Factors Related to Treatment Non-Adherence Among Caregivers of Pediatric and Adolescent Growth Hormone Deficiency Patients in Japan

Background

About one-third of caregivers of pediatric or adolescent growth hormone deficiency (pGHD) patients in Japan have reported poor treatment adherence. However, few studies have examined factors related to adherence for that group.

Objective

The aim of this study is to consider factors related to poor adherence to daily treatment among caregivers of pGHD patients in Japan.

Methods

A cross-sectional survey was conducted among caregivers of pGHD patients in Japan. Caregivers were asked about demographic and treatment characteristics, health literacy, treatment satisfaction, opinions about treatment, and treatment adherence. Health literacy was assessed using the 14-item health literacy scale (HLS-14). Adherence was assessed using the 8-item Morisky Medication Adherence Scale (MMAS-8). Statistical association with adherence was considered using Chi-square and Student's t-testing. An exploratory factor analysis (EFA) and K-means cluster analysis was conducted to consider the influence of treatment satisfaction and opinions concerning treatment on adherence.

Results

Responses were collected from 112 caregivers. The caregiver's age being 30-39 years old, the primary caregiver being male, the primary caregiver being employed, and low functional health literacy for the caregiver were associated with poor adherence. Patients being pre-elementary school age was also associated with poor adherence. Low satisfaction with drug treatment and/or their device and communication with healthcare professionals (HCPs), and lack of agreement with the importance of treatment management (eg, keeping injection records, getting informed about the disease/therapy, reporting non-adherence, and sticking to an administration schedule), were also associated with poor adherence.

Conclusion

Strategies to improve treatment adherence among caregivers of pGHD patients in Japan should consider the age, gender, and employment status of the caregiver - as well as their functional literacy. Improvement in satisfaction with the drug or device used, better communication with HCPs, and greater awareness of the importance of treatment management, may also lead to better adherence.

Use of analgesics before and after total joint replacement in working-age Japanese patients with knee and hip osteoarthritis: A retrospective database study

Background

Patterns of analgesic use before and after total joint replacement (TJR) in patients with knee/hip osteoarthritis (OA) is not well reported.

Methods

This retrospective longitudinal analysis used JMDC claims data of patients who underwent knee/hip replacement surgery from 2010 to 2019. Primary outcome was proportion of patients using analgesics pre-surgery, immediately post-surgery, and in post-surgery period. Factors affecting post-surgery analgesic withdrawal and opioid prescriptions were assessed using logistic regression.

Results

Of all (N = 3168) patients, those with knee OA (91.1 %) and hip OA (82.5 %) used analgesics pre-surgery, and 96.1 % with knee OA and 84.9 % with hip OA required analgesics even 3 months post-surgery. NSAIDs were most commonly used pre- and post-surgery in both OA groups. Before surgery, 15.6 % (knee OA) and 13.7 % of patients (hip OA) used weak opioids, and 23.1 % (knee OA) and 10.5 % (hip OA) of patients continued them post-surgery. Strong opioid use was noted in 2.2 % and 1.2 % of patients pre-surgery, and 5.8 % and 3.4 % of patients post-surgery in the knee and hip OA groups, respectively. Using pre-operative oral NSAIDs (odds ratio [OR]:0.56; 95 % confidence interval [CI]:0.44-0.72) and weak opioids (OR:0.58; 95 % CI:0.38-0.87) associated with withdrawal of post-surgery analgesics in patients with hip OA, and using intra-articular hyaluronic acid pre-surgery (OR:0.45; 95 % CI:0.21-0.97) was significant in patients with knee OA. Using weak (OR:4.59; 95 % CI:3.44-6.13) and strong opioids (OR:2.48; 95 % CI:1.01-6.07) pre-surgery associated with post-operative opioid use in patients with hip OA, and weak opioid use was significant in patients with knee OA (OR:7.00; 95 % CI:4.65-10.54).

Conclusion

This study reported difference in analgesic use before and after TJR, and that many patients required analgesics even 3 months after TJR surgery in Japan. Pre-operative analgesic use associated with continued use after surgery. Optimal pain management before and immediately after TJR is important to reduce post-operative analgesic use, especially opioids.

Perioperative Analgesics and Anesthesia as Risk Factors for Postoperative Chronic Opioid Use in Patients Undergoing Total Knee Arthroplasty: A Retrospective Cohort Study Using Japanese Hospital Claims Data

BACKGROUND

Patients with chronic postsurgical pain are commonly prescribed opioids chronically because of refractory pain although chronic opioid use can cause various severe problems.

OBJECTIVE

We aimed to investigate postoperative chronic opioid use and its association with perioperative pain management in patients who underwent a total knee arthroplasty in a Japanese real-world clinical setting.

METHODS

We conducted a retrospective cohort study using an administrative claims database. We used a multivariate logistic regression analysis to examine the association between perioperative analgesic and anesthesia prescriptions and postoperative chronic opioid use. We calculated all-cause medication and medical costs for each patient.

RESULTS

Of the 23,537,431 patient records, 14,325 patients met the criteria and were included in the analyses. There were 5.4% of patients with postoperative chronic opioid use. Perioperative prescriptions of weak opioids, strong and weak opioids, and the α₂δ ligand were significantly associated with postoperative chronic opioid use (adjusted odds ratio [95% confidence interval], 7.22 [3.89, 13.41], 7.97 [5.07, 12.50], and 1.45 [1.13, 1.88], respectively). Perioperative combined prescriptions of general and local anesthesia were also significantly associated with postoperative chronic opioid use (3.37 [2.23, 5.08]). These medications and local anesthesia were more commonly prescribed on the day following surgery, after routinely used medications and general anesthesia were prescribed. The median total direct costs were approximately 1.3-fold higher among patients with postoperative chronic opioid use than those without postoperative chronic opioid use.

