Joyce H. S. You

Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.

BACKGROUND After endoscopic treatment of bleeding peptic ulcers, bleeding recurs in 15 to 20 percent of patients. METHODS We assessed whether the use of a high dose of a proton-pump inhibitor would reduce the frequency of recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. Patients with actively bleeding ulcers or ulcers with nonbleeding visible vessels were treated with an epinephrine injection followed by thermocoagulation. After hemostasis had been achieved, they were randomly assigned in a double-blind fashion to receive omeprazole (given as a bolus intravenous injection of 80 mg followed by an infusion of 8 mg per hour for 72 hours) or placebo. After the infusion, all patients were given 20 mg of omeprazole orally per day for eight weeks. The primary end point was recurrent bleeding within 30 days after endoscopy. RESULTS We enrolled 240 patients, 120 in each group. Bleeding recurred within 30 days in 8 patients (6.7 percent) in the omeprazole group, as compared with 27 (22.5 percent) in the placebo group (hazard ratio, 3.9; 95 percent confidence interval, 1.7 to 9.0). Most episodes of recurrent bleeding occurred during the first three days, which made up the infusion period (5 in the omeprazole group and 24 in the placebo group, P<0.001). Three patients in the omeprazole group and nine in the placebo group underwent surgery (P=0.14). Five patients (4.2 percent) in the omeprazole group and 12 (10 percent) in the placebo group died within 30 days after endoscopy (P=0.13). CONCLUSIONS After endoscopic treatment of bleeding peptic ulcers, a high-dose infusion of omeprazole substantially reduces the risk of recurrent bleeding.

Public knowledge, attitudes and behavior on antibiotic use: a telephone survey in Hong Kong.

Background:This study aimed to examine public knowledge, attitudes and behaviors regarding antibiotic use in the community of Hong Kong.Methods:A cross-sectional phone survey was conducted in 2006 on people aged 18 or older who were uninstitutionalized Hong Kong residents regarding antibiotic use for upper respiratory tract infections (URTIs).Results:A total of 1,002 respondents participated in the survey and 77%, 72% and 85% of the respondents had adequate knowledge, appropriate attitude/belief and behavior on antibiotic use, respectively. Some respondents (26%) believed that antibiotic was needed for symptoms of URTIs if they felt sick enough to seek medical care and 8% would share antibiotic with family members. Eighty-nine (9%) respondents had acquired antibiotic without a prescription. During the most recent episode of URTI, 78% had completed the antibiotic treatment course. Stepwise multiple logistic showed that higher education level and family income were associated with adequate patient knowledge. Male gender was a predictor of poor behavior on antibiotic use. Appropriate belief was associated with tertiary level of education or above.Conclusions:Over 70% of the present cohort showed adequate knowledge, appropriate attitudes/beliefs and behavior on antibiotic use. Despite a small percent (8%–9%) of respondents reportedly shared and/or self-prescribed antibiotics, this would translate into the practice of half a million people in Hong Kong. Public education programmes should therefore be developed, targeting specific areas of misconceptions, misuse of antibiotic and vulnerable groups at risk of improper use of antibiotics.

Potential Clinical and Economic Outcomes of CYP2C9 and VKORC1 Genotype‐Guided Dosing in Patients Starting Warfarin Therapy

The US Food and Drug Administration has updated the label information for warfarin to encourage the use of genetic information before initiating treatment with the drug. We used decision‐tree modeling to simulate the outcomes of CYP2C9 and vitamin K epoxide reductase complex 1 (VKORC1) genotype–guided dosing in patients in whom warfarin therapy is to be initiated. The inputs for the model were derived from the literature. The incremental costs per unit outcome improved (ICERs) were US

Cost-Effectiveness of Dabigatran versus Genotype-Guided Management of Warfarin Therapy for Stroke Prevention in Patients with Atrial Fibrillation

347,059 per quality‐adjusted life‐year (QALY) gained,

The potential clinical and economic outcomes of pharmacogenetics-oriented management of warfarin therapy - a decision analysis

170,192 per adverse event averted, and

Cost-effectiveness analysis of quadrivalent influenza vaccine versus trivalent influenza vaccine for elderly in Hong Kong

1,106,250 per life saved. The outcomes of 10,000 Monte Carlo simulations demonstrate that the ICER per QALY gained was >

Pharmacoeconomic evaluation of warfarin pharmacogenomics

50,000 62.1% of the time. ICER was sensitive to baseline international normalized ratio (INR) control, reduction in out‐of‐range INRs by genotype‐guided dosing, and genotyping cost. In conclusion, genotype‐guided dosing for warfarin therapy does not appear to be cost‐effective, with the potential ICER per QALY being >

Factors affecting the maintenance stable warfarin dosage in Hong Kong Chinese patients.

