Cost-effectiveness of sitagliptin-based treatment regimens in European patients with type 2 diabetes and haemoglobin A1c above target on metformin monotherapy

OBJECTIVE

Sitagliptin is a novel oral incretin enhancer that acts by inhibiting the dipeptidyl peptidase 4 enzyme and is indicated in Europe as a treatment adjunct to metformin (MF), sulphonylurea (SU), MF plus SU and diet and exercise, in the management of type 2 diabetes mellitus. The objective of the current analysis was to evaluate the cost-effectiveness of adding sitagliptin to the regimens of patients with haemoglobin A1c (HbA1C) above the International Diabetes Federation goal (6.5%) while on MF in six European countries: Austria, Finland, Portugal, Scotland (United Kingdom), Spain and Sweden.

METHODS

A discrete event simulation model, which employed the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model risk equations for predicting risks of diabetes-related complication, was used. Lifetime costs and benefits were projected for alternative treatment strategies of adding sitagliptin, compared with adding rosiglitazone or a SU to MF in patients not at HbA1C goal on MF monotherapy. Changes in HbA1C as well as side effects associated with these different treatment strategies were based on clinical trial data. Mean baseline values from local epidemiologic studies involving patients with type 2 diabetes not at HbA1C goal on MF monotherapy were included in the current analysis. Costs of medications, side effects and direct costs of diabetes-related complications were based on country-specific data. UKPDS-based disutility weights associated with diabetes complications were incorporated. Disutilities associated with medication side effects were based on published data. All future costs and benefits were discounted according to local guidelines on cost-effectiveness analysis. One-way sensitivity analyses were conducted by varying key input parameters.

FINDINGS

The discounted incremental cost-effectiveness ratios (ICER) associated with the addition of sitagliptin to MF, compared with adding rosiglitazone, in the different countries analysed ranged from treatment with sitagliptin being dominant (cost saving with improved health outcome) to its being cost-effective [4,766 euros per quality-adjusted life year (QALY)]. Treatment with sitagliptin added to MF was cost-effective compared with adding a SU, with discounted ICER values ranging from 5949 euros/QALY to 20,350 euros/QALY across countries. Sensitivity analyses showed that these results were robust to changes in input parameters, including clinical efficacy, costs and utility weights for both diabetes-related complications and hypoglycaemia.

CONCLUSIONS

Compared with adding rosiglitazone or a SU to MF, adding sitagliptin to MF is projected to be either cost saving or cost-effective for patients with type 2 diabetes who are not at HbA1C goal on MF.

Patch testing - a valuable tool for investigating non-immediate cutaneous adverse drug reactions to antibiotics

BACKGROUND

Antibiotics are among the most frequent causes of cutaneous adverse drug reactions (CADR); patch testing may be an important tool in their evaluation and management. We assessed the role of patch testing as a diagnostic tool in non-immediate CADR to antibiotics, and evaluated cross-reactivity among them.

METHODS

We reviewed data from all patients with non-immediate CADR attributed to antibiotics, which were patch tested between 2000 and 2014 at our dermatology department.

RESULTS

Patch tests were performed in 260 patients, and showed overall reactivity to antibiotics of 21.5%, especially in the context of drug reactions with eosinophilia and systemic symptoms (DRESS) (31.6%), maculopapular exanthema (MPE) (21.8%), Stevens-Johnson syndrome/toxic epidermal necrolysis (20%) and acute generalized exanthematous pustulosis (AGEP) (18.1%). Patch test reactivity was higher for amoxicillin, mainly in DRESS (44.4%) and MPE (25.6%), and dicloxacillin (50% in AGEP and 37.5% in MPE). Reactivity to clindamycin occurred, especially in the setting of MPE (23.2%). In AGEP and DRESS, patch tests were useful in detecting reactivity to quinolones (50-100%). Overall reactivity was lower for vancomycin (9.1%), co-trimoxazole (8.6%), macrolides (4.8%) and cephalosporins (4.4%). Positive patch tests for more than one antibiotic occurred in 29/56 cases (51.8%), mostly explained by cross-reactions. Twenty of 24 cases reacted to both amoxicillin and ampicillin. All five cases reacting to ciprofloxacin cross-reacted with other quinolones.