CONCLUSIONS

Patients who require supplementary prescription of analgesics for acute postsurgical pain are at high risk of postoperative chronic opioid use and these prescriptions should be given careful consideration to mitigate the patient burden.

Physician and patient perceptions of surgical procedures for osteoarthritis of the knee in the United States, Europe, and Japan: results of a real-world study

BACKGROUND

Osteoarthritis (OA) is the most common form of arthritis, with the knee being the joint most frequently affected, and symptomatic knee OA affecting around one quarter of the general population. For patients who do not respond to non-pharmacologic or pharmacologic treatment, surgery is a recommended option. The objectives of this study were to compare the willingness of patients with knee OA to undergo surgery, together with reasons for delaying surgery, and factors affecting successful outcomes.

METHODS

A point-in-time survey was conducted in 729 primary care physicians, rheumatologists, orthopedic surgeons, and 2,316 patients with knee OA across three geographical regions: Japan, the United States (US), and Europe (EUR: France, Spain, Italy, Germany, and the United Kingdom), in order to garner their perceptions of knee surgery. Regression models were used to identify factors that might affect patients' and physicians' perceptions of surgery, including severity of OA (mild/moderate/severe), number of affected joints, surgery status, and willingness to undergo or delay surgery.

RESULTS

Baseline demographics were similar between US and EUR, although patients in Japan were more likely to be female, older, and only 7% in fulltime employment. We found that few patients with end-stage knee OA, across all regions, but particularly Japan, were willing to undergo surgery (Japan 17%, US 32%, EUR 38%), either through fear, or the lack of awareness of the risk/benefits. Moreover, surgeons are prepared to delay surgery in elderly or unwilling patients, due to their dissatisfaction with the outcome, and may defer surgery in younger patients due to the need for future revision. We also identified a disconnect between physicians, of whom over 80% consider improved functioning to be the most important outcome of surgery, and patients, who seek pain relief (Japan 60%, US 35%, EUR 14%). Since physicians across all regions considered pain reduction to be an indication of surgery success (Japan 27%, US 47%, EUR 43%), this may indicate a need for improved communication to patients on the potential benefits of surgery.

CONCLUSION

Managing the expectations of patients undergoing surgery remains an important goal in the treatment of knee OA and may help guide physician choice.

Cost-Effectiveness Analysis of the Treatment Strategies with or without Opioid Medications in Surgery-Eligible Patients with Osteoarthritis in Japan

AIM

The aim of this study was to evaluate the cost effectiveness of treatment strategies without opioid medications (non-opioid treatment strategy) versus strategies with opioid medications (opioid treatment strategy) among surgery-eligible patients with osteoarthritis (OA) of the knee or hip in Japan.

MATERIALS AND METHODS

We built a Markov cohort model to evaluate outcomes for the treatment strategies in surgery-eligible patients aged ≥ 65 years with OA of the knee or hip in Japan. The opioid treatment strategy as an intervention includes a health state with opioid medication in the treatment pathway. On the other hand, for the non-opioid treatment strategy, there is no health state with opioid medication. A targeted literature review and database analysis were conducted to identify and define the values of the variables included in the model. The time horizon was set to 30 years, and a 2% discount was applied for cost and quality-adjusted life-years (QALYs). Sensitivity analysis and scenario analysis were performed in the model. The outcomes were QALYs and the incremental cost-effectiveness ratio (ICER).

RESULTS

In the base-case analysis, the non-opioid treatment strategy was dominant over the opioid treatment strategy and associated with an incremental cost and QALYs of - 53,878 JPY (- 499 USD) and 0.03 QALYs, respectively, in patients with knee OA, and - 54,129 JPY (- 502 USD) and 0.02 QALYs, respectively, in patients with hip OA. One-way sensitivity analysis showed the ICER was most sensitive to the QALY for opioid monotherapy. Probabilistic sensitivity analyses showed a high degree of uncertainty associated with the results.

LIMITATIONS

Study limitations included assumptions related to transition probabilities of the health states, and a lack of Japanese-specific data for transition probabilities, incidence of adverse events and utility values.

CONCLUSIONS

This study suggests that the non-opioid treatment strategy is cost effective compared with the opioid treatment strategy in the management of surgery-eligible patients with OA of the knee or hip. However, this final conclusion may not be accurate as the methodology is heavily reliant on assumptions.

Safety risk associated with use of nonsteroidal anti-inflammatory drugs in Japanese elderly compared with younger patients with osteoarthritis and/or chronic low back pain: A retrospective database study

Purpose

This study aimed to assess the safety risks associated with using nonsteroidal anti‐inflammatory drugs (NSAIDs) in elderly patients (≥65 years) compared with younger patients (<65 years) with osteoarthritis (OA) and/or chronic low back pain (CLBP).

Methods

A retrospective analysis was conducted on anonymized claims data of patients prescribed NSAIDs for OA and/or CLBP from 2009 to 2018 using hospital‐based administrative database—Medical Data Vision (MDV). The key outcome was the incidence of developing gastrointestinal (GI), renal, and acute myocardial infarction (AMI) that are well‐known events associated with NSAID use.

Results

Of 288,715 patients included, 23.7%, 60.5%, and 15.8% had OA, CLBP, or both, respectively. Elderly patients used non‐oral NSAIDs more frequently than oral NSAIDs (57.8% and 38.7%, respectively), whereas younger patients showed comparable use (50.7% and 52.8%, respectively). The incidence of events per 10,000 person‐years (95% CI) was higher in the elderly than in younger patients: GI, 29.68(27.67–31.68) vs. 16.61(14.60–18.63); renal, 124.77(120.56–128.99) vs. 39.88(36.72–43.03); and AMI, 27.41(25.48–29.35) vs. 10.90(9.27–12.53), respectively. After adjusting for covariates, the increase in risk for these events was seen in patients >70 years compared with younger patients (18–30 years) and was remarkable in patients >80 years with 2‐fold, 10‐fold, and 7‐fold higher risk for developing GI, renal, and AMI events, respectively.

