Initiatives to promote access to medicines after publication of the Brazilian Policy on the Comprehensive Care of People with Rare Diseases.

BACKGROUND: Rare diseases affect a small number of people compared to prevalent diseases. The vast majority of these diseases are of genetic origin, have no cure, are chronic and can lead to death. Although the right to access medicines is included in the constitutionally guaranteed right to health in Brazil, problems in the supply of medicines for rare diseases are reported in the country. This study aimed to describe and analyse the initiatives to promote access to medicines for treating rare diseases in the Unified Health System, Brazil, after the publication of the Brazilian Policy on the Comprehensive Care of People with Rare Diseases. Based on the model published by the WHO Regional Office for Europe, which described access to medicines in prelaunch, perilaunch and postlaunch policies, the initiatives referring to each category were summarized based on documentary research searched in online databases from January 2014 to December 2020. RESULTS: Different actions and policy interventions were identified, which went through the expansion of resources for research and development, health regulations, incorporation of new drugs, review and publication of clinical guidelines, and expansion of the network of care facilities by the Ministry of Health. On the other hand, aspects related to care policies, pricing methods, technological development, and development of pharmaceutical service processes were not implemented. CONCLUSIONS: Although it is impossible to determine the explicit motivation of such actions concerning the Policy, its publication certainly was a landmark in Brazilian society, allowing greater recognition of the needs of rare disease patients and the specificities of treatment'. However, this study suggests that the steps that make up the life cycle of medicines are not linked, lacking articulation and integration of the care network, and consequently, there is no evidence that rare disease policy publication has generated a broad impact on the promotion of access to medicines to treat rare diseases in Brazil.

Pharmaceutical policies for gaining access to high-priced medicines: a comparative analysis between England and Brazil / Políticas farmacêuticas para acesso a medicamentos de alto preço: uma análise comparativa entre Inglaterra e Brasil

ABSTRACT Although the National Health Service (NHS) and the Unified Health System (SUS) are systems with similar universal principles, they can show different political measure patterns in the pharmaceutical field. This paper aimed to provide a comparative analysis of pharmaceutical policies highlighting strategies to guarantee access and sustainability to High-Price Medicines (HPMs) in Brazil and England. We performed an integrative literature review in electronic databases, supplemented by grey literature searched on governmental platforms (laws, decrees, ordinances, and resolutions). A total of Forty-seven articles and seven policies were selected and categorized for analysis. The results showed that both countries apply distinct policies to ensure access to HPMs, among them, policies to define price and reimbursement and actions to regulate the use inside the system. Also, these countries apply distinct policies to their sustainability as local partnerships for product development in Brazil and confidential managed agreements with multinational industries in the England. In conclusion, despite similarities in principles, these countries have been proposing and applying distinct pharmaceutical policies to maintain access and ensure the sustainability of their health systems.

RESUMO Embora o National Health Service (NHS) e o Sistema Único de Saúde (SUS) sejam sistemas com princípios universais semelhantes, diferentes políticas no campo farmacêutico podem coexistir. O objetivo deste artigo foi fornecer uma análise comparativa destacando estratégias para garantir o acesso e a sustentabilidade a Medicamentos de Alto Preço (MAP) no Brasil e na Inglaterra. Foi realizada uma revisão integrativa da literatura em bases de dados eletrônicas, complementada por literatura cinzenta pesquisada em plataformas governamentais (leis, decretos, portarias e resoluções). Um total de 47 artigos e 7 políticas foram selecionados e categorizadas para análise. Os resultados demostraram que ambos os países aplicam distintas políticas para garantir o acesso aos MAP, entre elas, políticas para definição de preço e reembolso e ações para regular a utilização destes medicamentos dentro do sistema. Além disso, os países aplicam políticas distintas à sua própria sustentabilidade como as parcerias para o desenvolvimento produtivo local no Brasil e acordos confidenciais com indústrias multinacionais na Inglaterra. Em conclusão, apesar das semelhanças nos princípios, estes países têm proposto e aplicado políticas farmacêuticas distintas para manter o acesso e a sustentabilidade de seus sistemas de saúde.

