Dapagliflozin cost-effectiveness analysis in heart failure patients in Egypt

AIMS

In Egypt, cardiovascular (CV) diseases are not only the cause of 33% of disability-adjusted life years but are also a leading cause of death. This study aimed to evaluate dapagliflozin's cost-effectiveness as an add-on to the standard of care (SOC) for the treatment of heart failure with reduced ejection fraction (HF-rEF) from the Egyptian healthcare system perspective.

MATERIALS AND METHODS

A state transition model was utilized to assess the cost-effectiveness of dapagliflozin as an add-on to the SOC and a cost-minimization analysis was performed to compare dapagliflozin to sacubitril/valsartan, as they have had similar efficacy. Patients were stratified into four health states using the KCCQ-TSS, in addition to a CV and non-CV mortality health states. Urgent heart failure (HF) visits and hospitalizations were captured as transient states. Clinical parameters and baseline characteristics were based on the DAPA-HF trial, utility scores were extracted from published articles, and costs were derived from the Universal Health Insurance Authority national database. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

The treatment costs of HF-rEF patients receiving dapagliflozin compared to SOC are 47,901EGP ($10,550) and 34,377EGP ($7,572), respectively. The quality-adjusted life-years (QALYs) of dapagliflozin compared to SOC are 4.57 and 4.20, respectively. This resulted in an incremental cost per effectiveness ratio (ICER) of 36,449EGP ($8,028) per QALY gained over the lifetime horizon, suggesting this is cost-effective. Results of the cost-minimization analysis showed cost savings where the annual costs of dapagliflozin vs. sacubitril/valsartan are 10,914EGP ($2,404) and 32,242EGP ($7,101), respectively.

CONCLUSION

Dapagliflozin was found to be a highly cost-effective and cost-saving medication when compared to SOC and sacubitril/valsartan, respectively, in the treatment of HF-rEF from Egyptian healthcare system perspective. The ICER was below the willingness-to-pay threshold because dapagliflozin improved outcomes (less frequent hospitalization and mortality).

Prognostic relevance of circulating matrix metalloproteinase-2 in acute myeloid leukaemia patients

Matrix metalloproteinases (MMPs) were postulated to have important implication in progression and invasiveness of many malignant disorders. On the other hand the biological role of MMP-2 in acute myeloid leukaemia (AML) is not fully clear. Serum samples from 37 adult patients with AML had been taken before chemotherapy was administered. In addition 20 out of the 37 patients were analysed again after achieving complete remission (CR). Ten samples from healthy volunteers were evaluated as the control. Total MMP-2 levels were measured using ELISA Kit obtained from R&D system. MMP-2 serum levels were significantly lower in pretreatment AML patients than that in the normal controls (p = 0.000) and in CR (p = 0.007). No significant correlations were detected between pretreatment sMMP-2 levels and FAB subtypes, peripheral blood blast cell counts, peripheral blood WBCs, bone marrow blast cell counts or blast cell distribution ratio. The prognostic value of MMP-2 was evaluated by dividing AML patients into high and low MMP-2 groups using the pretreatment median MMP-2 level of the AML group as the cut-off. The authors found that patients in the high group survived for a significantly shorter time than those patients in the lower MMP-2 group. High pretreatment levels of sMMP-2 among AML patients were associated with poor survival. Prospective studies are recommended to establish the clinical value of longitudinal sMMP-2 measurement.

A double blind comparative study of lisinopril and enalapril in patients with essential hypertension

The efficacy and safety profiles of lisinopril (10-40 mg) and enalapril (5-20 mg) were compared in 169 hypertensive patients during 12 weeks' treatment in a randomised double-blind parallel group study. BP was measured hourly for the first 8 hours following the first dose of lisinopril 10 mg and enalapril 5 mg. The peak reduction in sitting systolic and diastolic BP occurred approximately 6 hours post dose in both groups. At 8 hours post dose lisinopril had reduced sitting systolic and diastolic BP by 2.9 mmHg and 3.5 mmHg (P = 0.02) respectively, more than enalapril with similar results for standing BP. One patient on enalapril developed first dose postural hypotension. After 12 weeks' therapy lisinopril produced a greater decrease (P less than 0.05) in BP than enalapril. Sitting BP decreased by 25/15 mmHg on lisinopril and 17/12 mmHg with enalapril. Standing BP decreased by 24/14 mmHg compared with 16/10 mmHg on enalapril. Eighteen patients did not complete the study, 8 on lisinopril (6 adverse events, 1 uncontrolled BP, 1 protocol violator) and 10 on enalapril (8 adverse events, 1 uncontrolled BP, 1 protocol violator). Overall, the results indicated that while both drugs are well tolerated, the dose range of lisinopril 10-40 mg may produce a greater antihypertensive effect than enalapril 5-20 mg.

