Cost-Effectiveness Analysis of Molnupiravir Versus Best Supportive Care for the Treatment of Outpatient COVID-19 in Adults in the US.

BACKGROUND AND AIMS: Coronavirus disease 2019 (COVID-19) imposes a substantial and ongoing burden on the US healthcare system and society. Molnupiravir is a new oral antiviral for treating COVID-19 in outpatient settings. This study evaluated the cost-effectiveness profile of molnupiravir versus best supportive care in the treatment of adult patients with mild-to-moderate COVID-19 at risk of progression to severe disease, from a US payer's perspective. METHODS: The model was developed using a decision tree for the short-term acute phase of COVID-19 and a Markov state transition model for the long-term post-acute phase. This model compared molnupiravir with best supportive care as consistent with the MOVe-OUT trial. Costs were reported in 2021 US dollars. Transition probabilities were derived from the phase III MOVe-OUT trial and the TriNetX real-world electronic health records database. Costs were derived from the TriNetX database and utility values from a de novo, vignette-based utility study. Deterministic and probabilistic sensitivity analyses (DSA/PSA) were conducted. Primary outcomes included proportion hospitalized, proportion who died overall and by highest healthcare setting at the end of the acute phase, quality-adjusted life-years (QALYs), and incremental costs per QALY gained over a lifetime (100 years) horizon, discounted at 3% annually and assessed at a willingness-to-pay (WTP) threshold of $100,000 per QALY. RESULTS: In this model, the use of molnupiravir led to an increase in QALYs (0.210) and decrease in direct total medical costs (-$895) per patient across a lifetime horizon, compared with best supportive care in COVID-19 outpatients. Molnupiravir was the dominant intervention when compared with best supportive care. Patients treated with molnupiravir were less likely to be hospitalized (6.38% vs. 9.20%) and more likely to remain alive (99.88% vs. 98.71%) during the acute phase. Through DSA, molnupiravir treatment effect of hospitalization reduction was identified to be the most influential parameter, and through PSA, molnupiravir remained dominant in 84% of the total simulations and, overall, 100% cost effective. CONCLUSION: This analysis suggests that molnupiravir is cost effective compared with best supportive care for the treatment of adult outpatients with COVID-19. However, our study was limited by the unavailability of the most recent information on the rapidly evolving pandemic, including new viral variants, patient populations affected, and changes in standards of care. Further research should explore the impact of vaccination on the cost effectiveness of molnupiravir and other therapies, based on real-world data, to account for these changes, including the impact of vaccination and immunity.

In vitro assessment of a synergistic combination of gemcitabine and zebularine in pancreatic cancer cells.

Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest cancers with an extremely poor prognosis. Gemcitabine (Gem) is still the mainstay drug for the treatment of PDAC. However, rapid inactivation by cytidine deaminase (CDA) present in pancreatic cancer cells severely limits anticancer efficacy of Gem. In this study, we investigated the effect of a CDA inhibitor - Zebularine (Zeb) on anticancer activity of Gem in pancreatic cancer cell lines MiaPaCa-2, BxPC-3, and Panc-1. Zeb treatment synergistically increased Gem-induced cytotoxicity in all three pancreatic cancer cell lines. The strongest synergistic activity was found at 1:10 M ratio of Gem/Zeb (combination index 0.04-0.4). Additionally, Gem + Zeb treated cells showed marked decreased in the expressions of anti-apoptotic protein including Bcl-2 and survivin while significantly increased the cleaved caspase-3, and loss of mitochondrial membrane potential was observed. Multicellular 3D spheroids of MiaPaCa-2 cells treated with combination showed significant reduction (25-60%) in spheroid size, weight compared to single drug and control group. Live/dead cell imaging showed that Gem + Zeb treated spheroids exhibited a highly distorted surface with significantly higher number of dead cells (red). The results of the present study confirm that this synergistic combination is worthy of future investigations as a potential approach for the treatment of PDAC.

Intensive optimization and evaluation of global DNA methylation quantification using LC-MS/MS.