Transforming uncertainties into legitimate regulation? NICE and CONITEC agencies' decisions on rare diseases. / Transformando incertezas em regulamentação legitimadora? As decisões das agências NICE e CONITEC para doenças raras.

As a scientific and technological practice, the evaluation of health technologies (HTA) is, at the same time, a challenge to determine the value of the technologies to be incorporated. This study aimed to explore and compare the results and technical elements of the evaluations issued for rare diseases between the English (NICE) and the Brazilian agency (CONITEC). The first part of the study involved the systematic search for evaluations from 2013 to 2019. In the second stage, the reports were analyzed based on: (i) descriptive narrative review; and (ii) calculation of the absolute and relative frequency according to each domain and component (element) applied in the European HTA network model. Twenty-four medicines were distinctly assessed during the study period. Through 126 questions (elements) distributed among nine domains, the analysis revealed that 67 (53.2%) and 44 (35.0%) were described in the reports, 42 (33.3%) and 59 (47.0 %) were only considered partially, and 17 (13.5%) and 23 (18.0%) were not considered in the NICE and CONITEC reports, respectively. We identified a relatively low agreement between the Brazilian agency with the English agency in the reports issued for rare diseases. It remains to be seen whether the agencies are able to capture the various values ​​of these medicines, as well as manage uncertainties in the evaluations.

A avaliação de tecnologias em saúde (ATS), enquanto prática científica e tecnológica é, ao mesmo tempo, um desafio, a fim de determinar o valor das tecnologias a serem incorporadas. Este estudo teve como objetivo explorar e comparar os resultados e elementos técnicos das avaliações emitidas para doenças raras, entre a agência inglesa (NICE) e a brasileira (CONITEC). A primeira etapa do estudo envolveu a busca sistemática das avaliações no período de 2013 a 2019. Na segunda etapa, os relatórios foram analisados com base em: (i) revisão narrativa descritiva e (ii) cálculo da frequência absoluta e relativa de acordo com cada domínio e componente (elemento) aplicado do modelo da rede Europeia de ATS. O total de 24 medicamentos foram distintamente avaliados no período do estudo. Por meio de 126 questões (elementos) distribuídas entre nove domínios, a análise revelou que 67 (53,2%) e 44 (35,0%) estavam descritas nos relatórios, 42 (33,3%) e 59 (47,0%) foram consideradas apenas parcialmente e 17 (13,5%) e 23 (18,0%) não foram consideradas nos relatórios do NICE e da CONITEC, respectivamente. Foi constatado uma concordância relativamente baixa da agência brasileira em relação à inglesa nos relatórios emitidos para doenças raras. Permanece indeterminado se as agências são capazes de capturar os diversos valores desses medicamentos, bem como gerenciar as incertezas nas avaliações.

Transformando incertezas em regulamentação legitimadora? As decisões das agências NICE e CONITEC para doenças raras / Transforming uncertainties into legitimate regulation? NICE and CONITEC agencies' decisions on rare diseases

Resumo A avaliação de tecnologias em saúde (ATS), enquanto prática científica e tecnológica é, ao mesmo tempo, um desafio, a fim de determinar o valor das tecnologias a serem incorporadas. Este estudo teve como objetivo explorar e comparar os resultados e elementos técnicos das avaliações emitidas para doenças raras, entre a agência inglesa (NICE) e a brasileira (CONITEC). A primeira etapa do estudo envolveu a busca sistemática das avaliações no período de 2013 a 2019. Na segunda etapa, os relatórios foram analisados com base em: (i) revisão narrativa descritiva e (ii) cálculo da frequência absoluta e relativa de acordo com cada domínio e componente (elemento) aplicado do modelo da rede Europeia de ATS. O total de 24 medicamentos foram distintamente avaliados no período do estudo. Por meio de 126 questões (elementos) distribuídas entre nove domínios, a análise revelou que 67 (53,2%) e 44 (35,0%) estavam descritas nos relatórios, 42 (33,3%) e 59 (47,0%) foram consideradas apenas parcialmente e 17 (13,5%) e 23 (18,0%) não foram consideradas nos relatórios do NICE e da CONITEC, respectivamente. Foi constatado uma concordância relativamente baixa da agência brasileira em relação à inglesa nos relatórios emitidos para doenças raras. Permanece indeterminado se as agências são capazes de capturar os diversos valores desses medicamentos, bem como gerenciar as incertezas nas avaliações.

