Rickard E. Malmström

Policies to enhance prescribing efficiency in europe: findings and future implications.

Introduction: European countries need to learn from each other to address unsustainable increases in pharmaceutical expenditures. Objective: To assess the influence of the many supply and demand-side initiatives introduced across Europe to enhance prescribing efficiency in ambulatory care. As a result provide future guidance to countries. Methods: Cross national retrospective observational study of utilization (DDDs – defined daily doses) and expenditure (Euros and local currency) of proton pump inhibitors (PPIs) and statins among 19 European countries and regions principally from 2001 to 2007. Demand-side measures categorized under the “4Es” – education engineering, economics, and enforcement. Results: Instigating supply side initiatives to lower the price of generics combined with demand-side measures to enhance their prescribing is important to maximize prescribing efficiency. Just addressing one component will limit potential efficiency gains. The influence of demand-side reforms appears additive, with multiple initiatives typically having a greater influence on increasing prescribing efficiency than single measures apart from potentially “enforcement.” There are also appreciable differences in expenditure (€/1000 inhabitants/year) between countries. Countries that have not introduced multiple demand side measures to counteract commercial pressures to enhance the prescribing of generics have seen considerably higher expenditures than those that have instigated a range of measures. Conclusions: There are considerable opportunities for European countries to enhance their prescribing efficiency, with countries already learning from each other. The 4E methodology allows European countries to concisely capture the range of current demand-side measures and plan for the future knowing that initiatives can be additive to further enhance their prescribing efficiency.

l-Arginine and tetrahydrobiopterin protects against ischemia/reperfusion-induced endothelial dysfunction in patients with type 2 diabetes mellitus and coronary artery disease

Diminished levels of L-arginine and endothelial nitric oxide synthase (eNOS) uncoupling through deficiency of tetrahydrobiopterin (BH(4)) may contribute to endothelial dysfunction. We investigated the effect of L-arginine and BH(4) administration on ischemia-reperfusion (I/R)-induced endothelial dysfunction in patients with type 2 diabetes and coronary artery disease (CAD). Forearm blood flow was measured by venous occlusion plethysmography in 12 patients with type 2 diabetes or impaired glucose tolerance and CAD. Forearm ischemia was induced for 20 min, followed by 60 min of reperfusion. The patients received a 15 min intra-brachial infusion of L-arginine (20 mg/min) and BH(4) (500 microg/min) or 0.9% saline starting at 15 min of ischemia on two separate study occasions. Compared with pre-ischemia the endothelium-dependent vasodilatation (EDV) induced by acetylcholine was significantly reduced at 15 and 30 min of reperfusion when saline was infused (P<0.001), but not following L-arginine and BH(4) infusion. EDV was also significantly less reduced at 15 and 30 min of reperfusion following L-arginine and BH(4) infusion, compared to saline infusion (P<0.02). Endothelium-independent vasodilatation (EIDV) induced by nitroprusside was unaffected by I/R. Venous total biopterin levels in the infused arm increased from 37+/-7 at baseline to 6644+/-1240 nmol/l during infusion of L-arginine and BH(4) (P<0.0001), whereas there was no difference in biopterin levels during saline infusion. In conclusion L-arginine and BH(4) supplementation reduces I/R-induced endothelial dysfunction, a finding which may represent a novel treatment strategy to limit I/R injury in patients with type 2 diabetes and CAD.

Are new models needed to optimize the utilization of new medicines to sustain healthcare systems

Medicines have made an appreciable contribution to improving health. However, even high-income countries are struggling to fund new premium-priced medicines. This will grow necessitating the development of new models to optimize their use. The objective is to review case histories among health authorities to improve the utilization and expenditure on new medicines. Subsequently, use these to develop exemplar models and outline their implications. A number of issues and challenges were identified from the case histories. These included the low number of new medicines seen as innovative alongside increasing requested prices for their reimbursement, especially for oncology, orphan diseases, diabetes and HCV. Proposed models center on the three pillars of pre-, peri- and post-launch including critical drug evaluation, as well as multi-criteria models for valuing medicines for orphan diseases alongside potentially capping pharmaceutical expenditure. In conclusion, the proposed models involving all key stakeholder groups are critical for the sustainability of healthcare systems or enhancing universal access. The models should help stimulate debate as well as restore trust between key stakeholder groups.

Personalizing health care: feasibility and future implications.

Considerable variety in how patients respond to treatments, driven by differences in their geno- and/ or phenotypes, calls for a more tailored approach. This is already happening, and will accelerate with developments in personalized medicine. However, its promise has not always translated into improvements in patient care due to the complexities involved. There are also concerns that advice for tests has been reversed, current tests can be costly, there is fragmentation of funding of care, and companies may seek high prices for new targeted drugs. There is a need to integrate current knowledge from a payer’s perspective to provide future guidance. Multiple findings including general considerations; influence of pharmacogenomics on response and toxicity of drug therapies; value of biomarker tests; limitations and costs of tests; and potentially high acquisition costs of new targeted therapies help to give guidance on potential ways forward for all stakeholder groups. Overall, personalized medicine has the potential to revolutionize care. However, current challenges and concerns need to be addressed to enhance its uptake and funding to benefit patients.

