Hans De Loof

mTOR inhibition: a promising strategy for stabilization of atherosclerotic plaques.

Statins are currently able to stabilize atherosclerotic plaques by lowering plasma cholesterol and pleiotropic effects, but a residual risk for atherosclerotic disease remains. Therefore, effective prevention of atherosclerosis and treatment of its complications is still a major clinical challenge. A large body of evidence indicates that mammalian target of rapamycin (mTOR) inhibitors such as rapamycin or everolimus have pleiotropic anti-atherosclerotic effects so that these drugs can be used as add-on therapy to prevent or delay the pathogenesis of atherosclerosis. Moreover, bioresorbable scaffolds eluting everolimus trigger a healing process in the vessel wall, both in pigs and humans, that results in late lumen enlargement and plaque regression. At present, this phenomenon of atheroregression is poorly understood. However, given that mTOR inhibitors suppress cell proliferation and trigger autophagy, a cellular survival pathway and a process linked to cholesterol efflux, we hypothesize that these compounds can inhibit (or reverse) the basic mechanisms that control plaque growth and destabilization. Unfortunately, adverse effects associated with mTOR inhibitors such as dyslipidemia and hyperglycemia have recently been identified. Dyslipidemia is manageable via statin treatment, while the anti-diabetic drug metformin would prevent hyperglycemia. Because metformin has beneficial macrovascular effects, this drug in combination with an mTOR inhibitor might have significant promise to treat patients with unstable plaques. Moreover, both statins and metformin are known to inhibit mTOR via AMPK activation so that they would fully exploit the beneficial effects of mTOR inhibition in atherosclerosis.

Evaluating the implementation fidelity of New Medicines Service for asthma patients in community pharmacies in Belgium

Background: In October 2013, a New Medicines Service (NMS) was introduced in community pharmacies in Belgium to support asthma patients who are novice users of inhaler devices with corticosteroids. The protocol‐based intervention used the Asthma Control Test (ACT) and the Medication Adherence Report Scale (MARS) to assess asthma control and medication adherence. The NMS is the first initiative that puts advanced pharmaceutical care into practice in Belgium. The present study evaluated the degree to which the NMS program is delivered as intended, drawing on the concept of implementation fidelity (IF). Methods: The main dimensions of IF and potential moderating and facilitating factors for the implementation of NMS in community pharmacies were evaluated using telephone interviews with pharmacists (n = 497), semi‐structured interviews with patients eligible for NMS (n = 30), focus groups among general practitioners (n = 72) and lung specialists (n = 5), and a work system analysis in community pharmacies (n = 19). Results: The uptake of NMS in Belgian community pharmacies remains low. In addition to practical barriers, pharmacists found it difficult to identify new asthmatic patients when they were not informed about the diagnosis. A lack of commitment from physicians, patients and pharmacists was noted in the early start‐up phase of the program. Many pharmacists did not see how NMS differed from existing pharmaceutical care. Physicians considered this service as part of their own tasks and discouraged ACT for asthma follow‐up in the community pharmacy. Conclusions: The introduction of the NMS program was not sufficiently embedded in the Belgian health care organization, causing low uptake and resistance to its implementation by pharmacists, patients, and other health care professionals. To increase the uptake of this type of service and its possible extension to other patient groups, more collaboration among the different health care professionals during design and implementation is necessary, as well as systematic data collection to monitor the quality of the service, better training of pharmacists, and more information for patients and physicians.

Unintended consequences of co-payment regulations in Belgium: the case of atorvastatin.

Methods We related sales figures to coinciding price evolutions, and broke the costs down by their bearer. On the one hand we analysed a data extraction from IMS Health for Belgium for the period 2007-2013. The IMS Health database contains sales figures of a representative sample of community pharmacies including the number of packages sold (per CNK number) per month. On the other hand, we studied the corresponding unit price tables of the Belgian centre for Pharmaco-therapeutic Information (BCFI, an independent source).

Evolutions in Both Co-Payment and Generic Market Share for Common Medication in the Belgian Reference Pricing System

BackgroundIn Belgium, a co-insurance system is applied in which patients pay a portion of the cost for medicines, called co-payment. Co-payment is intended to make pharmaceutical consumers more responsible, increase solidarity, and avoid or reduce moral hazards.ObjectiveOur objective was to study the possible influence of co-payment on sales volume and generic market share in two commonly used medicine groups: cholesterol-lowering medication [statins (HMG-CoA reductase inhibitors) and fibrates] and acid-blocking agents (proton pump inhibitors and histamine H2 receptor antagonists).Methods and DataThe data were extracted from the Pharmanet database, which covers pharmaceutical consumption in all Belgian ambulatory pharmacies. First, the proportion of sales volume and costs of generic products were modelled over time for the two medicine groups. Second, we investigated the relation between co-payment and contribution by the national insurance agency using change-point linear mixed models.ResultsThe change-point analysis suggested several influential events. First, the generic market share in total sales volume was negatively influenced by the abolishment of the distinction in the maximum co-payment level for name brands and generics in 2001. Second, relaxation of the reimbursement conditions for generic omeprazole stimulated generic sales volume in 2004. Finally, an increase in co-payment for generic omeprazole was associated with a significant decrease in omeprazole sales volume in 2005. The observational analysis demonstrated several changes over time. First, the co-payment amounts for name-brand and generic drugs converged in the observed time period for both medicine groups under study. Second, the proportion of co-payment for the total cost of simvastatin and omeprazole increased over time for small packages, and more so for generic than for name-brand products. For omeprazole, both the proportion and the amount of co-payment increased over time. Third, over time the prescription of small packages shifted to an emphasis on larger packages.ConclusionsAs maximum co-payment levels decreased over time, they overruled the reference pricing system in Belgium. The changes in co-payment share over time also significantly affected sales volume, but whether physicians or patients are the decisive actors on the demand side of pharmaceutical consumption remains unclear.

Het begeleidingsgesprek nieuwe medicatie voor astmapatiënten door apothekers

SamenvattingHet begeleidingsgesprek nieuwe medicatie (BNM) is een dienstverlening waarbij de apotheker de doeltreffendheid van een astmatherapie tracht te vergroten door alle facetten van de behandeling toe te lichten aan patiënten, die voor het eerst in twaalf maanden een inhalatiecorticosteroïde gebruiken. Deze geïndividualiseerde begeleiding omvat twee gesprekken, die ongeveer twintig minuten duren, en heeft het aanleren van een correcte inhalatietechniek en het verbeteren van de therapietrouw als voornaamste doelstellingen.

Medicine price awareness in chronic patients in Belgium

INTRODUCTION Under increasing pressure to contain health expenditures governments across Europe have implemented policies to increase responsible medicine use, e.g. by increasing co-insurance paid for by patients. In times of austerity, how do chronic disease patients perceive the medicine price they have to pay? METHOD We used a mixed methods research design. First, we distributed a close-ended questionnaire among 983 chronic disease patients in 30 Flemish pharmacies. Second, we performed semi-structured interviews with 15 of these patients. We surveyed for knowledge on the prescription medicine they bought, as well as for their needs for information and their therapeutic compliance. RESULTS Although patients express a lack (and a need) of information on prices during the consultation with the general practitioner (GP), (s)he hardly addresses medicine prices. Patients often only know the medicine price when they are at the pharmacy and patients need to decide to buy the medicine or not. This often results in patients taking the medicine when considered affordable within their social and financial context. CONCLUSION It seems essential that patients are better informed about medicine prices as well as the constraints on physicians to prescribe cost-effectively. Therefore, medicine prices should be discussed more often during physician consults.