A dose finding study of the combination of atenolol and nifedipine in hypertension

A randomized, double-blind, crossover study was carried out to compare the antihypertensive efficacy and tolerability of two doses of a fixed combination of 50 mg atenolol and 20 mg nifedipine slow release (1 capsule or 2 capsules once daily) in 16 hypertensive patients, treated for 4 weeks with each dose. The results suggest that the combination exerted a greater antihypertensive effect at 3 hours compared with 24 to 28-hours post-dose. Demonstrable differences in resting blood pressure between the low and high dose of the combination occurred at the 3-hour but not at the 24 to 28-hour post-dose time point. This apparent difference was also evident under exercise conditions, although no significance between dose differences were demonstrable at either time point. Thus, it appears that any additional benefit in efficacy obtained with the higher dose is not sustained over a 24-hours period. Side-effects were relatively uncommon with the combination, occurring least commonly with the lower dose.

[Efficacy and acceptability of rilmenidine in mild to moderate arterial hypertension. A multicenter, randomized, double-blind trial, in comparison with methyldopa in 157 patients]

A dissociation between the hypotensive activity and the central side effects has been demonstrated with rilmenidine (RIL) in previous studies. The object of this trial was to compare RIL with methyldopa (MD) during a 12 weeks' treatment (Day 0 to Day 84) and after stopping therapy (Day 84-Day 91). In particular, the trial was designed to evaluate the acceptability of the two agents. After 4 weeks of placebo, 76 men and 81 women (average age 55 years) were allocated according to a randomised double-blind protocol to RIL (N = 78) or MD (N = 79). The two groups were comparable with systolic/diastolic BP of 165/102 mmHg and 165/101 mmHg respectively. Monotherapy was administered to all the patients from Day 0 to Day 56 in order to compare RIL (1 mg every morning or 1 mg twice daily if necessary) and MD (250 mg morning and evening or 500 mg twice daily if necessary). Hydrochlorothiazide (25 mg daily) was associated from Day 56 to Day 84 if the supine diastolic BP was greater than or equal to 90 mmHg. A placebo was substituted from Day 84 to Day 91 to study the effect of withdrawing therapy.

RESULTS

at Day 56 under monotherapy, the average supine systolic/diastolic BP had decreased significantly with RIL and MD to 140/110 mmHg and 140/100 mmHg respectively. An equivalent number of patients had normalised their blood pressures in both groups (systolic/diastolic BP less than or equal to 160/90 mmHg): 50% with RIL and 42% with MD (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

The pH-dependent structure of calf thymus DNA studied by Raman spectroscopy

The pH-dependent structure of calf thymus DNA is analyzed using Raman spectroscopy. The Raman spectra in the acidic region demonstrate that denaturation occurs in several steps. The binding of H+ to adenine and cytosine residues is accompanied by a decrease in the percentage of DNA in the B-conformation and a concurrent increase in a conformation most probably related to the C-form. The denaturation of DNA is observed at pH 3.3 and parallels the protonation of guanine bases. The Raman spectra of calf thymus DNA in the basic region (above pH 10) show that guanine residues are deprotonated at lower pH value than are thymine residues. In addition, Raman spectra in the basic region detect conformational changes of the phosphate backbone different from those found in the acidic region.

Heavy metal-nucleotide interactions. IX. Raman difference spectroscopic studies on the binding of CH3Hg(II) to 1-methylthymine, thymidine-5'-monophosphate, DNA models and native DNA

Raman spectra have been obtained for dTMP and its complex with CH3Hg (II) in aqueous solution as a function of pH. Difference spectroscopy is employed to increase the sensitivity of the Raman technique. The binding reaction is essentially quantitative from pH 3 to 9, and the value of the equilibrium constant for CH3HgOH2+ + dThd in equilibrium CH3Hg(dThdH--1) + H30+ is estimated from intensity measurements to be 0.6 in reasonable agreement with an earlier value based upon uv spectrophotometric data. Binding is to N(3) with substitution of CH3Hg+ for the proton. A similar reaction occurs with 1-MeThy. Raman spectra for aqueous and crystalline 1-MeThy and for the complex CH3Hg(1-MeThyH--1) are reported. The spectrum of crystalline Hg(1-MeThyH--1)2, for which the crystal structure is known, also was obtained for comparison. Raman difference spectroscopy was used to confirm that CH3Hg (II) binds to N(3) of dTMP and N(1) of GMP at r = 0.2 (MeHg+: phosphate) ratios with mixtures of GMP + CMP + AMP + dTMP. In contrast, native calf thymus DNA does not appear to bind CH3Hg(II) at these sites at r = 0.15, although no significant amount of free CH3HgOH is present. With r = 0.3, extensive binding occurs both to the Thy and Gua bases. Raman difference spectroscopy is a valuable technique for studying the binding of ions and molecules to polynucleotides in moderately dilute aqueous solution.

Detection of the sites of alkylation in DNA and polynucleotides by laser Raman spectroscopy

A laser Raman study of the alkylation of calf thymus DNA, poly(dG)-poly(dC) and poly(dA)-(dT) has been made using two water soluble alkylating agents: an antitumor drug, the difunctional methyl nitrogen mustard (HN2), which froms interstrand cross-links, and the dimethyl nitrogen half mustard (HN1). When an excess of the alkylating agent was used, the observed Raman frequencies due to the guanine ring modes in DNA and poly(dG)-poly(dC) changed virtually quantitatively to those of 7-methylguanosine (7-Me-Guo) showing that essentially all of the guanine bases were alkylated in the N-7 position. Furthermore, this alkylated DNA formed a stable double helical complex at neutral pH in which the alkylated guanine residues are in the keto form. No changes in the Raman bands of any of the other bases were observed in alkylated DNA. The DNA double helix, completely alkylated in at the N-7 position of guanine, melts about 35 degrees C below that of the native DNA. Upon melting, the alkylated guanine changes from the keto to the zwitterionic form.