DNA methylation is a typical epigenetic phenomenon. Numerous methods for detecting global DNA methylation levels have been developed, among which LC-MS/MS has emerged as an excellent method from the viewpoint of sensitivity, reproducibility, and cost. However, LC-MS/MS methods have limitations due to a lack of the stability and the standardization required for a laboratory assay. The present study aimed to establish a robust assay that guarantees highly accurate measurements of global DNA methylation levels. There are at least three facets of the developed method. The first is discovery of the solvent conditions to minimize sodium adducts. The second is improvement of separation of nucleosides by LC using the columns that had not been used in previous similar studies. The third is success in reduction of the uncertainty of the measurement results, which was achieved by the calibration using the ratio of mdC but not the absolute amount in the presence of internal standards. These facets represent the advantage over methods reported previously. Our developed method enables quantification of DNA methylation with a short time length (8 min) for one analysis as well as with the high reproducibility of measurements that is represented by the inter-day CV% being less than 5%. In addition, data obtained from measuring global DNA methylation levels in cultured cell lines, with or without pharmacological demethylation, support its use for biomedical research. This assay is expected to allow us to conduct initial screening of epigenetic alterations or aberration in a variety of cells.

Eficacia y seguridad del uso de decitabina: 5-AZA2': deoxicitidina para el tratamiento del síndrome mielodisplásico / Efficacy and safety of the use of decitabine: 5-AZA2': deoxycytidine for the treatment of myelodysplastic syndrome

INTRODUCCIÓN: Síndrome Mielodisplásico (myelodysplastic syndrome, SMD) se denomina a un grupo de afecciones que ocurren cuando se dañan las células productoras de sangre en la médula ósea. Su prevalencia es de 4.4 casos por cada 100.000 personas. OBJETIVO: Determinar la eficacia y la seguridad de DECITABINA: 5-AZA-2´-DEOXICITIDINA, en el tratamiento del Síndrome Mielodisplásico, para su posible incorporación al FTM. METODOLOGÍA: La búsqueda de información científica se realizó accediendo a la base de Revisiones de la Colaboración Cochrane, en Pubmed, NICE, Centro de Revisiones y Diseminación de la Universidad de York (Database HTA) y se obtuvieron publicaciones derivadas de las referencias bibliográficas de las publicaciones encontradas por estos medios. RESULTADOS: Los estudios comparados con el mejor tratamiento de soporte indican que la Decitabina muestra, en algunos parámetros, un avance en el tratamiento del paciente con síndrome Mielodisplásico (mediana de sobrevida libre de progresión 6.6 meses versus 3.0 meses), aunque no modifica la Sobrevida Global. La evidencia publicada sobre eventos adversos indicó que el tratamiento con Decitabina muestra un porcentaje significativamente mayor de efectos secundarios al tratamiento comparado con el mejor tratamiento de soporte (neutropenia febril grado 3-4, 25% versus 7% con el MTS; hipoplasia, 14% versus 0% en el MTS). La comparación de Decitabina con tratamiento con quimioterapia se evaluó en un estudio no aleatorizado mostrando beneficios para la Decitabina en la sobrevida y en la mortalidad a 3 meses. Se encontró poca evidencia comparando la Decitabina a otros agentes hipometilantes, y una comparación indirecta con la 5-azacitidina favoreció a esta última. DISCUSIÓN: La evidencia obtenida del uso de la Decitabina en el SMD no mostró resultados concluyentes para varias de las medidas evaluadas hasta el presente, frente a otras alternativas médicas. Las investigaciones realizadas hasta ahora son escasas y en algunos casos no tienen la calidad necesaria para indicar una diferencia importante en el tratamiento con este fármaco. CONCLUSIÓN: Se considera que la evidencia existente es insuficiente hasta el momento para concluir sobre la eficacia de este fármaco en el tratamiento de los Síndromes Mielodisplásicos especialmente al compararlo con otros fármacos como ser los hipometilantes que también se han evaluado para su ingreso al FTM.(AU)

Measuring topology of low-intensity DNA methylation sites for high-throughput assessment of epigenetic drug-induced effects in cancer cells.

