Health-related quality of life of ticagrelor versus clopidogrel in patients with acute coronary syndromes-results from the PLATO trial

OBJECTIVES

The purpose of this study was to compare the effects of ticagrelor versus clopidogrel on health-related quality of life in the PLATelet inhibition and patient Outcomes (PLATO) trial.

BACKGROUND

The PLATO trial showed that ticagrelor was superior to clopidogrel for the prevention of cardiovascular death, myocardial infarction, or stroke in a broad population of patients with acute coronary syndromes.

METHODS

HRQOL in the PLATO study was measured at hospital discharge, 6-month visit, and end of treatment (anticipated at 12 months) by using the EuroQol five-dimensional (EQ-5D) questionnaire. All patients who had an EQ-5D questionnaire assessment at discharge from the index hospitalization (n = 15,212) were included in the study. Patients who died prior to the end-of-treatment visit were assigned an EQ-5D questionnaire value of 0.

RESULTS

The EQ-5D questionnaire value at discharge among 7631 patients assigned to ticagrelor was 0.847 and among 7581 patients assigned to clopidogrel was 0.846 (P = 0.71). At 12 months, the mean EQ-5D questionnaire value was 0.840 for ticagrelor and 0.832 for clopidogrel (P = 0.046). Excluding patients who died resulted in mean EQ-5D questionnaire values of 0.864 among ticagrelor patients and 0.863 among clopidogrel patients (P = 0.69).

CONCLUSIONS

In patients hospitalized with acute coronary syndromes with or without ST-segment elevation, treatment with ticagrelor was associated with a lower mortality but otherwise no difference in quality of life relative to treatment with clopidogrel. The improved survival and reduction in cardiovascular events with ticagrelor are therefore obtained with no loss in quality of life.

Early intervention of recent onset mild persistent asthma in children aged under 11 yrs: the Steroid Treatment As Regular Therapy in early asthma (START) trial

Inhaled corticosteroids are known to be effective in persistent asthma, but their long-term effect in mild persistent disease of recent onset, which is particularly relevant in children, requires clarification. The objective of this study was to determine the long-term efficacy of regular inhaled low-dose budesonide in children aged <11 yrs with mild persistent asthma with onset within 2 yrs of enrollment. Children aged 5-10 yrs formed part of the population of the inhaled Steroid Treatment As Regular Therapy in early asthma (START) study, and they were randomized in a double-blind manner to treatment with once daily budesonide 200 microg or placebo via Turbuhaler in addition to usual clinical care and other asthma medication. The double-blind treatment phase continued for 3 yrs. Of the 1974 children, 1000 in the budesonide group and 974 in the placebo group, were analyzed for efficacy. Addition of once-daily budesonide to usual care was associated with a significant increase in the time to first severe asthma-related event (SARE) and significantly reduced risk of SARE over 3 yrs. The hazard ratio relative to usual care (placebo) was 0.60 (95% confidence interval: 0.40-0.90; p = 0.012), with a relative risk reduction of 40%. Children receiving budesonide also needed significantly less intervention with other inhaled corticosteroids (12.3% vs. 22.5% over 3 yrs; p < 0.01), with trends towards decreased usage of oral/systemic corticosteroids and inhaled short-acting beta2-agonists. Budesonide treatment also had a significant beneficial effect on lung function relative to placebo. In conclusion, early intervention adding once-daily budesonide to usual care in children with mild, persistent asthma of recent onset reduces the long-term risk and frequency of SAREs and improves lung function compared with usual care alone.

Cost-effectiveness of early intervention with once-daily budesonide in children with mild persistent asthma: results from the START study

The inhaled Steroid Treatment As Regular Therapy in early asthma (START) study has shown that early intervention with inhaled budesonide in mild persistent asthma improves clinical outcomes in both adults and children. The aim of this study was to estimate the incremental cost-effectiveness of early treatment with budesonide Turbuhaler in children aged 5-10 yr who participated in START. Direct and indirect costs associated with asthma were determined for 1974 children participating in the double-blind, 3-year part of the study. Randomization was to placebo or to budesonide 200 microg once daily in each case in addition to usual asthma care. Cost-effectiveness ratios were calculated from the healthcare payer's and societal perspectives (using US prices). The addition of once-daily budesonide therapy to usual asthma care was associated with 16 additional symptom-free days (SFDs) per child over the 3-yr period (p < 0.001), with a substantial reduction (50%) in the mean number of days spent in hospital, and with reduced frequency of emergency room visits and missed school and caregiver work days. From the healthcare payer's perspective (direct costs), the increase in mean direct cost over 3 yr with budesonide was 169 dollars, which translated into an incremental cost of early intervention with budesonide in children of 10.50 dollars (95% CI 1.20-33.30 dollars) per SFD gained. From the societal perspective, there was a cost reduction over 3 yr of 192 dollars with budesonide relative to placebo. From a societal perspective, budesonide was therefore dominant. In conclusion, early intervention with once-daily budesonide added to usual asthma care in children with mild persistent asthma is cost-saving from a societal perspective and is acceptably cost-effective when viewed from a healthcare payer perspective.