Heavy metal-nucleoside interactions. Binding of methylmercury(II) to inosine and catalysis of the isotopic exchange of the C-8 hydrogen studied by 1-H nuclear magnetic resonance and raman difference spectrophotometry

Raman difference spectrophotometry reveals that CH3HgII binds quantitatively to N(1) of inosine at pH 8, substituting for the proton. When N(1) is saturated, binding occurs at a second site. Measurements of the 1-H nuclear magnetic resonance spectra of both inosine and of CH3Hg-II are in agreement with the N(1) binding and indicate that the second site for mercuriation is N(7). This second binding reaction is observed to increase the rate of exchange of the C(8) hydrogen with solvent, consistent with results observed for alkylation at N(7). Coordination of the electrophilic CH3Hg-II to N(7) increases the acidity of H(8), facilitating OHminus--catalyzed proton abstraction and reprotonation by themedium. For comparison, the reaction of CH3Hg-II with [8-2-H]inosine has been studied. Displacement of the N(1) hydrogen upon mercuriation of inosine causes a significant electron delocalization into the ring, increasing the basicity of N(7), and accounting for the synergic effect in metal binding observed originally by Simpson. In contrast, 1-methylinosine interacts only slightly with CH3Hg-II at pH 8. Coordination appears to be at N(7), since H(8) again is observed to exchange rapidly with solvent protons. In acidic solution, pH less than 2, binding to inosine is almost quantitative and exclusively to N(7). The behavior of CH3Hg-II is compared with that of Pt(II) and with Ni(II), Co(II), AND Zn(II). A brief comparison is made among ultraviolet absorption spectrophotometry, nuclear magnetic resonance (NMR), and Raman difference spectrophotometry for studying reactions of nucleosides and nucleotides.

"Platinum-pyrimidine blues" and related complexes: a new class of potent antitumor agents

The diaquo species of cis-dichlorodiammineplatinum (II) reacts with pyrimidines and substituted pyrimidines to form very soluble, deep blue complexes. These are believed to consist of mainly monomeric species containing one pyrimidine moiety liganded to each platinum. The structures of the complexes are largely uncertain at this time. We describe the methods of synthesis and characterization of approximately 70 such complexes, with a suggested classification scheme, incluse complexes show superior activity against the ascites Sarcoma 180 tumor in Swiss mice when compared to cis-dichlorodiammineplatinum (II). Initial screening test results and dose schedule-dependency results indicate we can achieve 100% cures in this tumor-host system. Activity is also shown against the Rauscher leukemia, Ehrlich ascites, and ADJ/PC6A tumors. Microscopic histopathologic studies of resulting kidney lesions show that the "platinum-uracil blue" complex causes only minor focal damage to the proximal convoluted tubules at a therapeutic dose level, rather than the generalized degenerative changes so prominent and dose limiting noted with cis-dichlorodiammineplatinum (II).

Heavy metal-nucleotide interactions. III. The participation of amino groups in the binding of methylmercury (II) to cytidine and adenosine 5'-phosphate in aqueous solution: studies by Raman difference spectrophotometry

Raman difference spectrophotometry has been used to study the interaction of CH3Hg(II) with cytidine and Ado-5'-P at high pH. In contrast to the binding reactions which occur at lower pH or in non-aqueous solvents such as dimethyl sulfoxide, a proton is transferred from the amino group; and the complexes are CH3HgCydH-1 and CH3HgAdoH-1-5'-P. The spectra are significantly different from those of the cationic complexes. The integrated intensities of ligand modes which shift upon metalation can be used to measure the concentration of unreacted ligand and consequently the extent of the reaction. Equilibrium constants for the reactions CH3HgOH + L yields CH3HgLH-1 + H2O were estimated to be log KCyd equals 0.63 plus or minus 0.05 and log KAdo-5'-P equals 0.85 plus or minus 0.05, in fair agreement with values determined under very different conditions by ultraviolet spectrophotometry. The vibrational spectrum of the ligand in CH3HgCydH-1 is virtually the same as that of UrdH-1- which is isoelectronic. The spectrum of the ligand in CH3HgAdoH-1-5'-P is more similar to the isoelectronic base InoH-1-than to Ado-5'-P, although the resemblance is not so close as in the CydH-1---UrdH-1-case. The structures of these complexes are discussed on the basis of their vibrational spectra and similarities in the spectra of related compounds. It is concluded that the CH3Hg(II) binds to the amino nitrogen at high pH with both cytidine and Ado-5'-P. In neutral solution with excess CH3Hg(II), metalation occurs on the amino groups, on the ring, and also on the ribose.