Dabigatran - a case history demonstrating the need for comprehensive approaches to optimize the use of new drugs

Background: There are potential conflicts between authorities and companies to fund new premium priced drugs especially where there are safety and/or budget concerns. Dabigatran, a new oral anticoagulant for the prevention of stroke in patients with non-valvular atrial fibrillation (AF), exemplifies this issue. Whilst new effective treatments are needed, there are issues in the elderly with dabigatran due to variable drug concentrations, no known antidote and dependence on renal elimination. Published studies have shown dabigatran to be cost-effective but there are budget concerns given the prevalence of AF. There are also issues with potentially re-designing anticoagulant services. This has resulted in activities across countries to better manage its use. Objective: To (i) review authority activities in over 30 countries and regions, (ii) use the findings to develop new models to better manage the entry of new drugs, and (iii) review the implications for all major stakeholder groups. Methodology: Descriptive review and appraisal of activities regarding dabigatran and the development of guidance for groups through an iterative process. Results: There has been a plethora of activities among authorities to manage the prescribing of dabigatran including extensive pre-launch activities, risk sharing arrangements, prescribing restrictions, and monitoring of prescribing post-launch. Reimbursement has been denied in some countries due to concerns with its budget impact and/or excessive bleeding. Development of a new model and future guidance is proposed to better manage the entry of new drugs, centering on three pillars of pre-, peri-, and post-launch activities. Conclusion: Models for introducing new drugs are essential to optimize their prescribing especially where there are concerns. Without such models, new drugs may be withdrawn prematurely and/or struggle for funding.

Interface management of pharmacotherapy. Joint hospital and primary care drug recommendations

PurposeIn September 2012 an interactive course on the “Interface Management of Pharmacotherapy” was organized by the Stockholm Drug and Therapeutics Committee in cooperation with Department of Clinical Pharmacology at Karolinska Institutet and at Karolinska University Hospital in Stockholm, Sweden, in collaboration with the WHO. The basis for the course was the “Stockholm model” for the rational use of medicines but also contained presentations about successful models in interface management of pharmacotherapy in other European countries.MethodsThe “Stockholm model” consists of 8 components: 1) Independent Drug and Therapeutics Committee with key role for respected drug experts with policy for “interest of conflicts”, 2) The “Wise List”, recommendations of medicines jointly for primary and hospital care, 3) Communication strategy with continuous medical education, 4) Systematic introduction of new expensive medicines, 5) E-pharmacological support at “point of care”, 6) Methods and tools for follow-up of medicines use, 7) Medicines policy strategy and 8) Operative resources.ResultsThe course highlighted the importance of efficient and targeted communication of drug recommendations building on trust among prescribers and patients for the guidelines to achieve high adherence. Trust is achieved by independent Drug and Therapeutics Committees with a key role for respected experts and a strict policy for “conflicts of interest”. Representations of GPs are also crucial for successful implementation, being the link between evidence based medicine and practice.ConclusionThe successful models in Scotland and in Stockholm as well as the ongoing work in Catalonia were considered as examples of multifaceted approaches to improve the quality of medicine use across primary and hospital care.

Improving the managed entry of new medicines: sharing experiences across Europe.

The Managed Introduction of New Medicines Ljubljana, Slovenia, 19–21 March 2012 The 3-day course on the managed entry of new medicines was run by the Piperska group, which is a pan-European group striving to enhance the health of the public as a whole and the individual patient through exchanging ideas and research around the rational use of drugs. Participants included health authority and health insurance personnel, academics and those from commercial organizations. The principal aim of the conference was to bring together people to discuss ways to improve the managed entry of new drugs.

Characterization and molecular cloning of vascular neuropeptide Y receptor subtypes in pig and dog

Cloning with subsequent in vitro and in vivo characterization of vascular neuropeptide Y (NPY) receptor subtypes in porcine and canine peripheral tissues was performed. RT-PCR with Y1 and Y2 receptor-specific primers, indicated expression of Y1 receptors in both kidney and spleen of dog and pig, and expression of Y2 receptors in pig spleen. In pig kidney, expression of Y1 receptor mRNA was located to intrarenal arteries, as demonstrated with in situ hybridization using human probes. The cloned and sequenced canine Y1, porcine Y1 and Y2 receptors revealed high homologies to previously characterized mammalian NPY receptors. Membrane and autoradiographic receptor binding studies showed specific high-affinity binding sites for the purported Y1-selective radioligands 125I-[Leu31Pro34]peptide YY (PYY) and 3H-BIBP 3226 in dog spleen, and for the putative Y2-selective 125I-PYY(3-36) in dog and pig spleen. In the pig in vivo, [Leu31Pro34]PYY, administered i.v., evoked vasoconstriction in spleen and kidney, actions that were potently inhibited by the non-peptide Y receptor antagonist SR 120107A. In contrast, PYY(3-36) evoked vasoconstriction only in spleen and this effect was not influenced by SR 120107A. NPY evoked renal and splenic vasoconstriction in the dog in vivo, vascular responses that were inhibited by both BIBP 3226 and SR 120107A. Furthermore, the Y1 receptor agonist [Leu31Pro34]NPY also caused vasoconstriction in dog kidney and spleen, whereas the putative Y2 agonist N-acetyl[Leu28Leu31]NPY(24-36) evoked no such vascular responses. It is concluded that the pig spleen is likely to contain Y1 and Y2 receptors, both involved in splenic vasoconstriction. In contrast, the Y1 receptor seems to be the sole vascular NPY receptor subtype in pig kidney. Moreover, Y1 receptors predominate in dog spleen and kidney. Furthermore, the cloned canine Y1 receptor and the porcine Y1 and Y2 receptors show great homologies to, and possess ligand requirement profiles in accordance with, the human forms.