Conclusion

Risk for developing NSAID‐associated events was higher in the elderly; particularly, renal and AMI events that remarkably increased in patients >80 years. To reduce them, NSAIDs should be prescribed at the lowest effective dose for the shortest duration possible.

A Retrospective Database Study of Gastrointestinal Events and Medical Costs Associated with Nonsteroidal Anti-Inflammatory Drugs in Japanese Patients of Working Age with Osteoarthritis and Chronic Low Back Pain

CONTEXT

The real-world burden of gastrointestinal (GI) events associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in Japanese patients with osteoarthritis (OA) and/or chronic low back pain (CLBP) remains unreported.

OBJECTIVE

To assess the incidence and economic burden of NSAID-induced GI events by using data from large-scale real-world databases.

METHODS

We used the Japanese Medical Data Center database to retrospectively evaluate anonymized claims data of medical insurance beneficiaries employed by middle- to large-size Japanese companies who were prescribed NSAIDs for OA and/or CLBP between 2009 and 2018.

RESULTS

Overall, 180,371 patients were included in the analysis, of whom 32.9% had OA, 53.8% had CLBP, and 13.4% had both OA and CLBP. NSAIDs were administered as first-line analgesics to 161,152 (89.3%) of the patients in the sample, in oral form to 90.3% and as topical patches to 80.4%. A total of 65.1% used combined oral/topical patches. Of the 21.0% of patients consistently using NSAIDs (percentage of days supplied ≥70%), 54.5% received patches. A total of 51.5% patients used NSAIDs for >1 to ≤6 months. The incidence of GI events was 9.97 per 10,000 person-years (95% confidence interval: 8.92-11.03). The risk of developing GI events was high in elderly patients and patients with comorbidities and remained similar for patients receiving oral vs. topical NSAIDs. Longer treatment duration and consistent NSAID use increased the risk of GI events. The cost (median [interquartile range]) of medications (n = 327) was US$ 80.70 ($14.10, $201.40), that of hospitalization (n = 33) was US$ 2,035.50 ($1,517.80, $2,431.90), and that of endoscopic surgery (n = 52) was US$ 418.20 ($418.20, $418.20).

CONCLUSION

NSAID-associated GI toxicity imposes a significant health and economic burden on patients with OA and/or CLBP, irrespective of whether oral or topical NSAIDs are used.

Burden of Renal Events Associated with Nonsteroidal Anti-inflammatory Drugs in Patients with Osteoarthritis and Chronic Low Back Pain: A Retrospective Database Study

INTRODUCTION

Nonsteroidal anti-inflammatory drugs (NSAIDs) have long-term benefits but are limited by side effects. We assessed the health and economic burden of renal events associated with NSAID use in patients with osteoarthritis (OA) and/or chronic low back pain (CLBP).

METHODS

This retrospective, large-scale, medical claims database study of Japanese patients receiving NSAIDs for OA and/or CLBP between 2009 and 2018 assessed the incidence of renal events and effect of treatment duration, mode of administration, and usage consistency of NSAIDs.

RESULTS

Of 180,371 patients, NSAIDs were prescribed as first-line analgesics in 89.3%. Incidence per 10,000 person-years (95% confidence interval [CI]) for renal events was 23.46 (21.84-25.08) and for progression of chronic kidney disease (CKD) was 267.12 (189.93-344.32). Longer treatment duration (> 1 to  ≤ 3 years, risk ratio [RR] 1.32, 95% CI 1.12-1.54; P = 0.0007; > 3 to  ≤ 5 years, RR: 1.38, 95% CI 1.04-1.84; P = 0.0254 vs. < 1 year) and consistent use (RR: 1.24, 95% CI 0.99-1.55; P = 0.0595) increased the risk of renal events but the latter did not reach statistical significance. The risk was similar in patients using patch/oral NSAIDs and high in elderly patients and in those with diabetes, hypertension, and other cardiovascular disease. Following a renal event, median 1-year cost of drug treatment was $27.90; hospitalization, $1779.40; and dialysis, $33,018.40.

CONCLUSIONS

Risk of renal events significantly increased with prolonged and consistent NSAID use (irrespective of mode of administration), with age, and in patients with certain comorbidities. Careful NSAID use is recommended in patients with CKD and those at high risk for CKD.

POS0128 PHYSICIAN AND PATIENT PERCEPTIONS OF SURGICAL PROCEDURES FOR KNEE OA ACROSS JAPAN, THE US AND 5 EU COUNTRIES: RESULTS OF A REAL-WORLD STUDY

Background:

Patients with knee osteoarthritis (OA) who do not achieve adequate pain relief and functional improvement with a combination of non-pharmacologic and pharmacologic therapies are recommended an arthroplasty as an effective option to relieve severe pain and functional limitations. However, some patients are reluctant to undergo surgical interventions, and clinicians may choose to avoid or delay surgery due to safety risks and/or the financial cost. It is of interest to understand if the use and perception of surgery differs between countries, however, few published data exist.

Objectives:

To demonstrate how surgery and the use of surgical procedures differs across Japan, United States of America (US) and 5 major European countries (EU5) and to evaluate patient perception towards surgery.

Methods:

Data were drawn from the Adelphi OA Disease Specific Programme (2017-18), a point-in-time survey of primary care physicians (PCP), rheumatologists (rheums), orthopaedic surgeons (orthos) and their OA patients. Patients with physician-diagnosed knee OA were included and segmented into two categories: had previous surgery (PS) and never had surgery (NS). A Fisher’s exact test was performed on the two groups. Physicians reported on patient demographics; whether patients had undergone surgery; type of surgery; success of surgery; how success was defined; and reasons for wanting to delay surgery. Patients reported their willingness to undergo surgery; reasons for not wanting surgery; how successful their surgery was; and how they defined this success.