Country-specific cost-effectiveness of early intervention with budesonide in mild asthma

Early intervention with budesonide is an effective strategy for mild persistent asthma, which has been shown to provide additional clinical benefits at a low incremental cost using USA cost data. The present authors analysed whether this strategy would be cost-effective using cost data for other countries. Based on the 3-yr prospective, randomised, double-blind inhaled Steroid Treatment As Regular Therapy (START) in early asthma study (comparing budesonide and placebo combined with usual asthma therapy), the cost-effectiveness was estimated separately for eight different countries, from both healthcare payer and societal perspectives, of adding budesonide to usual asthma therapy. Local unit costs were applied to data for the total trial population. Incremental cost-effectiveness ratios (ICER) were estimated as cost per symptom-free day (SFD) gained. Budesonide increased SFDs by an average of 14.1 days annually. From a healthcare payer perspective, budesonide would reduce the total cost of asthma care in Australia. In Sweden, Canada, France, Spain, UK, China and the USA, the ICER ranged from US$2.4-11.3 per SFD. From a societal perspective, budesonide would be cost-saving in Australia, Canada and Sweden. In conclusion, for countries where costs with budesonide are higher, the policy implication has to be determined by that health system's willingness to pay for an additional symptom-free day. However, where budesonide therapy increases symptom-free days and reduces total costs, the policy conclusion clearly favours early intervention.

Design and analytic considerations in determining the cost-effectiveness of early intervention in asthma from a multinational clinical trial

Demand for economic and outcomes data in support of drug formulary listing in private and government-sponsored health programs has led to fundamental changes in drug development. In part as a response to these pressures, the pharmaceutical industry has begun to include economic and quality-of-life endpoints in clinical trials with the hope of providing information to answer health policy questions on the economic value of its products. Here, the design and health economic techniques that will be used to analyze the START (inhaled Steroid Treatment As Regular Therapy in early asthma) study-a multinational (31 countries), randomized, placebo-controlled trial of 7240 patients with mild asthma over 3 years-will be presented. START compares the effect of once-daily administration of an inhaled glucocorticosteroid (Pulmicort Turbuhaler to conventional therapy in the management of newly diagnosed asthma, for which the use of this therapy is currently not the standard. The START study will examine both clinical effectiveness (measured as symptom-free days) and asthma-related costs for both treatment arms, aggregated for all patients across all countries. We believe that presenting the analytical plan prior to disseminating the results is an important way of increasing the credibility of economic evaluations. However, using clinical trials for collecting economic data poses several challenges, and the methods for conducting such evaluations are being developed. This paper will present and discuss several methodological options and the current state of the art for conducting economic evaluations alongside multinational clinical trials.

Autoregressive models for describing non-linear changes in biological parameters fitted using BUGS

Many biological processes give outcome data which show a curvilinear association with time which tends to an asymptote. We show how autoregressive models can be used to describe this association within individual subjects. We also present a Bayesian approach implemented using statistical software, BUGS, to fit these models in a multi-level (hierarchical) setting that describes variation in the association between subjects. Peak expiratory flow data from a clinical trial involving subjects with asthma are used to illustrate the methods.

Automated rhinomanometry

In order to facilitate measurements and calculations in rhinomanometry a microprocessor is used. Pressure and flow signals, obtained from microtransducers, are automatically calibrated by drawing known volumes of air through a standardized test-nose, while the signals are read by the computer. When the patient is connected, the pressure-flow curves are displayed on a screen. At adequate breathing, the computer reads the pressure and flow 200 times per second for a few breaths. It performs all calculations and presents data describing the pressure-flow relationship, e.g. in terms of the resistance, where the curve crosses a circle with a certain radius in a polar coordinate system. Automatically calculated data were compared to manually derived ones in six healthy subjects and twenty patients with symptoms of nasal obstruction. There was a close correlation between the two sets of data. It is concluded that the described automated rhinomanometer facilitates the rhinomanometric procedure and gives accurate data on nasal airway resistance.

Tracheal relaxant and cardiostimulant actions of xanthines can be differentiated from diuretic and CNS-stimulant effects. Role of adenosine antagonism?