Abstract As a scientific and technological practice, the evaluation of health technologies (HTA) is, at the same time, a challenge to determine the value of the technologies to be incorporated. This study aimed to explore and compare the results and technical elements of the evaluations issued for rare diseases between the English (NICE) and the Brazilian agency (CONITEC). The first part of the study involved the systematic search for evaluations from 2013 to 2019. In the second stage, the reports were analyzed based on: (i) descriptive narrative review; and (ii) calculation of the absolute and relative frequency according to each domain and component (element) applied in the European HTA network model. Twenty-four medicines were distinctly assessed during the study period. Through 126 questions (elements) distributed among nine domains, the analysis revealed that 67 (53.2%) and 44 (35.0%) were described in the reports, 42 (33.3%) and 59 (47.0 %) were only considered partially, and 17 (13.5%) and 23 (18.0%) were not considered in the NICE and CONITEC reports, respectively. We identified a relatively low agreement between the Brazilian agency with the English agency in the reports issued for rare diseases. It remains to be seen whether the agencies are able to capture the various values ​​of these medicines, as well as manage uncertainties in the evaluations.

Anti-Inflammatory Profile of Jungia sellowii Less. by Downregulation of Proinflammatory Mediators and Inhibition of NF-κB and p38 Pathways.

Jungia sellowii Less. (Asteraceae) is a native plant found in Southeast Brazil used traditionally to treat inflammatory diseases. This study was conducted (1) to investigate the toxicity of the crude extract (CE) and (2) to investigate the mechanism of the anti-inflammatory action of J. sellowii L. roots. The potential acute toxicity of CE was performed by administration of only different doses of CE (500, 1,000, and 2,000 i.p.) on mice for 14 days. The anti-inflammatory effect was evaluated using carrageenan-induced acute pleural cavity inflammation in a mouse model, evaluated through the following inflammatory variables: leukocyte, protein concentrations of the exudate, myeloperoxidase (MPO), adenosine deaminase (ADA), nitric oxide metabolites (NOx), and proinflammatory cytokine (tumor necrosis factor alpha (TNF-α), interferon gamma (IFN-γ), interleukin- (IL-) 6, and IL-12) levels in mouse pleural fluid leakage. The p65 protein phosphorylation of nuclear factor NF-kappa B (p65 NF-κB) and p38 mitogen-activated protein kinase (p38 MAPK) phosphorylation were analyzed in lung tissue. Our results demonstrated that the administration of CE up to 2,000 mg/kg did not present a toxic effect. In addition, the pretreatment of mice with CE; its derived fractions (aqueous fraction (AqF), butanol fraction (BuOHF), and ethyl acetate fraction (EtOAcF)); and isolated compounds (curcuhydroquinone O-ß-glucose (CUR) and α and ß piptizol (Pip)) reduced the following inflammatory variables: neutrophils, protein concentrations of the exudate, MPO, ADA, NOx, and proinflammatory cytokine (TNF-α, IFN-γ, IL-6, and IL-12) levels in mouse pleural fluid leakage. The compounds CUR and Pip also decreased the p65 protein phosphorylation of NF-kappa B and p38 (MAPK) in lung tissue. J. sellowii L. has important anti-inflammatory activity with potential applications in drug development against inflammatory disorders. These effects found can be attributed to the ability of the new isolated compounds CUR and Pip to suppress p65 NF-κB and p-p38 MAPK pathways.

