1
|
The Development of Innovative Dosage Forms of the Fixed-Dose Combination of Active Pharmaceutical Ingredients. Pharmaceutics 2022; 14:pharmaceutics14040834. [PMID: 35456668 PMCID: PMC9025674 DOI: 10.3390/pharmaceutics14040834] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/20/2022] [Accepted: 04/06/2022] [Indexed: 02/01/2023] Open
Abstract
The development of innovative forms of combination drugs is closely related to the invention of the multilayer tablet press, polymers for pharmaceutical applications, the hot-melt extrusion process, and 3D printing in the pharmaceutical industry. However, combining multiple drugs within the same dosage form can bring many physicochemical and pharmacodynamic interactions. More and more new forms of fixed-dose combinations (FDCs) have been developed due to work to overcome the incompatibility of active substances or to obtain different drug release profiles in the same dosage form. This review provides discussions of the application of various innovation formulation technologies of FDC drugs such as bilayer system, multilayer tablet, active film coating, hot-melt extrusion, and 3D printing, taking into account the characteristics of the key ingredients in the FDC formulation and presenting technological problems and challenges related to the development of combination drugs. Moreover, the article summarizes the range of dosage forms that have been made using these technologies over the past 30 years.
Collapse
|
2
|
The Impact of Product and Process Related Critical Quality Attributes on Immunogenicity and Adverse Immunological Effects of Biotherapeutics. J Pharm Sci 2020; 110:1025-1041. [PMID: 33316242 DOI: 10.1016/j.xphs.2020.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 02/07/2023]
Abstract
The pharmaceutical industry has experienced great successes with protein therapeutics in the last two decades and with novel modalities, including cell therapies and gene therapies, more recently. Biotherapeutics are complex in structure and present challenges for discovery, development, regulatory, and life cycle management. Biotherapeutics can interact with the immune system that may lead to undesired immunological responses, including immunogenicity, hypersensitivity reactions (HSR), injection site reactions (ISR), and others. Many product and process related critical quality attributes (CQAs) have the potential to trigger or augment such immunological responses to the product. Tremendous efforts, both clinically and preclinically, have been invested to understand the impact of product and process related CQAs on adverse immunological effects. The information and knowledge are critical for the implementation of Quality by Design (QbD), which requires risk assessment and establishment of specifications and control strategies for CQAs. A quality target product profile (QTPP) that identifies the key CQAs through process development can help assign severity scores based on safety, immunogenicity, pharmacokinetics (PK) and pharmacodynamics (PD) of the molecule. Gaps and future directions related to biotherapeutics and emerging novel modalities are presented.
Collapse
|
3
|
Redón J, Usó R, Trillo JL, López C, Morales-Olivas F, Navarro J, Sanchís J, Gil V, Orozco-Beltrán D. Number of drugs used in secondary cardiovascular prevention and late survival in the population of Valencia Community, Spain. Int J Cardiol 2019; 293:260-265. [DOI: 10.1016/j.ijcard.2019.05.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 05/06/2019] [Accepted: 05/27/2019] [Indexed: 10/26/2022]
|
4
|
Ho CT, Tung Y, Chou S, Hsiao F, Lin Y, Chang C, Chu P. Clinical outcomes in hypertensive patients treated with a single‐pill fixed‐dose combination of renin‐angiotensin system inhibitor and thiazide diuretic. J Clin Hypertens (Greenwich) 2018; 20:1731-1738. [DOI: 10.1111/jch.13413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/07/2018] [Accepted: 09/14/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Chien-Te Ho
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chang Gung University College of Medicine Taipei Taiwan
| | - Ying‐Chang Tung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chang Gung University College of Medicine Taipei Taiwan
| | - Shing‐Hsien Chou
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chang Gung University College of Medicine Taipei Taiwan
| | - Fu‐Chih Hsiao
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chang Gung University College of Medicine Taipei Taiwan
| | - Yu‐Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chang Gung University College of Medicine Taipei Taiwan
| | - Chee‐Jen Chang
- Graduate Institute of Clinical Medical Sciences, College of Medicine Chang Gung University Taipei Taiwan
| | - Pao‐Hsien Chu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital Chang Gung University College of Medicine Taipei Taiwan
| |
Collapse
|
5
|
ten Cate H. Monitoring new oral anticoagulants, managing thrombosis, or both? Thromb Haemost 2017; 107:803-5. [DOI: 10.1160/th12-03-0130] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 03/06/2012] [Indexed: 11/05/2022]
|
6
|
|
7
|
|
8
|
Mueller C, Altenburger U, Mohl S. Challenges for the pharmaceutical technical development of protein coformulations. J Pharm Pharmacol 2017; 70:666-674. [DOI: 10.1111/jphp.12731] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 03/26/2017] [Indexed: 12/27/2022]
Abstract
Abstract
Objectives
This review discusses challenges to stability, analytics and manufacturing of protein coformulations. Furthermore, general considerations to be taken into account for the pharmaceutical development of coformulated protein drug products are highlighted.
Key findings
Coformulation of two or more active substances in one single dosage form has recently seen increasing use offering several advantages, such as increased efficacy and/or the overall reduction of adverse event incidents in patients. Most marketed coformulated drug products are composed of small molecules. As proteins are not only comparatively large but also complex molecules, the maintenance of their physicochemical integrity within a formulation throughout pharmaceutical processing, storage, transport, handling and patient administration to ensure proper pharmacokinetics and pharmacodynamics in vivo already represents various challenges for single-entity products. Thus, nowadays, only sparse biologics-based coformulations can be found, as additional complexity during development is given for these products.
Summary
The complexity of the dosage form and the protein molecules results into additional challenges to formulation, manufacture, storage, transport, handling and patient administration, stability and analytics during the pharmaceutical development of protein coformulations. Various points have to be considered during different stages of development in order to obtain a safe and efficacious product.
