Cost-effectiveness of the pharmacist-assisted warfarin monitoring program at a Medical Center in Taiwan.

OBJECTIVE: To investigate the cost-effectiveness of the first patient self-paying pharmacist-assisted warfarin monitoring (PAWM) program in Taiwan. DESIGN: A Markov model with a 1-month cycle length and a 20-year time horizon was employed in this study. The model is composed of the following eight states: three no-event states (i.e. 'subtherapeutic,' 'within therapeutic' and 'supratherapeutic' states), two serious adverse events (AEs) (i.e. bleeding and thromboembolism), two sequelae states and death. The likelihood of events, costs and utilities were derived from local databases and literature, if applicable. This study was conducted with a payer's perspective and all costs were discounted with a rate of 3%. SETTING: A pharmacist-led clinic. PARTICIPANTS: A hypothetical cohort of 10 000 participants. INTERVENTION(S): PAWM versus usual care. MAIN OUTCOME MEASURE(S): Average quality-adjusted life-years (QALYs) gained and cost increments per patient, and incremental cost-effectiveness ratios (ICERs). RESULTS: The PAWM program resulted in an average of 0.13 QALYs gained and a cost increment of NT$53 850 (US$1683) per patient. As the ICER (NT$410 749 [US$12 836]) was less than the gross domestic product per capita (NT$631 142 [US$19 723]), the PAWM was considered to be very cost-effective. The sensitivity analyses suggested that our result was robust and that the PAWM program had an 86% probability of being very cost-effective. CONCLUSIONS: Even if the costs saved from avoiding AEs were thought to be minimal due to the low-medical expenditures in Taiwan, the PAWM program was demonstrated to be economical. According to our findings, the policymakers should consider reimbursing such a service.

The Effects of Pharmacist-Led Medication Therapy Management on Medication Adherence and Use of Non-Steroidal Anti-Inflammatory Drug in Patients with Pre-End Stage Renal Disease.

Purpose: Patients with chronic kidney disease (CKD) are particularly vulnerable to the risks of polypharmacy, largely owing to various comorbid conditions. This vulnerability is further compounded by an escalated risk of renal function deterioration when exposed to nephrotoxic medications. As part of the national health insurance program in Taiwan, the pre-end-stage kidney disease patient care and education plan has included pharmaceutical care since October 2021. This study aims to explore the effect of pharmacist involvement in a multidisciplinary care team for patients with kidney disease in outpatient settings. Patients and Methods: This retrospective observational study was conducted at a single center. It analyzed data from May 2022 to May 2023, focusing on patients who received medication therapy management in the kidney disease pharmacist-managed clinic. The study assessed changes in patient medication adherence, non-steroidal anti-inflammatory drugs (NSAIDs) usage, CKD stage, and urine protein-to-creatinine ratio (UPCR) after pharmacist intervention. It also documented pharmacists' medication recommendations and the rate of acceptance by physicians. Results: A total of 202 patients who had at least two clinic visits were included in the study. After pharmacist intervention, the proportion of poor medication adherence reduced significantly from 67.8% to 43.1% (p<0.001). The proportion of NSAID users also decreased significantly from 19.8% to 8.4% (p=0.001). CKD stage showed a significant reduction (p=0.007), and the average UPCR improved from 2828.4 to 2111.0 mg/g (p<0.001). The pharmacists provided a total of 56 medication recommendations, with an acceptance rate of 86%. Conclusion: The involvement of pharmacists in the multidisciplinary care team can effectively provide medication-related recommendations, ensuring the effectiveness and safety of patients' medication use, and lead to better kidney function and lower proteinuria.

The effect of pharmacist-led medication therapy management in the multidisciplinary care of acute kidney injury survivors.