Cytotoxicity, antiprotozoal, and anti-inflammatory activities of eight curry powders and comparison of their UPLC-ESI-QTOF-MS chemical profiles.

BACKGROUND: Curry powder is a blend of spices that is extensively consumed worldwide and mainly in Central Asia. Its preparation is strictly related to each locality and, because of the health benefits of its constituents, eight commercial forms of this condiment were biologically and chemically investigated. This study aimed to compare their chemical profile as well as their anti-inflammatory, cytotoxic, and antiparasitic activities. RESULTS: Curry samples 1 and 7 inhibited leukocyte influx and myeloperoxidase activity, while only 7 was active on protein exudate and NOx species. 2, 6, and 8 displayed trypanocidal effect against Trypanosoma cruzi amastigote, whereas 6 showed antileishmanial activity on Leishmania amazonensis amastigote. 2, 6, and 8 also inhibited the growth of THP-1 cells used as the parasite's host. Among the cytotoxic samples (4 and 6), curry sample 6 induced apoptosis in MDA-MB-231 cells. Nevertheless, 4 and 6 were unselectively cytotoxic to non-tumoral and tumoral cells. The anti-inflammatory, cytotoxicity, and antiparasitic assays were respectively performed by carrageenan-induced pleurisy test, Alamar blue assay, and intracellular parasite-host cell model. Ultra-performance liquid chromatographic-electrospray ionization mass spectrometric data from the spices revealed both similar and different metabolites in their composition. CONCLUSION: The results obtained indicate that different formulations can contribute different health benefits as a result of their chemical composition. © 2018 Society of Chemical Industry.

Calea uniflora Less. attenuates the inflammatory response to carrageenan-induced pleurisy in mice.

Calea uniflora Less. (family Asteraceae), also named "arnica" and "erva-de-lagarto", is a native plant to the South and Southeast of Brazil. This species was used to treat rheumatism, respiratory diseases, and digestive problems in Brazilian folk medicine. In vitro studies have shown the important biological effects of C. uniflora. However no studies have focused on the mechanism of action of anti-inflammatory activity of C. uniflora. The aim of this study was to evaluate the anti-inflammatory effects of the crude extract, its fractions, and isolated compounds obtained from of C. uniflora, using mouse model of carrageenan-induced inflammation. The following inflammatory parameters: leukocyte influx, degree of exudation, myeloperoxidase (MPO) and adenosine deaminase (ADA) activities, nitric oxide metabolites (NOx), proinflammatory cytokines and phosphorylation of the p65 subunit of NF-κB (p-p65 NF-κB), and p38 mitogen-activated protein kinase (p-p38 MAPK) levels were determined. The crude extract of C. uniflora, its fractions and its isolated compounds reduced the leukocyte influx, degree of exudation, MPO and ADA activities, NOx, TNF-α, IFN-γ, MCP-1 and IL-6 levels (p<0.05). The isolated compounds reduced p-p65 NF-κB and p-p38 MAPK levels (p<0.01). This study demonstrated that C. uniflora exhibits a significant anti-inflammatory activity via inhibition of the leukocyte influx and degree of exudation. These effects were associated with a decrease in the levels of several proinflammatory mediators. The mechanism of the anti-inflammatory action of C. uniflora may be, at least in part, via the inhibition of p65 NF-κB and p38 MAPK activation by the isolated compounds.

Beneficial effect of Ageratum conyzoides Linn (Asteraceae) upon inflammatory response induced by carrageenan into the mice pleural cavity.