Collapse
Affiliation(s)
- Claudia Mueller
- Late-Stage Pharmaceutical and Process Development, Pharmaceutical Development and Supplies, PTD Biologics Europe (PTDE-P), F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Ulrike Altenburger
- Late-Stage Pharmaceutical and Process Development, Pharmaceutical Development and Supplies, PTD Biologics Europe (PTDE-P), F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Silke Mohl
- Late-Stage Pharmaceutical and Process Development, Pharmaceutical Development and Supplies, PTD Biologics Europe (PTDE-P), F. Hoffmann-La Roche Ltd., Basel, Switzerland
| |
Collapse
|
9
|
Management verschiedener kardiovaskulärer Risikofaktoren mit einem Kombinationspräparat („Polypill“). Herz 2017; 43:246-257. [DOI: 10.1007/s00059-017-4554-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 02/11/2017] [Indexed: 02/06/2023]
|
10
|
Olsen MH, Angell SY, Asma S, Boutouyrie P, Burger D, Chirinos JA, Damasceno A, Delles C, Gimenez-Roqueplo AP, Hering D, López-Jaramillo P, Martinez F, Perkovic V, Rietzschel ER, Schillaci G, Schutte AE, Scuteri A, Sharman JE, Wachtell K, Wang JG. A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet Commission on hypertension. Lancet 2016; 388:2665-2712. [PMID: 27671667 DOI: 10.1016/s0140-6736(16)31134-5] [Citation(s) in RCA: 586] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Michael H Olsen
- Department of Internal Medicine, Holbæk Hospital and Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, University of Southern Denmark, Odense, Denmark; Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa.
| | - Sonia Y Angell
- Division of Prevention and Primary Care, New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Samira Asma
- Global NCD Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Pierre Boutouyrie
- Department of Pharmacology and INSERM U 970, Georges Pompidou Hospital, Paris Descartes University, Paris, France
| | - Dylan Burger
- Kidney Research Centre, Ottawa Hospital Research Institute, Department of Cellular and Molecular Medicine, University of Ottawa, ON, Canada
| | - Julio A Chirinos
- Department of Medicine at University Hospital of Pennsylvania and Veteran's Administration, PA, USA
| | | | - Christian Delles
- Christian Delles: Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Anne-Paule Gimenez-Roqueplo
- INSERM, UMR970, Paris-Cardiovascular Research Center, F-75015, Paris, France; Paris Descartes University, F-75006, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Department of Genetics, F-75015, Paris, France
| | - Dagmara Hering
- The University of Western Australia-Royal Perth Hospital, Perth, WA, Australia
| | - Patricio López-Jaramillo
- Direccion de Investigaciones, FOSCAL and Instituto de Investigaciones MASIRA, Facultad de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | - Fernando Martinez
- Hypertension Clinic, Internal Medicine, Hospital Clinico, University of Valencia, Valencia, Spain
| | - Vlado Perkovic
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Ernst R Rietzschel
- Department of Cardiology, Ghent University and Biobanking & Cardiovascular Epidemiology, Ghent University Hospital, Ghent, Belgium
| | - Giuseppe Schillaci
- Department of Internal Medicine, University of Perugia, Terni University Hospital, Terni, Italy
| | - Aletta E Schutte
- Medical Research Council Unit on Hypertension and Cardiovascular Disease, Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa
| | - Angelo Scuteri
- Hypertension Center, Hypertension and Nephrology Unit, Department of Medicien, Policlinico Tor Vergata, Rome, Italy
| | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Kristian Wachtell
- Department of Cardiology, Division of Cardiovascular and Pulmonary Diseases Oslo University Hospital, Oslo, Norway
| | - Ji Guang Wang
- The Shanghai Institute of Hypertension, RuiJin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
11
|
Bramlage P, Sims H, Minguet J, Ferrero C. The polypill: An effective approach to increasing adherence and reducing cardiovascular event risk. Eur J Prev Cardiol 2016; 24:297-310. [DOI: 10.1177/2047487316674817] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Mahlow, Germany
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Sevilla, Spain
| | - Helen Sims
- Institute for Research and Medicine Advancement (IRM), Terrassa, Spain
| | - Joan Minguet
- Institute for Pharmacology and Preventive Medicine, Mahlow, Germany
- Institute for Research and Medicine Advancement (IRM), Terrassa, Spain
| | - Carmen Ferrero
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Sevilla, Spain
| |
Collapse
|
12
|
Abstract
Cardiovascular risk modification in terms of comprehensive medical therapy (antithrombotic therapy, lipid-lowering therapy, antihypertensive medication) and lifestyle modification (healthy diet, regular exercise, weight loss, smoking cessation) is the cornerstone of secondary prevention. It is now clear that even in those undergoing PCI or bypass surgery, appropriate lifestyle modification and aggressive medical therapy are paramount for optimizing long-term outcomes. However, what has emerged from studies that examined the role of medical therapy in the context of coronary heart disease is that only ∼50% of the patients in these studies are achieving target treatment goals for blood pressure, lipid and glycemic control. Non-adherence is thought to be a very large contributor to this problem; across all health-care categories, non-adherence is estimated to account for $290 billion of annual health-care expenditure in the United States and €1.25 billion in European Union, with poor adherence to CVD medication accounting for 9% of all European CVD events. Socioeconomic factors may have a role in patients' discontinuing their medications, and a major initiative to combat this problem is the increasing focus on the polypill. The idea of combining numerous medications into a single tablet to reduce CV risk was first proposed more than a decade ago. This combined formulation not only significantly enhances patient convenience and adherence but also drives savings for the healthcare systems. Several randomized clinical trials have consistently demonstrated the effects of polypills on CV risk factors and adherence, and major trials are underway to study the effect on hard clinical outcomes.