Results:

Physician/patient reported data were available for 302,230 (Japan), 527,283 (US) and 1487,726 (EU5) patients with diagnosed knee OA. Patients were categorised by their physicians as mild (40% Japan; 34% US; 24% EU5), moderate (49% Japan; 49% US; 56% EU5) or severe (9% Japan; 17% US; 19% EU5). Patients in Japan were more likely to be female (78% vs 54% US; 58% EU5), older (73 vs 65 US; 66 EU5) and have a lower BMI than patients in the US and EU5. Obesity and diabetes were much less prevalent among patients in Japan. One in ten patients in Japan had undergone a surgery (10%), far fewer than in the US (22%) or EU5 (17%). When surgery was performed, this was more likely to be a total joint replacement (TJR) in Japan, whereas in the EU and US, arthroscopic washout was more commonly performed.

For over half of Japanese patients (56%), successful surgery was more likely to be defined as having no more pain (vs. 35% US; 14% EU5). Improved mobility and a reduction in pain were also commonly reported reasons. Physicians (in each region) were more likely to suggest pain reduction, rather than no pain, and improved mobility as markers of success. Patients in Japan were much more likely to say they would not agree to surgery if recommended by their doctor, or were unsure (84% vs. 68% US; 62% EU5). The main reason for patient reluctance in Japan was fear of surgery, whereas in the US and EU5 the main reason given was that surgery was not needed. This finding was also evident among physicians in Japan, who frequently reported that patient reluctance was a key reason for delaying surgery. Physicians in Japan, do however, report that patient request was one of their main triggers for recommending surgery (45% vs 20% US; 16% EU5).

Conclusion:

Although surgery can be an effective option for those with OA who have exhausted other treatment options, some patients are reluctant to undergo surgery out of fear, especially in Japan, possibly due to the higher patient age. Physicians aiming to delay surgery were driven by patient reluctance in Japan, whereas cost to patient was a bigger factor in the US and EU5. The higher level of TJR vs. other surgery options among patients in Japan may suggest physicians are looking for higher levels of efficacy.

Disclosure of Interests:

Naoshi Fukui Speakers bureau: Pfizer, Consultant of: Pfizer, Philip G Conaghan Speakers bureau: Abbvie, Novartis, Consultant of: AstraZeneca, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer, Kanae Togo Shareholder of: Pfizer, Employee of: Pfizer, Nozomi Ebata Shareholder of: Pfizer, Employee of: Pfizer, Lucy Abraham Shareholder of: Pfizer, Employee of: Pfizer, James Jackson: None declared, Jessica Jackson: None declared, Mia Berry: None declared, Hemant Pandit Paid instructor for: Bristol Myers Squibb, Consultant of: Johnson and Johnson, Grant/research support from: GSK

A Cost-Effectiveness Analysis Of Pregabalin For The Treatment Of Patients With Chronic Cervical Pain With A Neuropathic Component In Japan

Purpose

To evaluate the cost-effectiveness of pregabalin versus other analgesics among patients with chronic cervical pain with neuropathic components during routine clinical practice in Japan.

Patients and methods

The analysis considered patients with chronic cervical pain with a neuropathic pain component (radiating pain to the upper limb) and who were treated with pregabalin with or without other analgesics (pregabalin-containing treatments) or other analgesics alone (usual care) for 8 weeks. Other analgesics included non-steroidal anti-inflammatory drugs (NSAIDs), weak opioids, antidepressants, and antiepileptic drugs. A Markov cohort simulation model was constructed to estimate costs and effectiveness (in terms of quality-adjusted life-years, QALYs) of each treatment over a 12-month time horizon. In the model, patients transitioned among three states of pain severity (no/mild, moderate, and severe). Data were derived from a previous observational study (pregabalin-containing treatments, n = 138; usual care, n = 211). Cost inputs included medical costs and productivity losses. QALYs were calculated using the EuroQol five-dimensional, five-level questionnaire. The cost-effectiveness was evaluated using incremental cost-effectiveness ratios (ICERs). Sensitivity analyses were conducted to assess the robustness of results.

Results

From the payer's perspective, pregabalin-containing treatments were more costly (JPY 61,779 versus JPY 26,428) but also more effective (0.763 QALYs versus 0.727 QALYs) than the usual care, with an ICER of JPY 970,314 per QALY gained. From the societal perspective, which also included productivity losses, the ICER reduced to JPY 458,307 per QALY gained. One-way sensitivity analyses demonstrated the robustness of the results. Given a hypothetical threshold value of one additional QALY of JPY 5,000,000, the probability of pregabalin-containing treatments being cost-effective was 100%.

Conclusion

Compared with using other analgesics alone, the use of pregabalin, alone or in addition to other analgesics, was cost-effective for the treatment of chronic cervical pain with a neuropathic pain component in Japan.

Patterns of drug treatment in patients with osteoarthritis and chronic low back pain in Japan: a retrospective database study

Purpose: Musculoskeletal diseases, including osteoarthritis (OA) and low back pain (LBP), are the leading causes of years lived with disability, and are associated with lowered quality-of-life, lost productivity, and increased healthcare costs. However, information publicly available regarding the Japanese real-world usage of prescription medications is limited. This study aimed to describe the clinical characteristics of patients with OA and chronic LBP (CLBP), and to investigate the patterns of medications and opioid use in Japanese real-world settings.

Materials and methods: A retrospective study was conducted using a Japanese administrative claims database between 2013 and 2017. The outcomes were patient characteristics and prescription medications, and they were evaluated separately for OA and CLBP.