CONCLUSION

Although oral rechallenge is considered the gold standard for confirming drug imputability in CADR, patch testing could be suggested as a first choice in the study of non-immediate reactions, since it is a safe and valuable procedure.

Influenza surveillance in community-dwelling elderly compared with children

BACKGROUND

Acute respiratory illnesses (ARIs) are the leading cause of medical visits for community-dwelling patients of all ages, but virologic and clinical descriptions of these illnesses in older adults are infrequent.

OBJECTIVES

To determine the feasibility of influenza surveillance in a population of community-dwelling elderly, to compare the patterns of influenza infection in elderly persons with that observed in young populations in which surveillance is usually conducted, and to describe the clinical presentation of influenza infection in elderly outpatients who seek medical attention for ARI.

DESIGN

Prospective clinical and viral surveillance of ARIs among ambulatory patients during 3 consecutive winter seasons.

SETTING

Nine internal medicine and 3 pediatric practices in Upstate New York in cooperation with the Medicare Influenza Vaccine Demonstration Project.

PATIENTS

Elderly (n=808) and pediatric (n=2080) outpatients with ARI office visits.

MEASUREMENTS

Frequency of influenza and other respiratory virus isolates and clinical profile of influenza among older adults and children with ARIs.

RESULTS

Influenza virus was the viral agent recovered most often from specimens obtained from patients in both age groups with ARI symptoms, especially those with fever. Influenza accounted for 11% of ARIs in adults (87 isolates) and 20% in children (408 isolates). At the initial illness visit, influenza infection was equally common in elderly individuals with or without underlying cardiopulmonary conditions. Lower respiratory tract signs occurred in 13% of the adults and in 7% of the children with influenza documented by laboratory studies. Other respiratory viruses were recovered from specimens obtained from 20 adults and from 259 children.

CONCLUSIONS

Viruses are important agents of ARIs in elderly outpatients. Children and older adults experience similar patterns of influenza infection and other epidemic respiratory pathogens, such as parainfluenza and respiratory syncytial viruses. Viral identification is feasible in older adults seen in physicians' offices and may contribute to improved measures of effects of influenza and other respiratory viruses on ARIs.

The economic impact of early retirement attributed to rheumatic diseases: results from a nationwide population-based epidemiologic study

OBJECTIVES

To measure early retirement due to self-reported rheumatic diseases (RDs) and to estimate the respective indirect costs and years of working life lost (YWLL).

METHODS

We used individual level data from the national, cross-sectional, population-based EpiReumaPt study (September 2011-December 2013) where 10,661 inhabitants were randomly surveyed in order to capture and characterize all cases of RD within a representative sample of the Portuguese population. In this analysis, we used all participants aged between 50 and 64 years, near the official retirement age. A national database was used to calculate productivity values by gender, age and region, using the human capital approach. YWLL were estimated as the difference between each participant's current age and the respective retirement age, while the potential years of working life lost (PYWLL) were given by the difference between official and actual retirement ages. We also calculated the percentage of time in inactivity (inactivity ratio = YWLL/Active age-range [15-64 years old]).

RESULTS

29.9% of the Portuguese population with ages between 50 and 64 years were retired with 13.1% self-reporting retirement due to RD. The estimated annual indirect cost following premature retirement attributed to RD was €910 million (€555 per capita; €1625 per self-reported RD patient and €13,592 per early retiree due to RD). Females contributed with 84% for these costs (€766 million; €882 per capita vs €187 from males). We observed a total number of 389,939 accumulated YWLL (228 per 1000 inhabitants) and 684,960 PYWLL (401 per 1000 inhabitants). The mean YWLL and PYWLL inactivity ratios were 12% and 21%, respectively. RD patients with higher values of disability have the highest risk of early retirement.

CONCLUSIONS

Early retirement attributed to self-reported RD amounts to approximately 0.5% of the national gross domestic product (GDP) in 2013, due to large YWLL. Both the public health concern and the economic impact highlight the need to prioritize investments in health and social protection policies targeting patients with rheumatic conditions.

