with an increasing total number of psychotropic drugs taken (p = 0.009), the pill burden (p = 0.026), and the percent of days depressed (p = 0.049).

CONCLUSION

Despite low missing percent of days, daily drug dosage may be irregular primarily due to single day omissions and dosage changes. Drug holidays are common. Physicians should expect to see partial adherence in clinical practice, especially with complex drug regimens. Daily dosage irregularity may impact the continuity of drug action, contribute to individual variation in treatment response, and needs further study.

Projected 24-hour post-dose ocular itching scores post-treatment with olopatadine 0.7% versus 0.2

Olopatadine is an antihistamine and mast cell stabilizer used for treating allergic conjunctivitis. Olopatadine 0.7% has been recently approved for daily dosing in the US, which supersedes the previously approved 0.2% strength. The objective of this analysis was to characterize patients who have better itching relief at 24 h when taking olopatadine 0.7% treatment instead of olopatadine 0.2% (in terms of proportions of responses) and relate this to the severity of baseline itching as an indirect metric of a patient’s sensitivity to antihistamines. A differential odds model was developed using data from two conjunctival allergen challenge (CAC) studies to characterize individual-level and population-level response to ocular itching following olopatadine treatment and the data was analyzed retrospectively. This modeling analysis was designed to predict 24 h ocular itching scores and to quantify the differences in 24 h itching relief following treatment with olopatadine 0.2% versus 0.7% in patients with moderate-to-high baseline itching. A one-compartment kinetic-pharmacodynamic E_max model was used to determine the effect of olopatadine. Impact of baseline itching severity, vehicle effect and the drug effect on the overall itching scores post-treatment were explicitly incorporated in the model. The model quantified trends observed in the clinical data with regards to both mean scores and the proportions of patients responding to olopatadine treatment. The model predicts a higher proportion of patients in the olopatadine 0.7% versus 0.2% group will experience relief within 24 h. This prediction was confirmed with retrospective clinical data analysis. The number of allergy patients relieved with olopatadine 0.7% increased with higher baseline itching severity scores, when compared to olopatadine 0.2%.

Pharmacokinetic drug evaluation of daclizumab for the treatment of relapsing-remitting multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system. Despite the availability of several disease-modifying therapies for relapsing MS, there is a need for highly efficacious targeted therapy with a favorable benefit-risk profile and a high level of treatment adherence. Daclizumab is a humanized monoclonal antibody directed against CD25, the α subunit of the high-affinity interleukin 2 (IL-2) receptor, that reversibly modulates IL-2 signaling. Areas covered: Daclizumab blocks the activation and expansion of autoreactive T cells that plays a role in the immune pathogenesis of MS. As its modulatory effects on the immune system, daclizumab's potential for use in MS was tested extensively showing a high efficacy in reducing relapse rate, disability progression and the number and volume of gadolinium-enhancing lesions on brain magnetic resonance imaging. Moreover, phase II and III trials showed a favorable pharmacokinetic (PK) profile with slow clearance, linear pharmacokinetics at doses above 100 mg and high subcutaneous bioavailability, not influenced by age, sex or other clinical parameters. Expert opinion: Among the new emerging drugs for MS, daclizumab also, thanks to a favorable PK profile, may represent an interesting and promising therapeutic option in the wide MS therapies armamentarium.

Understanding the Gap Between Efficacy in Randomized Controlled Trials and Effectiveness in Real-World Use of GLP-1 RA and DPP-4 Therapies in Patients With Type 2 Diabetes

OBJECTIVE

The objective of this study was to estimate and explain the gap between clinical efficacy and real-world (RW) effectiveness of type 2 diabetes medications.

RESEARCH DESIGN AND METHODS

This mixed-methods quasi-experimental study used retrospective claims (Optum/Humedica) to compare the change in HbA_1c of RW patients with type 2 diabetes 12 months after starting a glucagon-like peptide 1 receptor agonist (GLP-1 RA) or dipeptidyl peptidase 4 (DPP-4) inhibitor with published findings from randomized controlled trials (RCTs) evaluating these drugs. Selected RW patients were similar to RCT patients, and regression analysis was used in the RW data to adjust for differences between poorly adherent and adherent patients to explain why RCT and RW findings may differ.

RESULTS

RW patients initiating a GLP-1 RA (n = 221) or a DPP-4 (n = 652) experienced smaller reductions in HbA_1c (GLP-1 RA: -0.52% [-6 mmol/mol], DPP-4: -0.51% [-6 mmol/mol])than reported in RCTs (-1.30% [-14 mmol/mol] from seven GLP-1 RA RCTs, n = 2,600; -0.68% [-8 mmol/mol] from four DPP-4 RCTs, n = 1,889). Baseline HbA_1c, additional medications, and adherence were significant explanatory factors in the RW HbA_1c change. Modeled estimates of RCT efficacy (-1.04% GLP-1 RA [-12 mmol/mol], -0.69% DPP-4 [-8 mmol/mol]) were within the RCTs' reported range (GLP-1 RA: -0.84% to -1.60% [-9 to -18 mmol/mol], DPP-4: -0.47% to -0.90% [-5 to -10 mmol/mol]). Poor medication adherence accounted for approximately three-fourths of the gap between RW and expected RCT results (gap = 0.51% [6 mmol/mol] GLP-1 RA; 0.18% [3 mmol/mol] DPP-4).

CONCLUSIONS

Poor medication adherence is primarily why RW effectiveness is significantly less than RCT efficacy, suggesting an urgent need to effectively address adherence among patients with type 2 diabetes.