Collapse
Affiliation(s)
- José M Castellano
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, Madrid, Spain; Hospital Universitario Montepríncipe, HM Hospitales, Madrid, Spain; Mount Sinai Cardiovascular Institute, New York, USA
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, Madrid, Spain; Hospital Universitario 12 de Octubre and Instituto de investigación i+12, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain
| | - Valentín Fuster
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, Madrid, Spain; Mount Sinai Cardiovascular Institute, New York, USA.
| |
Collapse
|
13
|
Tamargo J, Castellano JM, Fuster V. WITHDRAWN: The fuster-CNIC-Ferrer cardiovascular polypill: A polypill for secondary cardiovascular prevention. Int J Cardiol 2016. [DOI: 10.1016/j.ijcard.2016.01.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
14
|
Tamargo J, Castellano JM, Fuster V. The Fuster-CNIC-Ferrer Cardiovascular Polypill: a polypill for secondary cardiovascular prevention. Int J Cardiol 2015; 201 Suppl 1:S15-22. [DOI: 10.1016/s0167-5273(15)31028-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
15
|
Hsiao FC, Tung YC, Chou SH, Wu LS, Lin CP, Wang CL, Lin YS, Chang CJ, Chu PH. Fixed-Dose Combinations of Renin-Angiotensin System Inhibitors and Calcium Channel Blockers in the Treatment of Hypertension: A Comparison of Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors. Medicine (Baltimore) 2015; 94:e2355. [PMID: 26705234 PMCID: PMC4698000 DOI: 10.1097/md.0000000000002355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Fixed-dose combinations (FDCs) of different regimens are recommended in guidelines for the treatment of hypertension. However, clinical studies comparing FDCs of angiotensin receptor blocker (ARB)/calcium channel blocker (CCB) and angiotensin-converting enzyme inhibitor (ACE inhibitor)/CCB in hypertensive patients are lacking.Using a propensity score matching of 4:1 ratio, this retrospective claims database study compared 2 FDC regimens, ARB/CCB and ACE inhibitor/CCB, in treating hypertensive patients with no known atherosclerotic cardiovascular disease. All patients were followed for at least 3 years or until the development of major adverse cardiovascular events (MACEs) during the study period. In addition, the effect of medication adherence on clinical outcomes was evaluated in subgroup analysis based on different portions of days covered.There was no significant difference in MACE-free survival (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 0.98-1.50; P = 0.08) and survival free from hospitalization for heart failure (HR: 1.15; 95% CI: 082-1.61; P = 0.431), new diagnosis of chronic kidney disease (HR: 0.98; 95% CI: 071-1.36; P = 0.906), and initiation of dialysis (HR: 0.99; 95% CI: 050-1.92; P = 0.965) between the 2 study groups. The results remained the same within each subgroup of patients with different adherence statuses.ARBs in FDC regimens with CCBs in the present study were shown to be as effective as ACE inhibitors at reducing the risks of MACEs, hospitalization for heart failure, new diagnosis of chronic kidney disease, and new initiation of dialysis in hypertensive patients, regardless of the medication adherence status.
Collapse
Affiliation(s)
- Fu-Chih Hsiao
- From the Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine (F-CH, Y-CT, S-HC, L-SW, C-PL, C-LW, Y-SL, P-HC); Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University (C-J C); Healthcare Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine (Y-SL, P-HC); and Heart Failure Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan (P-HC)
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Development of Sustained Release "NanoFDC (Fixed Dose Combination)" for Hypertension - An Experimental Study. PLoS One 2015; 10:e0128208. [PMID: 26047011 PMCID: PMC4457799 DOI: 10.1371/journal.pone.0128208] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/24/2015] [Indexed: 11/22/2022] Open
Abstract
Objectives The present study was planned to formulate, characterize and evaluate the pharmacokinetics of a novel “NanoFDC” comprising three commonly prescribed anti-hypertensive drugs, hydrochlorothiazide (a diuretic), candesartan (ARB) and amlodipine (a calcium channel blocker). Basic Methods The candidate drugs were loaded in Poly (DL-lactide-co-gycolide) (PLGA) by emulsion- diffusion-evaporation method. The formulations were evaluated for their size, morphology, drug loading and in vitro release individually. Single dose pharmacokinetic profiles of the nanoformulations alone and in combination, as a NanoFDC, were evaluated in Wistar rats. Results The candidate drugs encapsulated inside PLGA showed entrapment efficiencies ranging from 30%, 33.5% and 32% for hydrochlorothiazide, candesartan and amlodipine respectively. The nanoparticles ranged in size from 110 to 180 nm. In vitro release profile of the nanoformulation showed 100% release by day 6 in the physiological pH 7.4 set up with PBS (phosphate buffer saline) and by day 4-5 in the intestinal pH 1.2 and 8.0 set up SGF (simulated gastric fluid) and SIF (simulated intestinal fluid) respectively. In pharmacokinetic analysis a sustained-release for 6 days and significant increase in the mean residence time (MRT), as compared to the respective free drugs was noted [MRT of amlodipine, hydrochlorothiazide and candesartan changed from 8.9 to 80.59 hours, 11 to 69.20 hours and 9 to 101.49 hours respectively]. Conclusion We have shown for the first time that encapsulating amlodipine, hydrochlorothiazide and candesartan into a single nanoformulation, to get the “NanoFDC (Fixed Dose Combination)” is a feasible strategy which aims to decrease pill burden.