50,000. Lowering the genotyping cost, improving effectiveness of INR control of the genotype‐guided dosing algorithm, and applying the algorithm in practice sites with high out‐of‐range INRs would improve the cost‐effectiveness of the dosing algorithm.

Cost-effectiveness of quadrivalent influenza vaccine in Hong Kong – A decision analysis

Background Dabigatran is associated with lower rate of stroke comparing to warfarin when anticoagulation control is sub-optimal. Genotype-guided warfarin dosing and management may improve patient-time in target range (TTR) and therefore affect the cost-effectiveness of dabigatran compared with warfain. We examined the cost-effectiveness of dabigatran versus warfarin therapy with genotype-guided management in patients with atrial fibrillation (AF). Methodology/Principal Findings A Markov model was designed to compare life-long economic and treatment outcomes of dabigatran (110 mg and 150 mg twice daily), warfarin usual anticoagulation care (usual AC) with mean TTR 64%, and genotype-guided anticoagulation care (genotype-guided AC) in a hypothetical cohort of AF patients aged 65 years old with CHADS2 score 2. Model inputs were derived from literature. The genotype-guided AC was assumed to achieve TTR = 78.9%, adopting the reported TTR achieved by warfarin service with good anticoagulation control in literature. Outcome measure was incremental cost per quality-adjusted life-year (QALY) gained (ICER) from perspective of healthcare payers. In base-case analysis, dabigatran 150 mg gained higher QALYs than genotype-guided AC (10.065QALYs versus 9.554QALYs) at higher cost (USD92,684 versus USD85,627) with ICER = USD13,810. Dabigatran 110 mg and usual AC gained less QALYs but cost more than dabigatran 150 mg and genotype-guided AC, respectively. ICER of dabigatran 150 mg versus genotype-guided AC would be >USD50,000 (and genotype-guided AC would be most cost-effective) when TTR in genotype-guided AC was >77% and utility value of warfarin was the same or higher than that of dabigatran. Conclusions/Significance The likelihood of genotype-guided anticoagulation service to be accepted as cost-effective would increase if the quality of life on warfarin and dabigatran therapy are compatible and genotype-guided service achieves high TTR (>77%).

Cost-Effectiveness Analysis of Influenza and Pneumococcal Vaccination for Hong Kong Elderly in Long-term Care Facilities

Variant cytochrome P450 (CYP) 2C9 genotypes are associated with low maintenance dose requirement of warfarin therapy and increased risk of major bleeding events. The objective of the present study was to evaluate the potential clinical and economic outcomes of using CYP2C9 genotype data to guide the management of anticoagulation therapy and to identify influential factors affecting the cost-effectiveness of this treatment scheme. A decision tree was designed to simulate, over 12 months, the clinical and economic outcomes of patients newly started on warfarin associated with two alternatives: (1) no genotyping (non-genotyped group) and (2) CYP2C9 genotyping prior to initiation of warfarin therapy (genotyped group). Non-genotyped group patients would receive standard care of an anticoagulation clinic (AC). In the genotyped group, patients with at least one variant CYP2C9 allele would receive intensified anticoagulation service. Most of the clinical probabilities were derived from literature. The direct medical costs were estimated from the Diagnosis-Related Group charges and from literature. The total number of events and the direct medical cost per 100 patient-years in the genotyped and non-geno-typed groups were 9.58 and USD155,700, and, 10.48 and USD 150,500, respectively. The marginal cost per additional major bleeding averted in the genotyped group was USD 5,778. The model was sensitive to the variation of the cost and reduction of bleeding rate in the intensified anticoagulation service. In conclusion, the pharmacogenetics-oriented management of warfarin therapy is potentially more effective in preventing bleeding with a marginal cost. The cost-effectiveness of this treatment scheme depends on the relative cost and effectiveness of a pharmacogenetics-oriented intensified anticoagulation service comparing to the standard AC care.