Anti-Metalloprotease P-I Single-Domain Antibodies: Tools for Next-Generation Snakebite Antivenoms

In order to address the global antivenom crisis, novel antivenoms need to present high therapeutic efficacy, broad neutralization ability against systemic and local damage, sufficient safety, and cost-effectiveness. Due to biological characteristics of camelid single-domain antibodies (VHH) such as high affinity, their ability to penetrate dense tissues, and facility for genetic manipulation, their application in antivenoms has expanded considerably. VHHs that are active against the metalloprotease BjussuMP-II from the snake Bothrops jararacussu were selected. After isolation of BjussuMP-II, a camelid was immunized with the purified toxin in order to construct the recombinant phage library. Following a round of biopanning, 52% of the selected clones were able to recognize BjussuMP-II in an ELISA assay. After sequencing, seven sequence profiles were identified. One selected clone (VHH61) showed cross-reactivity to B. brazili venom, but did not recognize the Crotalus and Lachesis genera, indicating specificity for the Bothrops genus. Through in vitro tests, the capacity to neutralize the toxicity triggered by BjussuMP-II was observed. Circular dichroism spectroscopy indicated a robust secondary structure for VHH61, and the calculated melting temperature (T M) for the clone was 56.4°C. In silico analysis, through molecular docking of anti-BjussuMP-II VHHs with metalloprotease, revealed their potential interaction with amino acids present in regions critical for the toxin's conformation and stability. The findings suggest that anti-BjussuMP-II VHHs may be beneficial in the development of next-generation antivenoms.

Effect of exercise training on amyloid-like protein aggregates among patients with heart failure

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): MG and CS were supported by a PhD FCT grant (SFRH/BD/128893/2017) and by an individual grant from CAPES [BEX 0554/14-6], respectively. This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). iBiMED is a research unit supported by the Portuguese Foundation for Science and Technology (REF: UID/BIM/04501/2020) and FEDER/Compete2020 funds).

Introduction

Amyloid-like protein aggregates play a decisive role in the pathology of heart failure. Alterations in protein homeostasis, in particular, the clearance of toxic amyloid-like aggregates are emerging therapeutic targets in cardiovascular medicine. The clinical benefits of cardiac rehabilitation and exercise training are widely accepted in heart failure; however, little is known about the potential benefit of exercise training in amyloid-like protein aggregates.

Purpose

To assess the effects of a moderate-intensity exercise training program on amyloid-like protein aggregates levels among patients with heart failure with reduced ejection fraction.

Methods

Eighteen subjects participated in the study; eight patients (age: 66.6 ± 5.9 years; FEVE: 38.4 ± 8.9%) with heart failure with reduced ejection fraction participated in a 3-month exercise training program (2 x 60 min sessions per week of moderate-intensity aerobic and resistance exercise). Ten healthy subjects (age: 68. 4 ± 3.1 years) were recruited to an age-matched reference group.  Amyloid-like protein aggregates were assessed before and after 3 months of exercise training. Clinical data, medication, anthropometrics, and cardiorespiratory fitness were also assessed. Thioflavin T (ThT) dye fluorescence was used to quantify the plasma levels of amyloid-like aggregates and the Fourier transform infrared spectroscopy (FTIR) was applied to evaluate the conformation of cross-β-sheet structures characteristic of amyloid protein aggregates.

Results

Exercise program improved cardiorespiratory fitness by 14.0 ± 17.1% (17.4 ± 3.2 to 19.7 ± 2.9 ml/kg/min) and reduced NT-proBNP levels by 16.5% (34.2) (median concentration of 632 pg/mL (720.8) to 517.5 pg/mL (707.0)) in the heart failure patients. A slight decrease of amyloid-like aggregates levels was observed in post-exercise training samples (a reduction of 3.1%); interestingly, after the exercise training program, the heart failure patients showed levels of amyloid-like aggregates similar to the reference group (1132.0 ± 114.2 vs. 1094.8 ± 132.9 a.u.). Additionally, the PLS-R multivariate analysis of the amide I region of the FTIR spectra revealed enrichment of antiparallel β-sheets (1693 cm-1) assigned to amyloid-like oligomers in the samples of heart failure patients before, but not after, the exercise program. Of note, oligomeric species, as intermediates of amyloid assembly, can contribute to the increase of amyloid burden, but also, some have been reported to be highly reactive and toxic to cells, being key elements of amyloid pathogenesis.