Collapse
|
17
|
Becerra V, Gracia A, Desai K, Abogunrin S, Brand S, Chapman R, García Alonso F, Fuster V, Sanz G. Cost-effectiveness and public health benefit of secondary cardiovascular disease prevention from improved adherence using a polypill in the UK. BMJ Open 2015; 5:e007111. [PMID: 25991449 PMCID: PMC4452741 DOI: 10.1136/bmjopen-2014-007111] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE To evaluate the public health and economic benefits of adherence to a fixed-dose combination polypill for the secondary prevention of cardiovascular (CV) events in adults with a history of myocardial infarction (MI) in the UK. DESIGN Markov-model-based cost-effectiveness analysis, informed by systematic reviews, which identified efficacy, utilities and adherence data inputs. SETTING General practice in the UK. PARTICIPANTS Patients with a mean age of 64.7 years, most of whom are men with a recent or non-recent diagnosis of MI and for whom secondary preventive medication is indicated and well tolerated. INTERVENTION Fixed-dose combination polypill (100 mg aspirin, 20 mg atorvastatin and 2.5, 5, or 10 mg ramipril) compared with multiple monotherapy. PRIMARY AND SECONDARY OUTCOME MEASURES CV events prevented per 1000 patients; cost per life-year gained; and cost per quality-adjusted life-year (QALY) gained. RESULTS The model estimates that for each 10% increase in adherence, an additional 6.7% fatal and non-fatal CV events can be prevented. In the base case, over 10 years, the polypill would improve adherence by ∼20% and thereby prevent 47 of 323 (15%) fatal and non-fatal CV events per 1000 patients compared with multiple monotherapy, with an incremental cost-effectiveness ratio (ICER) of £8200 per QALY gained. Probabilistic sensitivity analyses for the base-case assumptions showed an 81.5% chance of the polypill being cost-effective at a willingness-to-pay threshold of £20,000 per QALY gained compared with multiple monotherapy. In scenario analyses that varied structural assumptions, ICERs ranged between cost saving and £21,430 per QALY gained. CONCLUSIONS Assuming that some 450,000 adults are at risk of MI, a 10 percentage point uptake of the polypill could prevent 3260 CV events and 590 CV deaths over a decade.The polypill appears to be a cost-effective strategy to prevent fatal and non-fatal CV events in the UK.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Valentín Fuster
- The Mount Sinai Medical Center, New York, New York, USA
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Ginés Sanz
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| |
Collapse
|
18
|
Gorst-Rasmussen A, Skjøth F, Larsen TB, Rasmussen LH, Lip GYH, Lane DA. Dabigatran adherence in atrial fibrillation patients during the first year after diagnosis: a nationwide cohort study. J Thromb Haemost 2015; 13:495-504. [PMID: 25594442 DOI: 10.1111/jth.12845] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is a perception among physicians that lack of routine monitoring with non-vitamin K antagonist oral anticoagulants (NOACs) may lead to poor adherence to medication. We studied adherence during the first year of usage in a cohort of patients with newly diagnosed non-valvular atrial fibrillation (AF) started on the NOAC, dabigatran etexilate. METHODS AND RESULTS Nationwide Danish patient and prescription purchase registries were used to identify newly diagnosed AF patients taking dabigatran, comorbidities, and refill patterns under a twice-daily, one pill regimen. Adherence was characterized among remaining users (N = 2960) after 1 year using the proportion of days covered (PDC), gap rates and restart rates. The overall 1-year PDC was 83.9%, with 76.8% of patients having a 1-year PDC in excess of 80%. Patients with a CHA2 DS2 -VASc score ≥ 2 were more adherent to medication regimes than patients with a CHA2 DS2 -VASc score of 1 (PDC ratio, 1.12; 95% confidence interval [CI], 1.08-1.17) and generally patients with higher morbidity showed more adherence. Patients with prior bleeding were not less adherent to medication regimes than patients with no prior bleeding (PDC ratio, 1.02; 95% CI, 0.98-1.06). The overall gap rate was 1.4 gaps per year. There were no clear tendencies in gap rates among subgroups, although patients with higher morbidity tended to have slightly more, but shorter, gap periods. CONCLUSIONS More than 75% of patients were showed > 80% adherence to medication regimes during the first year. Patients with higher morbidity, including patients with a higher risk of stroke or bleeding, exhibited better adherence. This improvement may be attributable to more regular contact with the healthcare system.
Collapse
Affiliation(s)
- A Gorst-Rasmussen
- Aalborg AF Study Group, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | | | | | | | | | | |
Collapse
|
19
|
Megiddo I, Chatterjee S, Nandi A, Laxminarayan R. Cost-effectiveness of treatment and secondary prevention of acute myocardial infarction in India: a modeling study. Glob Heart 2014; 9:391-398.e3. [PMID: 25592792 DOI: 10.1016/j.gheart.2014.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 07/07/2014] [Accepted: 07/15/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Cardiovascular diseases are the single largest cause of death in India, with acute myocardial infarction (AMI) accounting for one-third of all heart disease deaths. Although effective treatment is available for AMI, access to treatment is dictated by cost and ability to pay. With scarce treatment resources, healthcare decisions are guided by local cost-effectiveness, for which country-level data are lacking. OBJECTIVES We calculate the cost-effectiveness of policies that expand the use of aspirin, injection streptokinase, beta-blockers, angiotensin-converting enzyme inhibitors, and statins for the treatment and secondary prevention of AMI in India. We also estimate the cost-effectiveness of a hypothetical polypill (combining aspirin, beta blockers, angiotensin-converting enzyme inhibitors, and statins) for secondary prevention. METHODS We conduct cost-effectiveness analyses of AMI treatment and secondary prevention for patients with previous coronary heart disease events in India. We estimate coronary heart disease events using Framingham risk scores and disease prevalence using a cohort ordinary differential model. Other parameter estimates are from the literature. Polypill treatment is assumed to cost less than the additive cost of all 4 oral medications, but it is not assumed to increase adherence. We conduct a Latin hypercube sampling sensitivity analysis on the model parameters. RESULTS Increasing coverage of AMI treatment with aspirin and streptokinase would be cost-effective and could avert approximately 335,000 (191,000 to 503,000) disability-adjusted life years among 30- to 69-year-olds in India. Secondary prevention with aspirin and beta-blockers at 80% coverage (and at lower rates) would be highly cost-effective, and the addition of angiotensin-converting enzyme inhibitors would also be cost-effective. Introducing the polypill dominates a strategy of a 4-drug regimen with the aforementioned drugs and statins. The cost-effectiveness ratio of 80% coverage with the polypill would be $1,690 ($1,220 to $2,410) per disability-adjusted life years averted. CONCLUSIONS Policies expanding both treatment and preventive therapies are cost-effective, based on gross domestic product per capita comparison. Introducing the polypill would be more effective than providing its components separately, even without accounting for the likely increase in treatment adherence.