BACKGROUND: The Acute Disease Quality Initiative advocates multidisciplinary care for the survivors of acute kidney injury (AKI). The bundled care strategy recognizes the role of pharmacists. However, their specific contributions in this context remain underexplored. METHODS: This retrospective study examined the efficacy of pharmacist-led post-AKI pharmaceutical care in outpatient settings at a single center. Adults with recent AKI during hospitalization, maintaining an estimated glomerular filtration rate <45 mL/min/1.73 m2 postdischarge, were enrolled in a multidisciplinary team care program from March 2022 to January 2023, with a 6-month follow-up period. Pharmacist-delivered care adhered to international multidisciplinary consensus guidelines. Efficacy was evaluated by analyzing medication-related recommendations, medication adherence, nephrotoxic drug utilization, and renoprotective medication usage before and after the intervention. RESULTS: A total of 40 patients were referred to the pharmacist-managed clinic. Of these, 33 patients (mean age, 63 ± 15 years; 60.6% male) attended the clinic. Nineteen patients completed follow-up visits. The pharmacist provided 14 medication-related recommendations to relevant physicians, with 10 of these recommendations (71.4%) being accepted. There was a significant decrease in the use of modifiable nephrotoxic drugs (p = 0.03). However, no significant improvements were noted in medication adherence or the utilization of renoprotective medications. CONCLUSION: Our study underscores the potential benefits of pharmacist-led post-AKI bundled care strategy in outpatient settings. We observed a significant reduction in the utilization of modifiable nephrotoxic drugs, indicating the effectiveness of pharmacist interventions in optimizing medication regimens to mitigate renal harm.

Effects of a pharmacist-managed anticoagulation outpatient clinic in Taiwan: evaluation of patient knowledge, satisfaction, and clinical outcomes.

Objective: The study aimed to evaluate the improvement of patient knowledge of warfarin use, satisfaction with pharmacists, and the quality of international normalized ratio (INR) control after the implementation of an anticoagulant clinic (ACC) service.Methods: This was a prospective single-group pre- and post-comparison study. Patients who were at least 20 years of age and participated in a pharmacist-managed ACC service were enrolled from February 2012 to September 2015. Each participant completed a self-administered questionnaire before and after the ACC service to evaluate changes in warfarin knowledge. Another questionnaire was distributed after the ACC to evaluate participants' satisfaction with the pharmacist service in the ACC. The INR levels before and after the ACC intervention were obtained to calculate the proportion of time spent in the therapeutic INR range (time in therapeutic range, TTR). Paired t-tests were used to compare changes in participants' knowledge related to warfarin use. Multiple linear regressions were performed to explore the predictors associated with the participants' knowledge scores and TTR after the ACC intervention.Results: One hundred and forty-eight participants were enrolled in this study. A significant improvement (31.5%,p<0.001) in the knowledge of warfarin use was observed at the end of the ACC intervention. The interaction between warfarin and food was the most confusing factor for participants in warfarin use. More than 95% of the participants perceived a positive value of the pharmacist-managed ACC service. However, the consultation fee was the least satisfactory of the ACC service. The average TTR increased from 51.0±34.3% to 78.6±24.5% (p<0.001) after the ACC service was implemented. Participants' education levels and baseline knowledge scores were significant determinants associated with the knowledge improvement in the appropriate warfarin use (p<0.001).Conclusions: A pharmacist-managed ACC improved patient knowledge of warfarin use and INR control, and led to high satisfaction with the pharmacist service in the ACC in Taiwan. Pharmacists should focus on patients with lower education levels to facilitate their understanding of the appropriate warfarin use for better health outcomes.

The anti-inflammatory actions of LCY-2-CHO, a carbazole analogue, in vascular smooth muscle cells.

LCY-2-CHO has anti-inflammatory actions on macrophages. To understand its therapeutic implication in atherosclerosis, we examined its effects on the expressions of anti-inflammatory and inflammatory proteins in cultured rat aortic vascular smooth muscle cells (VSMC). LCY-2-CHO is able to induce heme oxygenase-1 (HO-1) protein expression through a transcriptional action. The HO-1 inducting effect of LCY-2-CHO was inhibited by SB203580, N(G)-nitro-l-arginine methylester (l-NAME), and wortmannin, but was not affected by U0126 or SP600125. In accordance LCY-2-CHO increased protein phosphorylation of p38, Akt, and eNOS. Nrf2 is a transcription factor essential for HO-1 gene induction and we showed that LCY-2-CHO is able to cause Nrf2 nuclear translocation and this action depends on p38, Akt and eNOS. In addition to induce anti-inflammatory HO-1, LCY-2-CHO reduced interleukin-1beta (IL-1beta)-induced inflammatory mediators, inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2), growth-related oncogene protein-alpha (GRO-alpha), and interleukin-8 (IL-8). Inhibitory effect on IL-1beta-mediated NF-kappaB activation was evidenced by the diminishment of IkappaB kinase (IKK) phosphorylation and IkappaBalpha degradation. In contrast, IL-1beta-mediated ERK and JNK activations were not changed by LCY-2-CHO, while p38 activation by IL-1beta and LCY-2-CHO displayed the non-additivity. Taken together, given the overall anti-inflammatory properties of LCY-2-CHO in VSMC, in terms to induce HO-1 gene expression and inhibit inflammatory gene expression, these results highlight the therapeutic potential of LCY-2-CHO in atherosclerosis.