ETHNOPHARMACOLOGICAL RELEVANCE: Ageratum conyzoides Linn (Asteraceae), a tropical plant that is very common in West Africa and some parts of Asia and South America, has been used to treat inflammatory disorders. In Brazil, teas made from A. conyzoides L. are used as anti-inflammatory, analgesic and anti-diarrheic agents. Therefore, it is necessary to study the mechanism of anti-inflammatory action of A. conyzoides L. to support its medicinal use for treating inflammatory conditions. These studies will also support the development of effective pharmacological agents with potent anti-inflammatory properties. AIM OF THE STUDY: To evaluate the anti-inflammatory effects of the crude extract (CE), its derived fractions: ethanol (EtOH-F), hexane (HEX-F), ethyl acetate (EtOAc-F) and dichloromethane (DCM-F) and isolated compounds, such as 5'-methoxy nobiletin (MeONOB), 1,2-benzopyrone and eupalestin, which are obtained from the aerial parts of A. conyzoides L. MATERIALS AND METHODS: These evaluations were performed using an animal model of inflammation induced by carrageenan. The following inflammatory parameters were analysed: leukocyte influx, protein concentration of the exudate, myeloperoxidase (MPO), adenosine deaminase (ADA) and nitric oxide metabolites (NOx) concentrations, interleukin 10 (IL-10), interleukin 17A (IL-17A), interleukin 6 (IL-6), tumor necrosis factor (TNF), interferon gamma (IFN-γ) and phosphorylation of p65 subunit of NF-κB (p-p65 NF-κB), p38 mitogen-activated protein kinases (p-p38 MAPK) were also analysed. RESULTS: CE, its EtOH-F, HEX-F, EtOAc-F and DCM-F and the isolated compounds, including MeONOB, 1,2-benzopyrone and eupalestin, significantly reduced leukocyte influx, protein concentration of the exudate, MPO, ADA, and NOx concentrations (p<0.05). CE, EtOH-F and isolated compounds significantly reduced IL-17A, IL-6, TNF and IFN-γ levels (p<0.05). CE, EtOH-F and isolated compound 1,2-benzopyrone also increased IL-10 levels (p<0.05). Isolated compounds, MeONOB, 1,2-benzopyrone and eupalestin, reduced p-p65 NF-κB and p-p38 MAPK (p<0.01). CONCLUSIONS: This study demonstrates that A. conyzoides L. exerts its important anti-inflammatory properties by inhibiting leukocyte influx and protein concentration of the exudate, as well as reducing the levels of several pro-inflammatory mediators. The anti-inflammatory action of A. conyzoides L. may be because of the inhibition of p65 NF-κB and MAPK activation by the isolated compounds.

Jungia sellowii suppresses the carrageenan-induced inflammatory response in the mouse model of pleurisy.

This study was conducted to explore the anti-inflammatory effect of Jungia sellowii (Asteraceae) using a murine model of pleurisy induced by carrageenan (Cg). This plant is used in southern Brazil to treat inflammatory diseases. J. sellowii leaves were extracted with ethanol/water to obtain the crude extract (CE), which was fractionated with different solvents, yielding n-hexane (Hex), dichloromethane (DCM), ethyl acetate (EtOAc) and n-butanol (BuOH) fractions, and aqueous fraction (Aq). The major compounds succinic acid (SA) and lactic acid (LA) were isolated from Aq fraction, and their structures were determined by (1)H and (13)C NMR. Pleurisy was induced by Cg (Saleh et al. 1996). The leukocytes, exudation, myeloperoxidase (MPO) and adenosine-deaminase (ADA) activities, metabolites of nitric oxide (NO x ) levels, protein levels and mRNA expression for interleukin 1 beta (IL-1ß), tumour necrosis factor alpha (TNF-α), interleukin 17A (IL17A) and inducible of nitric oxide synthase (iNOs), and p65 protein phosphorylation (NF-κB) were analysed 4 h after pleurisy induction. Animals pre-treated with CE, BuOH, Aq, SA, or LA inhibited leukocytes, exudation, MPO and ADA activities, NO x , IL-1ß, TNF-α, and IL-17A levels, and the mRNA expression for IL-1ß, TNF-α, IL-17A, iNOS, and p65 protein phosphorylation (NF-κB) (p < 0.05). Our study demonstrated that J. sellowii can protect against inflammation induced by Cg by decreasing the leukocytes and exudation. Its effects are related to the decrease of either proinflammatory cytokines and/or NO x . The isolated compounds SA and LA may play an important role in this anti-inflammatory action by inhibiting all the studied parameters. The anti-inflammatory properties of these compounds are due to the downregulation of NF-κB.