Collapse
Affiliation(s)
- Itamar Megiddo
- Center for Disease Dynamics, Economics, and Policy, Washington, DC, USA.
| | | | - Arindam Nandi
- Center for Disease Dynamics, Economics, and Policy, Washington, DC, USA; Public Health Foundation of India, New Delhi, India
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics, and Policy, Washington, DC, USA; Public Health Foundation of India, New Delhi, India
| |
Collapse
|
20
|
|
21
|
Sanz G, Castellano JM, Fuster V. Polypill: chimera or reality? ACTA ACUST UNITED AC 2014; 67:689-92. [PMID: 25172063 DOI: 10.1016/j.rec.2014.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 05/13/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Ginés Sanz
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
| | - José M Castellano
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Cardiovascular Institute, Mount Sinai School of Medicine, New York, United States
| | - Valentín Fuster
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Cardiovascular Institute, Mount Sinai School of Medicine, New York, United States
| |
Collapse
|
22
|
Abstract
Ischemic heart disease (IHD) is the greatest single cause of mortality and loss of disability-adjusted life years worldwide, and a substantial portion of this burden falls on low- and middle-income countries (LMICs). Deaths from IHD and acute coronary syndrome (ACS) occur, on average, at younger ages in LMICs than in high-income countries, often at economically productive ages, and likewise frequently affect the poor within LMICs. Although data about ACS in LMICs are limited, there is a growing literature in this area and the research gaps are being steadily filled. In high-income countries, decades of investigation into the risk factors for ACS and development of behavioral programs, medications, interventional procedures, and guidelines have provided us with the tools to prevent and treat events. Although similar tools can be, and in fact have been, implemented in many LMICs, challenges remain in the development and implementation of cardiovascular health promotion activities across the entire life course, as well as in access to treatment for ACS and IHD. Intersectoral policy initiatives and global coordination are critical elements of ACS and IHD control strategies. Addressing the hurdles and scaling successful health promotion, clinical and policy efforts in LMICs are necessary to adequately address the global burden of ACS and IHD.
Collapse
Affiliation(s)
- Rajesh Vedanthan
- From the Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, NY (R.V., V.F.); Department of Biology and School of Medicine, Stanford University, Palo Alto, CA (B.S.); and Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.)
| | - Benjamin Seligman
- From the Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, NY (R.V., V.F.); Department of Biology and School of Medicine, Stanford University, Palo Alto, CA (B.S.); and Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.)
| | - Valentin Fuster
- From the Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, NY (R.V., V.F.); Department of Biology and School of Medicine, Stanford University, Palo Alto, CA (B.S.); and Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.).
| |
Collapse
|
23
|
Castellano JM, Sanz G, Fuster V. Evolution of the Polypill Concept and Ongoing Clinical Trials. Can J Cardiol 2014; 30:520-6. [DOI: 10.1016/j.cjca.2014.02.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 02/11/2014] [Accepted: 02/11/2014] [Indexed: 12/17/2022] Open
|
24
|
Rao NS, Oomman A, Bindumathi PL, Sharma V, Rao S, Moodahadu LS, Patnaik A, Kumar BRN. Efficacy and tolerability of fixed dose combination of metoprolol and amlodipine in Indian patients with essential hypertension. J Midlife Health 2014; 4:160-6. [PMID: 24672188 PMCID: PMC3952407 DOI: 10.4103/0976-7800.119000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: This open-labeled, post-marketing study was conducted to assess the efficacy and tolerability of fixed dose combination of amlodipine and metoprolol extended release capsules in mild to moderate hypertension in adult Indian patients. Materials and Methods: Of 101 enrolled patients, 64 drug naïve patients were treated with regimen A (amlodipine 5 mg + metoprolol 25 mg) and those with prior history of hypertension (n = 37) were treated with regimen B (amlodipine 5 mg + metoprolol 50 mg) for 8 weeks. Treatment response was assessed at week 4 and 8. Dose up titration to regimen B was carried out for those who failed to achieve the target blood pressure (BP) at week 4 in regimen A and additional antihypertensives were added to those in regimen B. Safety laboratory tests were performed at baseline and end of study. Results: Mean age (±SD) of patients was 53.36 (±11.26) years and body weight (±SD) 63.40 (10.03) kg. Ninety five patients (94.06%) were only hypertensive and 6 (5.94%) had hypertension with history of coronary artery disease; mean duration (±SD) of hypertension was 42.50 (48.07) months. At baseline, patients had a mean (±SD) systolic blood pressure (SBP) and diastolic blood pressure (DBP) of 154.98 (±7.76) mmHg and 95.55 (±5.70) mmHg respectively. There was a statistically significant (P < 0.001) reduction of 12.16% and 14.69% in SBP, 11.49% and 14.65% in DBP at week 4 and week 8 respectively, compared to baseline. Normalization of overall BP was achieved in 49.49% and 70.71% patients at week 4 and 8, respectively. Peripheral edema was reported in 2.97% (3/101) patients. Conclusion: This combination was safe, efficacious, and well-tolerated in study population.