Results: The mean age of 118,996 patients with OA and 256,402 patients with CLBP was 68.8±13.1 years and 64.8±16.4 years, respectively. Approximately 90% of patients with OA and CLBP were prescribed non-steroidal anti-inflammatory drugs (NSAIDs). Other prescriptions included hyaluronate injection (35.6%), acetaminophen (21.4%), and steroid injection (20.0%) in patients with OA, and pregabalin (39.0%) and acetaminophen (22.4%) in patients with CLBP. Weak opioids were prescribed to 10.7% and 20.6% of patients with OA and CLBP, respectively. The prescription of COX-2 inhibitors (OA: +6.5%; CLBP: +6.7%) and acetaminophen (OA: +16.4%; CLBP: +14.4%) increased between 2013 and 2017. The first commonly prescribed medication among patients with OA and CLBP were NSAIDs; hyaluronate injection (patients with OA) and pregabalin (patients with CLBP) were also common first-line medications. Acetaminophen, steroid injection (patients with OA), and weak opioids were prescribed more in the later phases of treatment.

Conclusion: Most patients were prescribed limited classes of pain drugs, with NSAIDs being the most common pain medication in Japan for patients with OA and CLBP. Opioid prescription was uncommon, and were weak opioids when prescribed.

Effectiveness of pregabalin for treatment of chronic cervical radiculopathy with upper limb radiating pain: an 8-week, multicenter prospective observational study in Japanese primary care settings

Background: Despite high prevalence of chronic neck pain in Japan and the negative impact pain has on patient’s quality of life (QoL), the therapeutic value of pregabalin for chronic neck pain with a neuropathic pain (NeP) component has not been assessed in a typical Japanese health care setting.

Methods: An 8-week, non-interventional, multicenter, observational study of Japanese adults (≥20 years) with chronic refractory cervical pain including a NeP element (for ≥12 weeks) and sleep disturbance on the Pain-Related Sleep-Interference Scale (PRSIS) ≥1 (from 0 “does not interfere with sleep” to 10 “completely interferes”). Patients received either usual care with conventional analgesics or pregabalin (150–600 mg/day) for 8 weeks. “Usual care” with analgesics or other treatment(s) was determined based on physician’s best clinical judgment. Primary endpoint was change from baseline to week 8 in PRSIS. Secondary endpoints included: change from baseline to week 4 in PRSIS, and to week 4 and 8 in pain Numerical Rating Scale (NRS; from 0 “no pain” to 10 “worst possible pain”), and on the Neck Disability Index (NDI). Other assessments of QoL were undertaken. Safety was monitored.

Results: Overall, 369 patients received pregabalin (n=145) or usual care (n=224). The median (range) dose of pregabalin was 49.6 (25.0–251.5) mg/day. Least-squares mean change in PRSIS from baseline to week 8 favored pregabalin (–1.167 vs –0.269; treatment difference –0.898 [95% CI –1.262, –0.535], P<0.001). Similar observations were seen at week 4 in favor of pregabalin versus usual care (P<0.001). Pregabalin significantly improved pain NRS and NDI scores at weeks 4 and 8 (all P<0.001). Improvements in QoL versus usual care were also observed. Pregabalin was generally well tolerated.

Conclusion: In this open-label study, pregabalin improved PRSIS and resulted in clinically meaningful reductions in pain in Japanese patients with NeP associated with chronic cervical pain.

ClinicalTrials.gov identifier: NCT02868359.

Humanistic and economic burden of fibromyalgia in Japan

Purpose

The aim of this study was to examine the health and economic burden associated with fibromyalgia among adults in Japan.

Materials and methods

Data from the 2011–2014 Japan National Health and Wellness Survey (n=115,271), a nationally representative survey of adults, were analyzed. The greedy matching algorithm was used to match the respondents who self-reported a diagnosis of fibromyalgia with those not having fibromyalgia (n=256). Generalized linear models, controlling for covariates (eg, age and sex), examined whether the respondents with fibromyalgia differed from matched controls based on health status (health utilities; Mental and Physical Component Summary scores from Medical Outcomes Study: 12-item Version 2 and 36-item Version 2 Short Form Survey), sleep quality (ie, sleep difficulty symptoms), work productivity (Work Productivity and Activity Impairment Questionnaire – General Health Version 2.0), health care resource use, and estimated annual indirect and direct costs (based on published annual wages and resource use events) in Japanese yen (¥).

Results

After adjustment for covariates, respondents with fibromyalgia relative to matched controls scored significantly lower on health utilities (adjusted means =0.547 vs 0.732), Mental Component Summary score (33.15 vs 45.88), and Physical Component Summary score (39.22 vs 50.81), all with P<0.001; these differences exceeded the clinically meaningful levels. In addition, those with fibromyalgia reported significantly poorer sleep quality than those without fibromyalgia. Respondents with fibromyalgia compared with those without fibromyalgia experienced significantly more loss in work productivity and health care resource use, resulting in those with fibromyalgia incurring indirect costs that were more than twice as high (adjusted means =¥2,826,395 vs ¥1,201,547) and direct costs that were nearly six times as high (¥1,941,118 vs ¥335,140), both with P<0.001.

Conclusion

Japanese adults with fibromyalgia experienced significantly poorer health-related quality of life and greater loss in work productivity and health care use than those without fibromyalgia, resulting in significantly higher costs. Improving the rates of diagnosis and treatment for this chronic pain condition may be helpful in addressing this considerable humanistic and economic burden.

Cost-effectiveness analysis of pregabalin for treatment of chronic low back pain in patients with accompanying lower limb pain (neuropathic component) in Japan

OBJECTIVE

To assess the cost-effectiveness of pregabalin for the treatment of chronic low back pain with accompanying neuropathic pain (CLBP-NeP) from the health care payer and societal perspectives.

METHODS

The cost-effectiveness of pregabalin versus usual care for treatment of CLBP-NeP was evaluated over a 12-month time horizon using the incremental cost-effectiveness ratio (ICER). Quality-adjusted life years (QALYs), derived from the five-dimension, five-level EuroQol (EQ-5D-5L) questionnaire, was the measure of effectiveness. Medical costs and productivity losses were both calculated. Expected costs and outcomes were estimated via cohort simulation using a state-transition model, which mimics pain state transitions among mild, moderate, and severe pain. Distributions of pain severity were obtained from an 8-week noninterventional study. Health care resource consumption for estimation of direct medical costs for pain severity levels was derived from a physician survey. The ICER per additional QALY gained was calculated and sensitivity analyses were performed to evaluate the robustness of the assumptions across a range of values.