Depressive symptoms moderate the relationship between medication regimen complexity and objectively measured medication adherence in adults with heart failure

Patients with heart failure (HF) take many medications to manage their HF and comorbidities, and 20-50% experience depression. Depressed individuals with more complex medication regimens may be at greater risk for poor adherence. The aim of this study was to assess depressive symptoms as a moderator of the relationship between medication regimen complexity and medication adherence in an observational study of patients with HF. In hierarchical linear regression with the final sample of 299, the interaction of medication regimen complexity and depressive symptoms predicted medication adherence, p < .05. For individuals with higher levels of depressive symptoms [1 standard deviation (SD) above the mean], more regimen complexity was associated with lower adherence. For individuals with low (1 SD below the mean) or average levels of depressive symptoms, regimen complexity was unrelated to medication adherence. Care management strategies, including pillboxes and caregiver involvement, may be valuable in HF patients with depression.

Glucagon-like Peptide-1 Receptor Agonist Treatment Attributes Important to Injection-Naïve Patients with Type 2 Diabetes Mellitus: A Multinational Preference Study

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) differ in efficacy, side effects, dosing frequency, and device-related attributes. This study assessed the relative importance of treatment-related attributes in influencing preferences for GLP-1RAs among injection-naïve patients with type 2 diabetes mellitus (T2DM).

METHODS

Injection-naïve T2DM patients from five countries completed a Web-based discrete choice experiment (DCE) survey. Patients chose between hypothetical treatment profiles reflecting important and differentiating attributes of GLP-1RAs. Eight attributes were included: efficacy, side effects, device size, needle size, titration, preparation, evidence of long-term efficacy/safety, and dosing frequency. Odds ratios (ORs) and 95% confidence intervals were calculated using a conditional logit model to indicate the likelihood of choosing a treatment with a given attribute level versus a reference attribute level. The influence of individual attributes when considering full treatment profiles was examined using exenatide once weekly (QW) and liraglutide once daily (QD) as case examples.

RESULTS

A total of 1482 patients with T2DM completed the DCE survey. Side effects, efficacy, and dosing frequency were the three most important attributes influencing preferences; needle size, device size, and required preparation were least important. Total sample analysis indicated that a profile of GLP-1RA approximating exenatide QW (single pen) was preferred over a profile approximating liraglutide QD (OR 3.36; p < 0.001), when efficacy was assumed to be equal.

CONCLUSION

The most influential drivers of treatment preferences for a hypothetical GLP-RA profile were side effects, efficacy, and dosing frequency among injection-naïve T2DM patients. Preference elicitation can promote patient-centered care and inform new generations of T2DM treatments, which can lead to improved adherence and health outcomes.

The impact of adjunctive guanfacine extended release on stimulant adherence in children/adolescents with attention-deficit/hyperactivity disorder

Aim: To assess stimulant adherence among children/adolescents with attention-deficit/hyperactivity disorder (ADHD) augmenting stimulants with guanfacine extended-release (GXR). Patients & methods: Inclusion criteria: 6–17 years, ≥1 ADHD diagnosis, ≥1 long-acting and/or short-acting stimulant with GXR augmentation. Modified medication possession ratio (mMPR; days medication available/days in period, excluding medication holidays) was assessed; mMPR <0.80 nonadherent. Regression models assessed change in mMPR adjusting for demographic and clinical characteristics. Results: Among patients nonadherent to stimulants pre-augmentation (n = 165), unadjusted mean (SD) pre- and post-stimulant mMPRs were 0.68 (0.11) and 0.87 (0.16). Adjusted mean change in mMPR was 0.20 for long-acting versus 0.18 for short-acting stimulants (p = 0.34). Conclusion: Among patients nonadherent to stimulants, GXR augmentation was associated with increased stimulant adherence.

Tenfold risk increase of major cardiovascular events after high limb amputation with non-compliance for secondary prevention measures

Background The aim of the study was to evaluate the impact of compliance with lifestyle recommendations and medication on 1-year prevention of major adverse cardiovascular events (MACE) in patients with type 2 diabetes (T2D) after trans-femoral amputation (TFA). Methods In this prospective single-center interventional cohort study, 179 consecutive T2D patients with symptomatic coronary artery disease (CAD) underwent 1-year follow-up examination after TFA in 2013. Lower limb and coronary artery CT angiography were provided before surgery; physical examination and laboratory tests were performed at baseline and every month after TFA for 1 year. A total of 77 patients (43%) were defined as compliant. They followed all recommendations, including >80% drug intake (anti-diabetic, antihypertensive drugs, dual antiplatelet and statin treatment), healthy diet, smoking cessation, physical exercise ≥30 min/day. A total of 102 patients (57%) were non-compliant (drug intake ≤80%, and did not fully follow lifestyle change recommendations). Results There were no significant differences at baseline between the two groups. Fuster-BEWAT score in 1 year was 9.83 ± 3.1 in compliant and 7.74 ± 2.9 in non-compliant patients ( p = 0.0001). At 1-year follow-up, there were 43 myocardial infarctions (40 patients (93%) were non-compliant) and 28 deaths (26 cases (92.8%) were non-compliant). Patients from the non-compliant group with three- and two-vessel obstructive CAD had higher 1-year MACE rate than those with one-vessel obstructive and non-obstructive CAD (95.24% and 70.5% versus 17.2% and 8.6%; p < 0.0001); more proximal coronary lesions were related to a worse prognosis. Conclusions Non-compliant diabetic patients had a tenfold increased risk for MACE within 1 year after TFA.