Collapse
Affiliation(s)
- N Srinivasa Rao
- Department of General Medicine, Osmania General Hospital and Medical College, Hyderabad, Andhra Pradesh, India
| | - Abraham Oomman
- Department of Cardiology, Apollo Hospital, Chennai, Tamil Nadu, India
| | - P L Bindumathi
- Department of General Medicine, Dr. BR Ambedkar Medical College, Bengaluru, Karnataka, India
| | - Vikram Sharma
- Department of Neurology, St. Theresa's General Hospital, Hyderabad, Andhra Pradesh, India
| | - Satish Rao
- Department of General Medicine, Kasturba Medical College, Mangalore, Karnataka, India
| | | | - Ashis Patnaik
- Global Medical Affairs, Dr. Reddy's Laboratories, Hyderabad, Andhra Pradesh, India
| | - B R Naveen Kumar
- Global Medical Affairs, Dr. Reddy's Laboratories, Hyderabad, Andhra Pradesh, India
| |
Collapse
|
25
|
Caron J, Maksimenko A, Mougin J, Couvreur P, Desmaële D. Combined antitumoral therapy with nanoassemblies of bolaform polyisoprenoyl paclitaxel/gemcitabine prodrugs. Polym Chem 2014. [DOI: 10.1039/c3py01177a] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
26
|
Muth C, Beyer M, Fortin M, Rochon J, Oswald F, Valderas JM, Harder S, Glynn LG, Perera R, Freitag M, Kaspar R, Gensichen J, van den Akker M. Multimorbidity's research challenges and priorities from a clinical perspective: the case of 'Mr Curran'. Eur J Gen Pract 2013; 20:139-47. [PMID: 24160250 DOI: 10.3109/13814788.2013.839651] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Older patients, suffering from numerous diseases and taking multiple medications are the rule rather than the exception in primary care. A manifold of medical conditions are often associated with poor outcomes, and their multiple medications raise additional risks of polypharmacy. Such patients account for most healthcare expenditures. Effective approaches are needed to manage such complex patients in primary care. This paper describes the results of a scoping exercise, including a two-day workshop with 17 professionals from six countries, experienced in general practice and primary care research as well as epidemiology, clinical pharmacology, gerontology and methodology. This was followed by a consensus process investigating the challenges and core questions for multimorbidity research in primary care from a clinical perspective and presents examples of the best research practice. Current approaches in measuring and clustering multimorbidity inform policy-makers and researchers, but research is needed to provide support in clinical decision making. Multimorbidity presents a complexity of conditions leading to individual patient's needs and demanding complex processes in clinical decision making. The identification of patterns presupposes the development of strategies on how to manage multimorbidity and polypharmacy. Interventions have to be complex and multifaceted, and their evaluation poses numerous methodological challenges in study design, outcome measurement and analysis. Overall, it can be seen that complexity is a main underlying theme. Moreover, flexible study designs, outcome parameters and evaluation strategies are needed to account for this complexity.
Collapse
Affiliation(s)
- Christiane Muth
- Institute of General Practice, Johann Wolfgang Goethe University , Frankfurt/Main , Germany
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Qi-shen-yi-qi dripping pills for the secondary prevention of myocardial infarction: a randomised clinical trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:738391. [PMID: 23935677 PMCID: PMC3725842 DOI: 10.1155/2013/738391] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 05/25/2013] [Indexed: 01/22/2023]
Abstract
Background. Several types of drugs have been recommended for the secondary prevention of myocardial infarction (MI). However, these conventional strategies have several limitations, such as low adherence, high cost, and side effects during long time use. Novel approaches to this problem are still needed. This trial aimed to test the effectiveness and safety of Qi-Shen-Yi-Qi Dripping Pills (QSYQ), a multi-ingredient Chinese patent medicine, for the secondary prevention of MI. Methods and Findings. A total of 3505 eligible patients were randomly assigned to QSYQ group (1746 patients) or aspirin group (1759). Patients took their treatments for 12 months. The final follow-up visit took place 6 months after the end of the trial drugs. The 12-month and 18-month estimated incidences of the primary outcome were 2.98% and 3.67%, respectively, in the QSYQ group. The figures were 2.96% and 3.81% in the aspirin group. No significant difference was identified between the groups. Conclusions. This trial did not show significant difference of primary and secondary outcomes between aspirin and QSYQ in patients who have had an MI. Though inconclusive, the result suggests that QSYQ has similar effects to aspirin in the secondary prevention of MI.
Collapse
|
28
|
Sharma KK, Mathur M, Gupta R, Guptha S, Roy S, Khedar RS, Gupta N, Gupta R. Epidemiology of cardioprotective pharmacological agent use in stable coronary heart disease. Indian Heart J 2013; 65:250-5. [PMID: 23809376 DOI: 10.1016/j.ihj.2013.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 01/23/2013] [Accepted: 04/03/2013] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine use of class and type of cardioprotective pharmacological agents in patients with stable coronary heart disease (CHD) we performed a prescription audit. METHODS A cross sectional survey was conducted in major districts of Rajasthan in years 2008-09. We evaluated prescription for classes (anti-platelets, β-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), calcium channel blockers (CCB) and statins) and specific pharmacological agents at clinics of physicians in tertiary (n = 18), secondary (n = 69) and primary care (n = 43). Descriptive statistics are reported. RESULTS Prescriptions of 2290 stable CHD patients were audited. Anti-platelet use was in 2031 (88.7%), β-blockers 1494 (65.2%), ACE inhibitors 1196 (52.2%), ARBs 712 (31.1%), ACE inhibitors - ARB combinations 19 (0.8%), either ACE inhibitors or ARBs 1908 (83.3%), CCBs 1023 (44.7%), statins 1457 (63.6%) and other lipid lowering agents in 170 (7.4%). Among anti-platelets aspirin-clopidogrel combination was used in 88.5%. Top three molecules in β-blockers were atenolol (37.8%), metoprolol (26.4%) and carvedilol (11.9%); ACE inhibitors ramipril (42.1%), lisinopril (20.3%) and perindopril (10.9%); ARB's losartan (47.7%), valsartan (22.3%) and telmisartan (14.9%); CCBs amlodipine (46.7%), diltiazem (29.1%) and verapamil (9.5%) and statins were atorvastatin (49.8%), simvastatin (28.9%) and rosuvastatin (18.3%). Use of metoprolol, ramipril, valsartan, diltiazem and atorvastatin was more at tertiary care, and atenolol, lisinopril, losartan, amlodipine and simvasatin in primary care (p < 0.01). CONCLUSIONS There is low use of β-blockers, ACE inhibitors, ARBs and statins in stable CHD patients among physicians in Rajasthan. Significant differences in use of specific molecules at primary, secondary and tertiary healthcare are observed.