Celecoxib induces heme oxygenase-1 expression in macrophages and vascular smooth muscle cells via ROS-dependent signaling pathway.

The multiple cytoprotective mechanisms of heme oxygenase (HO)-1 make it a promising therapeutic target. This study investigated whether the selective cyclooxygenase (COX)-2 inhibitor, celecoxib, can upregulate HO-1 expression. Murine J774 macrophages and rat aortic vascular smooth muscle cells (VSMCs) were used to study the effect of celecoxib on HO-1 expression. A signal transduction pathway involving reactive oxygen species (ROS) was also investigated. We found that celecoxib can upregulate HO-1 gene and protein expressions in J774 macrophages and VSMCs. This effect was not diminished by prostaglandin E(2) or 15dPGJ(2), while it was additive to hypoxia-induced HO-1 expression, suggesting an event independent of COX-2 activity or hypoxia-inducible factor-1α. Moreover, celecoxib activated ERK, p38, Akt, and Nrf2 as well as increased ROS production. All these events contributed to the increase in the expression of HO-1 caused by celecoxib. In this study, we also, for the first time, demonstrated that AMP-activated protein kinase (AMPK) can mediate HO-1 expression via the downstream activation of p38 and Akt. However, the HO-1-inducing actions of celecoxib and hypoxia were not associated with AMPK. This study demonstrates a COX-2-independent action of celecoxib in upregulating HO-1 in macrophages and VSMCs. This action is dependent on ROS, Akt, ERK, p38, and Nrf2 activation. These findings provide new insights into the action mechanism of celecoxib with broad implications for anti-inflammation therapy.

AICAR induces cyclooxygenase-2 expression through AMP-activated protein kinase-transforming growth factor-beta-activated kinase 1-p38 mitogen-activated protein kinase signaling pathway.

AMP-activated protein kinase (AMPK), a critical signaling molecule for regulating energy homeostasis, might bi-directionally regulate inflammation, and its action mechanism leading to inflammation is not fully understood. We utilized 5-aminoimidazole-4-carboxamide riboside (AICAR) as a pharmacological activator of AMPK to unveil the effects of and signaling cascades mediated by AMPK on cyclooxygenase (COX)-2 gene expression in rat aortic vascular smooth muscle cells (VSMCs), murine macrophage cell line (J774), and human umbilical vein endothelial cells (HUVECs). Biochemical approaches were further conducted to elucidate interactions among signaling molecules. We found that AICAR could induce COX-2 protein expression in the cell types tested. This event was mediated by COX-2 gene transcription, and abrogated by compound C and 5'-iodotubercidin, suggesting the essential role of AMPK in COX-2 induction. Pharmacological and biochemical studies indicated that p38 mitogen-activated protein kinase (MAPK) activation is the common downstream signal of AMPK in COX-2 expression in all three cell types. Furthermore, we also found that TAK1 is associated with AMPKalpha2, and this binding requires an interaction between the kinase domains of both molecules. Notably data of TAK1 phosphorylation indicate that the activating state is enhanced upon AMPK activation in vivo and in vitro. Our data for the first time prove a pivotal role of TAK1 in the AMPK signaling axis. Such interaction gives AMPK an additional pathway for regulating cellular functions. Via a downstream p38 MAPK signaling cascade, AMPK-dependent TAK1 activation leads to the expression of the inflammatory COX-2 gene in various cell types.