RESULTS

Direct medical costs and hospitalization costs were both lower in the pregabalin arm compared with usual care. The estimated ICERs in the base case scenarios were approximately ¥2,025,000 and ¥1,435,000 per QALY gained with pregabalin from the payer and societal perspectives, respectively; the latter included indirect costs related to lost productivity. Sensitivity analyses using alternate values for postsurgical pain scores (0 and 5), initial pain severity levels (either all moderate or all severe), and the actual EQ-5D-5L scores from the noninterventional study showed robustness of results, with ICERs that were similar to the base case. Development of a cost-effectiveness acceptability curve showed high probability (≥75%) of pregabalin being cost-effective.

CONCLUSION

Using data and assumptions from routine clinical practice, pregabalin is cost-effective for the treatment of CLBP-NeP in Japan.

Effectiveness of pregabalin for the treatment of chronic low back pain with accompanying lower limb pain (neuropathic component): a non-interventional study in Japan

Objective

To evaluate the impact of pregabalin on sleep, pain, function, and health status in patients with chronic low back pain with accompanying neuropathic pain (CLBP-NeP) under routine clinical practice.

Methods

This prospective, non-interventional, observational study enrolled Japanese adults (≥18 years) with CLBP-NeP of duration ≥3 months and severity ≥5 on a numerical rating scale (0= no pain, 10= worst possible pain). Treatment was 8 weeks with pregabalin (n=157) or usual care alone (n=174); choice of treatment was determined by the physician. The primary efficacy outcome was change from baseline to 8 weeks in pain-related interference with sleep, assessed using the Pain-Related Sleep Interference Scale (PRSIS; 0= did not interfere with sleep, 10= completely interferes with sleep). Secondary endpoints were changes in PRSIS at week 4, and changes at weeks 4 and 8 in pain (numerical rating scale), function (Roland-Morris Disability Questionnaire), and quality of life (EuroQol 5D-5L); global assessments of change were evaluated from the clinician and patient perspectives at the final visit.

Results

Demographic characteristics were similar between cohorts, but clinical characteristics suggested greater disease severity in the pregabalin group including a higher mean (standard deviation) pain score, 6.3 (1.2) versus 5.8 (1.1) (P<0.001). For the primary endpoint, pregabalin resulted in significantly greater improvements in PRSIS at week 8, least-squares mean changes of −1.3 versus −0.4 for usual care (P<0.001); pregabalin also resulted in greater PRSIS improvement at week 4 (P=0.012). Relative to usual care at week 8, pregabalin improved pain and function (both P<0.001), and showed global improvements since beginning study medication (P<0.001). Pregabalin was well tolerated.

Conclusion

In clinical practice in patients with CLBP-NeP, pregabalin showed significantly greater improvements in pain-related interference with sleep relative to usual care. In addition, pregabalin significantly improved pain, function, and health status, suggesting the benefits of pregabalin for overall health and well-being relative to usual care in these patients. (Clinicaltrials. gov identifier NCT02273908).

The association between lower back pain and health status, work productivity, and health care resource use in Japan

Introduction

This study investigated the effect of pain severity on health status, work productivity, health care resource use, and costs among respondents with lower back pain (LBP), in Japan.

Materials and methods

Data from the 2013 Japan National Health and Wellness Survey, a survey of Japanese adults, were analyzed (N=30,000). All respondents provided informed consent, and the protocol was institutional review board-approved. Respondents who reported experiencing LBP were propensity score–matched to those without LBP, based on demographics and health history. Using regression modeling, patients with mild, moderate, and severe pain were compared against matched controls, with respect to health status (Mental and Physical Component Summary scores, and health utilities from the Short Form^®-36 Health Survey version 2), work productivity (Work Productivity and Activity Impairment – General Health version), health care resource use, and annual per-patient costs (estimated using published annual wages and resource use event costs).

Results

A total 1,897 patients reported experiencing LBP in the past month (6.32%); 52.45% reported their pain as mild, 32.79% as moderate, and 14.76% as severe. Increasing pain severity was associated with significantly lower levels of mental component scores (46.99 [mild], 42.93 [moderate], and 40.58 [severe] vs 48.10 [matched controls]), physical component scores (50.29 [mild], 46.74 [moderate], and 43.94 [severe] vs 52.93 [matched controls]), and health utilities (0.72 [mild], 0.66 [moderate], and 0.62 [severe] vs 0.76 [matched controls]) (all P<0.05). Indirect costs were significantly higher (P<0.05) among those with moderate (¥1.69 million [MM] [equivalent to $17,000, based on United States dollar exchange rates on September 1, 2014]) and severe (¥1.88 MM [$19,000]) pain, relative to matched controls (¥0.95 MM [$9,500]). Direct costs were only marginally different (P=0.05) between those with severe pain and matched controls (¥1.33 MM [$13,000] vs ¥0.54 MM [$5,000]).

Conclusion

Increasing pain severity among respondents with LBP was associated with significantly worse health status, to a clinically-relevant degree, along with greater indirect and direct costs, in Japan.

Production of colony-stimulating factor in human dental pulp fibroblasts

Class II major histocompatilibity complex (MHC)-expressing cells are usually distributed in dental pulp, and it was postulated that the colony-stimulating factor (CSF) derived from dental pulp fibroblasts contributes to the migration of class II MHC-expressing cells into pulp tissue. This study aimed to investigate the CSF production of human dental pulp fibroblasts. In pulp tissue sections, granulocyte (G)-CSF was detected from normal teeth, while G-CSF, macrophage (M)-CSF, and granulocyte-macrophage (GM)-CSF were detected from teeth with dentinal caries. In cultured dental pulp fibroblasts, G-CSF was detected by immunostaining, immunoprecipitation, and ELISA, and mRNAs of G-CSF, M-CSF, and GM-CSF were detected by RT-PCR. The dental pulp fibroblasts cultured with TNF-alpha were found to increase the G-CSF expression and to produce M-CSF and GM-CSF. These findings suggest that dental pulp fibroblasts usually produce G-CSF. In the presence of TNF-alpha, dental pulp fibroblast express M-CSF and GM-CSF.