Collapse
Affiliation(s)
- Krishna Kumar Sharma
- Research Scholar, Department of Clinical Research, Fortis Escorts Hospital, Jaipur, India.
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Delgado-Montero A, Zamorano JL. Atorvastatin calcium plus amlodipine for the treatment of hypertension. Expert Opin Pharmacother 2012; 13:2673-85. [DOI: 10.1517/14656566.2012.742064] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
30
|
De Smedt D, Kotseva K, De Bacquer D, Wood D, De Backer G, Dallongeville J, Seppo L, Pająk A, Reiner Ž, Vanuzzo D, Georgiev B, Gotcheva N, Annemans L. Cost-effectiveness of optimizing prevention in patients with coronary heart disease: the EUROASPIRE III health economics project. Eur Heart J 2012; 33:2865-72. [DOI: 10.1093/eurheartj/ehs210] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
|
31
|
Lonn E, Bosch J, Teo KK, Pais P, Xavier D, Yusuf S. The polypill in the prevention of cardiovascular diseases: key concepts, current status, challenges, and future directions. Circulation 2012; 122:2078-88. [PMID: 21098469 DOI: 10.1161/circulationaha.109.873232] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Eva Lonn
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | | | | | | | | | | |
Collapse
|
32
|
Cherukuvada S, Nangia A. Fast dissolving eutectic compositions of two anti-tubercular drugs. CrystEngComm 2012. [DOI: 10.1039/c2ce06391c] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
33
|
Sanz G, Fuster V, Guzmán L, Guglietta A, Arnáiz JA, Martínez F, Sarria A, Roncaglioni MC, Taubert K. The fixed-dose combination drug for secondary cardiovascular prevention project: improving equitable access and adherence to secondary cardiovascular prevention with a fixed-dose combination drug. Study design and objectives. Am Heart J 2011; 162:811-817.e1. [PMID: 22093195 DOI: 10.1016/j.ahj.2011.08.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 08/19/2011] [Indexed: 01/31/2023]
Abstract
In spite of advances in prevention and treatment, the burden of cardiovascular diseases is increasing. A fixed-dose combination (FDC) pill, or "polypill," composed of evidence-based drugs has been proposed as a means of improving cardiovascular prevention by reducing cost and increasing patient adherence to treatment. The aim of the FOCUS project, funded by the 7th Framework Programme of the European Commission, is to characterize the factors that underlie inadequate secondary prevention and to test a new FDC. To achieve these goals, a 9-member consortium has been constituted, including institutions from Argentina, France, Italy, Spain, and Switzerland. FOCUS Phase-1 will examine factors potentially related to lack of adequate secondary prevention in 4,000 post-myocardial infarction (MI) patients and analyze the relationship between these factors and patient treatment adherence. Primary end points will be (1) the percentage of patients receiving aspirin, angiotensin-converting enzyme inhibitors, and statins and (2) adherence to treatment measured by the Morisky-Green test. FOCUS Phase-2 is a randomized trial that will compare adherence to treatment in 1,340 post-myocardial infarction patients either receiving an FDC comprising aspirin (100 mg), ramipril (2.5, 5, or 10 mg), and simvastatin (40 mg) or receiving the same 3 drugs separately.
Collapse
Affiliation(s)
- Ginés Sanz
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Zeymer U, Jünger C, Zahn R, Bauer T, Bestehorn K, Senges J, Gitt A. Effects of a secondary prevention combination therapy with an aspirin, an ACE inhibitor and a statin on 1-year mortality of patients with acute myocardial infarction treated with a beta-blocker. Support for a polypill approach. Curr Med Res Opin 2011; 27:1563-70. [PMID: 21682553 DOI: 10.1185/03007995.2011.590969] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Large randomized clinical trials have shown the efficacy of aspirin, ACE (angiotensin converting enzyme) inhibitors and statins as secondary prevention measures in patients after an acute coronary syndrome with and without ST elevations. Therefore we aimed to determine the effect of a combination therapy with these three drugs on 1-year mortality after acute myocardial infarction (AMI). METHODS We prospectively followed 9998 survivors of acute myocardial infarction treated with a beta-blocker for 1 year. Patients were divided into three groups according to their therapy with aspirin, ACE inhibitors and statins: 3 drugs, 2 drugs or 0-1 drug. RESULTS The majority of patients (n = 6260, 62.6%) were treated with 3 drugs, 2986 (29.9%) with 2 drugs and 752 (7.5%) with 0-1 drug. In the univariate analysis 1-year mortality was 4.9%, 9.7% and 13.6%, respectively. After adjusting for confounding factors in the propensity score analysis the odds ratios for 1-year mortality were significantly increased with 0-1 drug (odds ratio 1.67, 95% CI 1.24-2.27) and with 2 drugs (odds ratio 1.54, 95% CI 1.26-1.87) in comparison with the group treated with all 3 drugs. However, in the ACOS registry the treatment was left to the discretion of the physician. This could lead to a selection bias, which cannot be fully eliminated by using multiple regression analysis. CONCLUSIONS A combination therapy with aspirin, an ACE inhibitor and a statin reduces 1-year mortality in patients after AMI. Therefore a polypill approach with these three agents should be considered to increase drug compliance and reduce mortality after acute myocardial infarction.