Evaluation of circulating levels of inflammatory and bone formation markers in axial spondyloarthritis.

Studies have demonstrated the important role of bone remodelling and osteoimmunology in the progression of inflammatory lesions in axial spondyloarthritis (SpA) disease. This study was conducted to evaluate the inflammatory response by analysis of the serum levels of pro-inflammatory and new bone formation markers in patients with axial SpA who were treated or not treated with anti-tumour necrosis factor-α (anti-TNF-α) or non-steroidal drugs (NSAIDs) and to identify whether these drugs modify the activity and severity of the disease. The serum levels of myeloperoxidase (MPO), adenosine deaminase (ADA), nitric oxide metabolites (NOx), bone alkaline phosphatase (BAP), Dickkopf-1 (DKK-1), and osteoprotegerin (OP) were measured in 52 SpA patients who were treated or not with anti-TNF-α or NSAIDs and in 26 healthy controls using colourimetric and enzyme immunoassay tests. The activity and the severity of illness in patients with SpA were assessed using questionnaires (Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Functional Index (BASFI), and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)). A significant difference between the controls and the patients without medication was observed in relation to NOx, BAP, and OP (p<0.01). When the patients were compared with regard to their treatment, there were no clinically significant differences between the groups (p>0.05). In conclusion, The NOx, BAP, and OP are emerging as important inflammatory pathways in axial SpA. Also the anti-TNF-α or non-steroidal drugs reduce the inflammation and destructions, however these treatments do not modify the serum levels of these biomarkers.

Croton antisyphiliticus Mart. attenuates the inflammatory response to carrageenan-induced pleurisy in mice.

The aim of this study was to investigate the anti-inflammatory effect of the crude hydroalcoholic extract (CHE) from the aerial parts of Croton antisyphiliticus, its fractions and isolated compounds derived from it on the mouse model of pleurisy induced by carrageenan. The aerial parts of C. antisyphiliticus were dried, macerated and extracted with ethanol to obtain the CHE, which was fractionated by liquid-liquid extraction using solvents with increasing polarity to obtain hexane (Hex), ethyl acetate (EA) and aqueous (Aq) fractions. Vitexin and quinic acid were isolated from Aq fraction. Capillary electrophoresis analysis, physical characteristics and spectral data produced by infrared (IR), nuclear magnetic resonance ((1)H and (13)C NMR) and mass spectrometry analyses were used to identify and elucidate the structure of the isolated compounds. The experimental model of pleurisy was induced in mice by a single intrapleural injection of carrageenan (1 %). Leukocytes, exudate concentrations, myeloperoxidase (MPO) and adenosine-deaminase (ADA) activities and nitrate/nitrite (NOx), tumor necrosis factor-α (TNF-α) and interleukin-17 (IL-17) levels were determined in the pleural fluid leakage at 4 h after pleurisy induction. Animals pre-treated with CHE, Hex, EA, Aq, vitexin and quinic acid exhibited decreases in leukocytes, exudate concentrations, MPO and ADA activities and NOx levels (p < 0.05). Also CHE, Hex, EA and vitexin but not quinic acid inhibited TNF-α and IL-17 levels (p < 0.05). C. antisyphiliticus caused anti-inflammatory effect by inhibiting the activated leukocytes, exudate concentrations, NOx, TNF-α, and IL-17 levels. The compounds vitexin and quinic acid may be responsible for this anti-inflammatory action.