Immunoelectron microscopic study of PECAM-1 expression on lymphatic endothelium of the human tongue

The expression of platelet-endothelial cell adhesion molecule-1 (PECAM-1) on lymphatic and blood vessels of the human tongue was examined with fluorescence and transmission electron microscopy (TEM). The study used anti-desmoplakins antiserum for light microscopic identification of the lymphatic vessels, plus a pre-embedding immunogold electron microscopic technique for TEM observations. Before making TEM observations, cryostat serial sections were immunostained with anti-desmoplakins or anti-PECAM-1 and then embedded. Semithin sections from each cryostat section were photographed under a light microscope and compared in order to identify the lymphatic vessels expressing PECAM-1. In fluorescence microscopy, PECAM-1 expression on lymphatic vessels was weaker than that on blood vessels. TEM observations showed that PECAM-1 expression on the blood vessels was observed only on the luminal surface of the endothelium. In lymphatic vessels, PECAM-1 expression was found both on the luminal and abluminal surfaces of the endothelium. The density of the PECAM-1 reaction products was lower in lymphatic vessels than in blood vessels. The density of PECAM-1 reaction products on the luminal surface of lymphatic vessels was higher than on the abluminal surfaces. The results suggest that blood vessels are more active than lymphatic vessels in leukocyte migration. The expression of PECAM-1 on the abluminal surface of lymphatic endothelium may allow leukocytes to adhere to the endothelium and interact in their migration from tissue into lymphatic vessels.

Desmoplakin as a specific marker of lymphatic vessels

The usefulness of immunostaining with anti-desmoplakin antibody for light microscopic identification of lymphatic vessels was examined in cryostat sections of the human tongue. The results were compared with laminin, 5'-nucleotidase (5'-Nase), and factor VIII staining. Immunoelectron microscopic observation was also performed to confirm that the vessels reacting with anti-desmoplakin were lymphatic vessels. Under the immunoelectron microscopic, the vessels reacting with anti-desmoplakin showed ultrastructural features characteristic of lymphatic vessels: thin endothelial walls, no or incomplete basal lamina, open junctions, and overlapping endothelium. In general, lymphatic vessels identified by anti-desmoplakin reacted strongly with 5'-Nase, but showed weak or no reactivity with anti-laminin and anti-factor VIII. Blood vessels showed no reactivity with anti-desmoplakin, but reacted strongly with anti-laminin and anti-factor VIII. However, some blood and lymphatic vessels showed intermediate reactivity with anti-laminin, anti-factor VIII, and 5'-Nase. It was difficult to identify these as blood or lymphatic vessels only by the reactivity differences. The results indicate that anti-desmoplakin antibody specifically distinguishes lymphatic vessels and is useful for studying the fine distribution of lymphatic vessels under light microscopy.

Double expressions of connexin 43 and 32 in human periodontal ligament fibroblasts

The expressions of connexin 43 and 32 in cultured and intact human periodontal ligament fibroblasts (PDLFs) were examined using immunohistochemical methods, and western blot analysis was conducted with anti-connexin 43 and 32 in cultured PDLFs. The PDLFs both in cultured cells and tissue sections reacted with anti-connexin 43 and 32, and western blot analysis showed bands of approximately 43 kD and 27 kD reacted with anti-connexin 43 and 32 respectively, suggesting the existence of gap junctions in human PDLFs. In cultured PDLFs there were no reaction products of connexin 43 when the cells were not in contact with adjacent cells, but reaction products were increasingly observed with increases in cell-cell contacts. Different from connexin 43, the reaction products of connexin 32 were found in the cytoplasm, regardless of whether the cells were or were not in contact with adjacent cells. Further, the reaction activity of connexin 32 varied among PDLFs; some were strong, some moderate, and some weak. The expressions of connexin 43 and 32 in human PDLFs are suggested to be related to the regulation of two different functions of the PDLFs.

Desmosomal proteins in cultured and intact human periodontal ligament fibroblasts

This study examined the kinds of desmosomal proteins in the human periodontal ligament fibroblasts (PDLFs). The PDLFs obtained from young and older patients were cultured and the amounts of desmosomal proteins were measured by ELISA with antibodies to desmoplakins, desmogleins, and desmocollins. Cultured cells and tissue sections of the human periodontal ligament were immunostained with the same antibodies. Expression of desmosomal proteins in the PDLFs was clearly demonstrated both by ELISA and the immunohistochemical studies, suggesting the existence of desmosome-like junctions in the PDLFs. The junctions are considered to protect gap junctions in the PDLFs against cell transformation caused by cell contraction, which may relate to tooth eruption and repair of periodontal tissue, and/or strong occlusal forces. Statistically significant differences (P < 0.0001) in the expression of desmoplakins and desmogleins between younger and older patients were observed in this study.

Immunohistochemical study on leukocyte adhesion molecules expressed on lymphatic endothelium

Leukocyte adhesion molecules expressed on the lymphatic endothelium in human small intestine and submandibular lymph node were studied immunohistochemically. Lymphatic capillaries in the lamina propria, mucosal muscle layer, and submucosal connective tissue of the intestine and in the capsule of the lymph node showed strong expression of platelet-endothelial cell adhesion molecule-1 (PECAM-1). A few lymphatic capillaries that weakly expressed intercellular adhesion molecule-1 (ICAM-1) were found in the capsule of the lymph node but in the small intestine, no lymphatic capillaries expressed detectable amounts of ICAM-1. Lymphatic capillaries also did not express detectable amounts of endothelial cell-selectin in the small intestine and lymph node. When lymphocytes migrate from tissue into lymphatic capillaries, multiple adhesion molecules may not be required for the migration. PECAM-1, however, may contribute to adherence of lymphocytes to lymphatic endothelium and the expression of adhesion molecules on lymphatic endothelium may be different between tissues.