Collapse
Affiliation(s)
- Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen an der Universität Heidelberg, Germany. Uwe.Zeymert-online.de
| | | | | | | | | | | | | |
Collapse
|
35
|
Fuster V, Sanz G. Compuestos de dosis fija en la prevención secundaria de la cardiopatía isquémica. Rev Esp Cardiol 2011; 64 Suppl 2:3-9. [DOI: 10.1016/j.recesp.2011.02.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 02/20/2011] [Indexed: 10/17/2022]
|
36
|
Should There Be a Different Cardiovascular Prevention Polypill Strategy for Women and Men? CURRENT CARDIOVASCULAR RISK REPORTS 2011. [DOI: 10.1007/s12170-011-0161-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
37
|
Abstract
The purpose of this review is to describe novel pharmacologic and nonpharmacologic preventive therapies, as well as new strategies to improve delivery of available therapies. Cardiovascular disease (CVD) is the leading cause of death worldwide, and prevention plays a critical role in curbing the global epidemic. Despite available treatment for tobacco addiction, platelet inhibition, blood pressure, and lipid lowering for reduction of atherosclerotic disease, significant gaps in treatment of total CVD remain. We review a range of new preventive treatment options, including drugs for tobacco cessation, platelet/thrombotic inhibition, lipid- and blood pressure-lowering; nonpharmacologic options such as left atrial appendage closure devices and caloric restriction; and strategies such as fixed-dose combination drugs, laboratory screening for drug tailoring, and community-based prevention programs. CVD preventive research continues to evolve and provide clinicians and patients with novel pharmacologic and nonpharmacologic therapies, including new preventive strategies.
Collapse
Affiliation(s)
- Mark D Huffman
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
| | | |
Collapse
|
38
|
Jin Y, Xin R, Tong L, Du L, Li M. Combination Anti-HIV Therapy with the Self-Assemblies of an Asymmetric Bolaamphiphilic Zidovudine/Didanosine Prodrug. Mol Pharm 2011; 8:867-76. [DOI: 10.1021/mp100457d] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Yiguang Jin
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, Beijing 100850, China
- Institute of Pharmacy, Pharmaceutical College of Henan University, Henan 475004, China
| | - Rui Xin
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, Beijing 100850, China
- Institute of Pharmacy, Pharmaceutical College of Henan University, Henan 475004, China
| | - Li Tong
- College of Life Sciences, Beijing Normal University, Beijing 100875, China
| | - Lina Du
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Miao Li
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, Beijing 100850, China
| |
Collapse
|
39
|
Sanz G, Fuster V. Polypill and Global Cardiovascular Health Strategies. Semin Thorac Cardiovasc Surg 2011; 23:24-9. [DOI: 10.1053/j.semtcvs.2011.05.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2011] [Indexed: 11/11/2022]
|
40
|
Sanz G. Beyond Cholesterol in the Primary Prevention of Cardiovascular Disease: Is The Polypill the Answer? CURRENT CARDIOVASCULAR RISK REPORTS 2010. [DOI: 10.1007/s12170-010-0135-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
41
|
Current world literature. Curr Opin Cardiol 2010; 25:411-21. [PMID: 20535070 DOI: 10.1097/hco.0b013e32833bf995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
42
|
Abstract
Patients with established coronary heart disease (CHD) have a high risk of subsequent cardiovascular events, including myocardial infarction (MI), stroke, and death from cardiovascular disease. Adherence to evidence-based secondary prevention therapies for CHD has improved in recent years but still remains suboptimal. Mortality from CHD in the United States (US) has decreased substantially in recent decades. The decline in US deaths from CHD from 1980 through 2000 has been attributed to reductions in major risk factors and utilization of evidence-based medical therapies. It has been estimated that optimization of secondary prevention strategies could save as many as 80,000 more lives per year in the US. The American College of Cardiology (ACC) and American Heart Association (AHA) updated its guidelines for secondary prevention for patients with atherosclerotic vascular disease in 2006. The guidelines emphasize evidence-based developments in the field of CHD secondary prevention and also reinforce the need to implement these recommendations in actual clinical practice through programs such as the ACC's Guidelines Applied to Practice and the AHA's Get With The Guidelines. This review will discuss the epidemiology and risk assessment of CHD, current pharmacologic and nonpharmacologic strategies available for the secondary prevention of CHD, and summarize the guidelines and evidence that support these treatment options. There will be an emphasis on antiplatelet therapy given the important role of thrombosis in clinical cardiovascular events.
Collapse
|
43
|
Abstract
PURPOSE OF REVIEW In spite of great scientific advances, cardiovascular disease is the commonest cause of death worldwide and current cardiovascular prevention strategies fail to achieve the full potential of risk modification. A large amount of evidence supports the use of pharmacological treatments both in primary and secondary prevention and it was hypothesized that a fixed-dose combination of such drugs, a 'polypill', may greatly simplify and improve current prevention strategies. RECENT FINDINGS Several polypill formulations have been developed and a recent trial demonstrated the short-term feasibility, safety and efficacy (in reducing risk factor levels) of a polypill in individuals at moderate risk. Many challenges remain and studies are underway, which will address questions related to formulation of polypill(s), the long-term safety and tolerability, the efficacy in reducing risk factor levels and cardiovascular events, physician, patient and societal acceptability, adherence, regulatory requirements, cost and impact on lifestyle habits. SUMMARY Theoretical models suggest that a polypill containing low-dose aspirin, three blood pressure-lowering drugs at half dose and a potent statin, administered to a large proportion of the population at risk for cardiovascular events, could reduce ischemic heart disease and strokes by over 80%. The feasibility of this approach has recently been shown in a clinical trial and ongoing studies will define whether the postulated benefits of the polypill will be observed.
Collapse
Affiliation(s)
- Eva Lonn
- Population Health Research Institute and Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada.
| | | |
Collapse
|
44
|
Current world literature. Curr Opin Lipidol 2009; 20:512-9. [PMID: 19935200 DOI: 10.1097/mol.0b013e328334096a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|