The neuropeptide Y (NPY) Y1 receptor antagonist BIBP 3226: effects on vascular responses to exogenous and endogenous NPY in the pig in vivo

The antagonistic effects of the neuropeptide Y (NPY) Y1 receptor antagonist BIBP 3226 on equally prominent vascular responses evoked by sympathetic nerve stimulation and exogenous NPY were compared during different intravenous (i.v.) infusions of the antagonist (0.19–190 nmol kg−1 min−1, for 30 min). High frequency sympathetic nerve stimulation in reserpine‐treated pigs in vivo evoked non‐adrenergic vasoconstrictor responses in kidney and hind limb, in the latter followed by a long‐lasting phase of decreased blood flow. The vascular response in the kidney and the long‐lasting phase in hind limb resembled the effects of exogenous NPY administered i.v. (kidney) and intraarterially (i.a.) (in the hind limb, which only responded to higher NPY doses). Plasma levels of BIBP 3226 reached a plateau within 20 min and the inhibitory effects on vascular responses were studied during the last ten minutes of infusion. The elimination of BIBP 3226 from plasma was found to fit a two‐compartment model with an α‐phase of 2.0±0.2 min and a β‐phase of 20.1±0.9 min. Significant inhibition of presumably Y1 receptor‐mediated vascular responses evoked by both endogenous and exogenous NPY in kidney and hind limb was seen even during low‐dose infusion of BIBP 3226 (1.9 nmol kg−1 min−1), when plasma levels of the antagonist reached 59±8 nM. The maximum inhibitory effects of BIBP 3226 were seen during the highest‐dose infusion (190 nmol kg−1 min−1), when the long‐lasting vasoconstrictor responses in hind limb to sympathetic nerve stimulation and exogenous NPY administration (i.a.) were abolished. Simultaneously, the vascular responses in kidney to exogenous NPY were inhibited by 89% and to sympathetic nerve stimulation by 60%. It is concluded that BIBP 3226 has a short half‐life in plasma and should preferably be given by i.v. infusions to maintain blockade and avoid non‐specific effects. Furthermore, BIBP 3226 dose‐dependently and with similar potency antagonizes vascular responses to exogenous and endogenous NPY both in the kidney and hind limb of the reserpine‐treated pig in vivo. Thus, inhibition of vascular responses to exogenous NPY may be a good indicator of the dose of this antagonist needed to inhibit sympathetic Y1 receptor‐transmission.

On the monitoring of dabigatran treatment in “real life” patients with atrial fibrillation

INTRODUCTION The oral direct thrombin inhibitor dabigatran is increasingly used to prevent thromboembolic stroke in patients with atrial fibrillation (AF). Routine laboratory monitoring is currently not recommended, but measurements of dabigatran and/or its effect are desirable in certain situations. We studied dabigatran exposure and compared different tests for monitoring of dabigatran in a real-life cohort of AF patients. MATERIAL AND METHODS Ninety AF patients (68 ± 9 years, 67% men, mean CHADS2 score 1.5) were treated with dabigatran 150 (n=73) or 110 mg BID (n=17). Trough plasma concentrations of total and free dabigatran by liquid chromatography-tandem mass-spectrometry (LC-MS/MS) were compared to indirect measurements by Hemoclot thrombin inhibitors (HTI) and Ecarin clotting assay (ECA), as well as PT-INR and aPTT. RESULTS Total plasma dabigatran varied 20-fold (12-237 ng/mL with 150 mg BID) and correlated well with free dabigatran (r(2)=0.93). There were strong correlations between LC-MS/MS and HTI or ECA (p<0.001) but these assays were less accurate with dabigatran below 50 ng/mL. The aPTT assay was not dependable and PT-INR not useful at all. There were weak correlations between creatinine clearance (Cockcroft-Gault) and LC-MS/MS, HTI and ECA (p<0.001 for all). A high body weight with normal kidney function was associated with low dabigatran levels. CONCLUSIONS HTI and ECA reflect the intensity of dabigatran anticoagulation, but LC-MS/MS is required to quantify low levels or infer absence of dabigatran. Most real life patients with a normal creatinine clearance had low dabigatran levels suggesting a low risk of bleeding but possibly limited protection against stroke.