Lymphatic endothelium of the human tongue expresses multiple leukocyte adhesion molecules

The expression of leukocyte adhesion molecules on lymphatic vessels of the human tongue was examined using histochemical and immunohistochemical methods. Three different types of lymphatic vessels were distinguished: type I vessels expressed intercellular adhesion molecule-1 (ICAM-1), platelet-endothelial cell adhesion molecule-1 (PECAM-1), and endothelial cell-selectin (ELAM-1); type II vessels expressed ICAM-1 and PECAM-1; and type III vessels expressed PECAM-1 only. The lymphatic vessels located very close to the oral epithelium (lymphatic capillaries) and the other lymphatic vessels near the oral epithelium were type I. The lymphatic vessels in the submucosal connective tissue (collecting lymphatic vessels) were type II and type III. The results suggest that there may be functional differences in the lymphatic endothelium, where lymphatic capillaries are more active than collecting lymphatic vessels in lymphocyte migration from tissue into the lymphatic vessels.

Saponins from the root of Bupleurum falcatum

Three new saponins and nine known saponins were isolated from the dried roots of Bupleurum falcatum. On the basis of chemical and spectral analyses, the structures of new compounds, named 4''-O-acetylsaikosaponin d and hydroxysaikosaponins a and c, were established. In aqueous acidic conditions, saikosaponins a and d were converted into not only known compounds, saikosaponins b1 and b2, but also hydroxysaikosaponins a and d, respectively. Furthermore, quantitative analysis of the decoction of Bupleuri Radix itself by HPLC exhibited that it contained saikosaponins a, c and d, and hydroxysaikosaponins a, c and d.

Quantitation of apolipoprotein A-I in pooled human serum by single radial immunodiffusion and sodium dodecyl sulfate-polyacrylamide gel electrophoresis

Apolipoprotein A-I was released from human HDL particles by treatment with 8 M urea, and the free apolipoprotein exhibited identical antigenicity and the same low mobility as purified apolipoprotein A-I in electrophoresis. Treatment of serum with 8 M urea enabled enabled quantitation of apolipoprotein A-I by single radial immunodiffusion assay, as judged by comparison with sodium dodecyl sulfate-polyacrylamide gel electrophoresis.

Silver stain for detecting 10-femtogram quantities of protein after polyacrylamide gel electrophoresis

A rapid and highly sensitive silver stain and color stain were developed for visualizing proteins. The procedure is simple and the bands were clear. This silver stain detects 100 pg quantities of proteins. In order to stain quickly, sensitively, and sharply a protein matrix in a gel, the repeated shrinkage and swelling gel was developed with a hyper- and hypotonic solution to remove the sodium dodecyl sulfate (SDS) from SDS-protein complex and to generate influx of staining solution into the gel. We have found that the silver staining method with the repeated exposure to hyper- and hypotonic solution and a narrow well produced 10 fg order of proteins.

Occurrence of four subunits in high molecular weight forms of polypeptide chain elongation factor 1 from wheat embryo

In contrast to high molecular weight forms of elongation factor 1 (EF-1H) from animal sources which contain three subunits, EF-1a, EF-1b, and EF-1c, EF-1H from wheat embryo consisted of four subunits, EF-1a, EF-1b, EF-1b', and EF-1c, in an equimolar ratio. The molecular weights of EF-1a, EF-1b, EF-1b', and EF-1c from wheat embryo were 52,000, 29,000, 28,000, and 48,000, respectively. In the animal system, EF-1a and EF-1b correspond functionally to EF-Tu and EF-Ts, respectively. In the wheat system, however, both EF-1b and EF-1b' had the EF-Ts-like activity to stimulate EF-1a-dependent binding of aminoacyl-tRNA to ribosomes. EF-1b and EF-1b' from wheat embryo gave 21 and 20 tryptic peptides, respectively. Twenty peptides were common.

Generation of spontaneous respiratory rhythm in high spinal cats

Spontaneous respiratory neuronal activities within cervical spinal cord were investigated in two groups of 36 adult cats: cervical spinalized and non-spinalized preparations. In the first group of 18 animals, spontaneous breathing was abolished after total spinal transection at C1. However, spontaneous rhythmic breathing reappeared within 2 h after transection in 13 animals. In the other 6 animals spinalized at C3 level, we could not induce spontaneous breathing. The spinal respiratory movements were found to be mainly due to rhythmic diaphragmatic contraction. Such spinal respiratory activity continued for 30 min-1 h with a steady rate of 19-24/min and then they steadily deteriorated. Spinal respiratory activity developed usually without hindlimb muscle activity and even when hindlimb stepping rhythm was seen simultaneously, it was not locked to respiratory rhythmicity. During spinal respiration, phrenic motoneuron discharges were recorded from the C5-C6 ventral horn. The burst discharges containing 4.8-40.0 spikes were all in synchrony with the inspiratory phase of respiratory cycles. Even after breathing movements were temporarily paralyzed by gallamine, the rhythmic bursts still persisted for an appreciable time. In the second group of 12 lightly anesthetized cats, microelectrode explorations of the upper cervical cord were made in an attempt to record neuronal activities associated with respiratory movements. A total of 24 burst discharges of inspiratory type units which represent presumed cell body activities was recorded. The recording sites were histologically located in the intermediate zone of the spinal gray matter of C1-C2 cervical cord. These results suggested the possible existence of some intrinsic respiratory rhythm generators within the cervical cord. Possible neuronal mechanisms for generation of spontaneous respiratory rhythm were discussed.