Conclusions

 Our preliminary results indicate that 3 months of exercise training may have significant effects on amyloid-like oligomers, and start hindering the formation of the larger ThT-positive aggregates among patients with heart failure.

Abstract Figure.

Population structure and genetic diversity of wild Helianthus species from Mozambique

The production of sunflower suffered a major decline in Mozambique after its independence in 1975. Civil war, human activities and environmental damage subjected the species to an ecological stress contributing to reduce the number and size of wild populations. As this reduction is often related to a loss of genetic variation we estimated the genetic diversity within and among populations of wild Helianthus from five districts of Mozambique using RAPD markers. The 44 accessions studied grouped into four major clusters exhibiting structured variability with regard to geographic origin. A high level of genetic diversity (He = 0.350 and I = 0.527) was retained at the population level. The genetic variation among populations was high (59.7%), which is consistent with low gene flow (Nm = 0.338). The proportion of total genetic diversity residing among these populations should be kept in mind to devise different conservation strategies in order to preserve these populations. Currently wild Helianthus genetic resources present in Maputo and Sofala are on the edge of extinction mainly due to excessive urbanization. Therefore, conservation of what remains of this plant genetic diversity is essential for sustainable utilization and can be useful for breeding programs.

P5243Indirect costs of acute myocardial infarction in Portugal

Introduction

Cardiovascular diseases are the main cause of death in Portugal. The high incidence of acute myocardial infarction (AMI) is also a major problem, particularly due to the economic burden caused by productivity losses (indirect costs) associated with temporary absence from work, not yet sufficiently studied in Portugal. Our objective was to quantify the indirect costs of AMI in the first year after admission.

Methods

All consecutive patients admitted in a single center with <66 years (official retirement age) during one year that survived to discharge were included in the present study. Employment status on admission was assessed in every patient. For each employed patient, working at the time of admission, the monthly wage was estimated from market wage rates from national public sources (grossed up by social security contributions) according to gender and age. A day-cost was calculated to assess the cost of temporary absence from work. A half-day absence was considered for Cardiology medical appointments and exams. The duration of temporary absence from work was assessed by a first follow-up contact at 30-day and a second follow-up evaluation up to one-year after admission. The cost of temporary absence from work per episode was calculated in this sample and results were applied to the total number of MI in Portugal during the year 2016 (last available national data) and separately according to ST-elevation AMI (STEAMI) or non-ST-elevation acute coronary syndrome (NSTACS).

Results

We included 219 patients (54±7 years, 83% males), from which, 66.2% were working, 16.4% early-retired, 11.9% unemployed and 5.5% in long-term exit from work due to non-cardiac disease. During the one-year follow-up there were no changes in employment status. In our sample, mean monthly labor cost was 1802 euros (69 euros/day). Median number of days absent from work were 34 days (31 days in men and 52 days in women) and a median of 2 half-days were also obtained for Cardiology appointments / exams. We obtained a total cost of 760.521,55 euros. We used available data from 2016 to estimate indirect costs at a national level. There were 4133 patients with <66 years admitted in Portugal due to AMI that survived to discharge. We performed an analysis, using the proportions of 41% of cases with STEAMI and 59% with NSTACS that came out of the Portuguese Registry on Acute Coronary Syndromes and the working patient's proportions in each group. Costs were higher in patients with STEAMI. We estimate an indirect total cost in Portugal of € 10.12 million in the first year after MI.

Conclusions

In Portugal, the costs to society of disability generated losses of productivity are over ten million euros during the first year after AMI. Strategies to improve time of return to work are very important to lower these costs.