Theophylline (1, 3-dimethylxanthine) and enprofylline (3-propylxanthine) have been examined for effects in the rat. Enprofylline was 3.8 times as potent as theophylline as a tracheal relaxant in vitro, and 1.3 times as potent as theophylline to increase the rate of isolated perfused hearts. An oral dose (5 mg/kg) of enprofylline to rats was almost completely recovered in the urine as unchanged drug, showing that this xanthine is well absorbed and negligibly metabolised. Theophylline (10 and 30 mg/kg p.o.) significantly and dose-dependently increased locomotor activity in rats whereas the same doses of enprofylline were without effect on behaviour. Theophylline ( 5-20 mg/kg p.o.) produced significant and dose-dependent natriuretic and volume diuretic effect with little augmentation of potassium excretion. Enprofylline up to 10 mg/kg was without diuretic effects. At the large dose of 20 mg/kg enprofylline decreased sodium excretion and produced some volume diuresis. It is suggested that lack of diuretic and CNS-stimulant behavioural effects by enprofylline is due to its low ability to antagonise adenosine receptor stimulation. Pharmacodynamic differences between enprofylline and the potent adenosine antagonist theophylline may indicate a functional importance of endogenous adenosine.

Rhinomanometry. II. A system for numerical description of nasal airway resistance

Various ways of expressing rhinomanometric results have been an obstacle for exchange of information. A method that could be generally accepted must: 1) easily give the clinician an informative figure describing the nasal airway patency in all cases: 2) provide a basis for statistical evaluation: and 3) allow a numerical description of the whole pressure-flow (P-V) curve. In our system P-V curves are traced X-Y wise and described with polar coordinates (angles and radii). The system can be applied in three modes. The 'clinical' mode describes resistance at a standardized condition defined by a circle of the pressure-flow diagram. Data can be read direct from the pressure-flow curve. The 'statistical' mode yields nearly normal distribution. The 'mathematical' mode describes the whole pressure-flow curve, in terms of changing angle with radius. This mode brings about good and stable curve-fitting. Calculation of properties of the total nose from data of each cavity can be done with a pocket calculator.

Reduction of metacholine-induced nasal secretion by treatment with a new topical steroid in perennial non-allergic rhinitis

The value of three objective tests of the nasal mucosa in 22 patients with perennial non-allergic rhinitis treated with a topical corticosteroid has been investigated. Placebo and three different dosages of a new steroid, budesonide, were administered intranasally using a double-blind, cross-over technique. Nasal airway resistance was not reduced by the steroid treatment as compared with the placebo treatment. Eosinophilia in nasal smears was reduced by budesonide. However, the value of this test was decreased by the fact that eosinophilia was found in less than 50% of the patients at the beginning of the trial. Metacholine-induced nasal secretion was significantly reduced by the budesonide treatment. Symptom scores for nasal obstruction, secretion and sneezing attacks were also significantly reduced by the steroid.

Masticatory efficiency

A method for measuring masticatory efficiency is described as well as a mathematical formula expressing the masticatory efficiency as an index. A silicone compound was used as test material. The masticatory efficiency index was calculated as the mean of the best four out of five consecutive measurements of masticatory efficiency calculated from a specially designed formula.

The adrenoceptor blocking properties of the new beta 2-selective antagonist, IPS 339 on tracheal smooth muscle and on slow contracting skeletal muscle

The beta-adrenoceptor blocking properties of IPS 339 and propranolol were studied on isolated preparations of trachea and of the slow-contracting soleus muscle from the guinea-pig. Both compounds antagonized the relaxation of the trachea and the depression of subtetanic contractions of the soleus produced by the beta2-selective agonist, terbutaline. On the soleus muscle the pA2-values for IPS 339 and propranolol were similar and close to those obtained for propranolol on the trachea. However, on the trachea the slope of the Schildplot for IPS 339 against terbutaline became less than one and a reliable pA2-value could not be calculated.

A universal way to evaluate the curve in rhinomanometry

A new way to evaluate the curve of nasal airway resistance has been developed. With polar coordinates, all curves can be described. Also, tightly closed or wide open noses can be compared with angles. The method is of value in clinical as well as in scientific work, especially when dealing with statistics.

A model of the breakdown and removal of the chromatin components during Feulgen acid hydrolysis

A stochastic model of Feulgen hydrolysis is proposed. The model, constructed so as to embody the main features of chromatin structure, is simple enough to allow the calculation of extraction rates. Extraction rate curves generated by the model are compared with experimental curves obtained under various conditions (different fixatives and hydrolysis solutions). A good correspondence is found between the experiments and the predictions of the model.