Epigenetic anti-cancer drugs with demethylating effects have shown to alter genome organization in mammalian cell nuclei. The interest in the development of novel epigenetic drugs has increased the demand for cell-based assays to evaluate drug performance in pre-clinical studies. An imaging-based cytometrical approach that can measure demethylation effects as changes in the spatial nuclear distributions of methylated cytosine and global DNA in cancer cells is introduced in this paper. The cells were studied by immunofluorescence with a specific antibody against 5-methylcytosine (MeC), and 4,6-diamidino-2-phenylindole (DAPI) for delineation of methylated sites and global DNA in nuclei. In the preprocessing step the segmentation of nuclei in three-dimensional images (3-D) is followed by an automated assessment of nuclear DAPI/MeC patterns to exclude dissimilar entities. Next, low-intensity MeC (LIM) and low-intensity DNA (LID) sites of similar nuclei are localized and processed to obtain specific nuclear density profiles. These profiles sampled at half of the total nuclear volume yielded two parameters: LIM(0.5) and LID(0.5). The analysis shows that zebularine and 5-azacytidine-the two tested epigenetic drugs introduce changes in the spatial distribution of low-intensity DNA and MeC signals. LIM(0.5) and LID(0.5) were significantly different (p<0.001) in 5-azacytidine treated (n=660) and zebularine treated (n=496) vs. untreated (n=649) DU145 human prostate cancer cells. In the latter case the LIM sites were predominantly found at the nuclear border, whereas treated populations showed different degrees of increase in LIMs towards the interior nuclear space, in which a large portion of heterochromatin is located. The cell-by-cell evaluation of changes in the spatial reorganization of MeC/DAPI signals revealed that zebularine is a more gentle demethylating agent than 5-azacytidine. Measuring changes in the topology of low-intensity sites can potentially be a valuable component in the high-throughput assessment of demethylation and risk of chromatin reorganization in epigenetic-drug screening tasks.

Combinations of 2'-C-methylcytidine analogues with interferon-alpha2b and triple combination with ribavirin in the hepatitis C virus replicon system.

BACKGROUND: Hepatitis C virus (HCV) polymerase is an essential enzyme for HCV replication and has multiple inhibitor binding sites making it a major target for antiviral intervention. It is apparent that no single drug can inhibit HCV replication in humans. Hence, combinations of nucleoside analogues beta-D-2'-C-methylcytidine (2'-C-MeC; NM-107) or beta-D-2'-deoxy-2'-fluoro-2'-C-methyleytidine (2'-F-C-MeC; PSI-6130) with interferon-alpha2b (IFN-alpha2b) or triple combination with ribavirin (RBV) were evaluated. METHODS: Huh-7 cells containing the self-replicating subgenomic HCV replicon (Clone B) were used for drug combination studies. After drug treatment for 5 days, total cellular RNA was then extracted and both ribosomal RNA and HCV replicon RNA were amplified in a single-step multiplex real-time PCR assay. Drug interaction analyses were performed using the CalcuSyn program. RESULTS: Double combinations of 2'-C-MeC or 2'-F-C-MeC with IFN-alpha2b at all ratios tested had weighted average combination index (Cl(wt)) values <1 indicating synergistic inhibition of HCV replication in the replicon system. For the triple combinations of IFN-alpha2b plus RBV with either 2'-C-MeC or 2'-F-C-MeC, the Cl(wt) values at 1:1:1 ratio tested were 0.5 and 0.8, respectively, indicating synergistic antiviral effects. No apparent cytotoxicity effects were observed with any of the combinations tested. CONCLUSION: These promising in vitro data warrant clinical investigation of the nucleosides analogues such as 2'-C-MeC or 2'-F-C-MeC in their prodrug forms, together with IFN-alphac2b and RBV, for successful treatment of HCV infections.

Ammonium ion representation in Monte Carlo simulations of biomolecular solutions.

Monte Carlo computer simulation techniques may be used to predict structural properties of solvent networks in helical fragments of nucleic acids, provided that suitable potential functions are available to describe the interactions between nucleic acid atoms, water and counterions. Previous studies have shown that simple non-bonded and point charge parameters are adequate for mononuclear ions such as sodium and calcium. In this study a model interaction potential for the polynuclear ammonium ion is evaluated. The parameters used take account of the distribution of charge over the constituent atoms in the ion. Simulations are carried out on the ammonium salt of a small nucleic acid crystal hydrate and a comparison is made between the predicted and experimental results. It is shown that the simulated structure is in reasonable agreement with experiment. It is therefore feasible to use this potential in studies of ammonium-containing bimolecular systems.

Monte Carlo simulations of nucleotide crystal hydrates and their counter-ions.

A knowledge of structural and energetic aspects of water- and ion-nucleic acid interactions is essential for the understanding of the role of solvent and counterions in stabilising the various helical forms of nucleic acids. In this study, Monte Carlo computer simulation techniques have been used to predict structural properties of solvent networks in small nucleic acid crystal hydrates containing the ions sodium, ammonium and calcium. Appropriate parameters to describe the interaction potentials of the ions are added to those previously developed for water and nucleic acid atoms. A comparison is made between the predicted and experimental results and it is concluded that the potential functions used lead to simulated solvent structure in reasonable agreement with experimental data, at least in the cases of sodium and calcium. It is now feasible to use these functions in studies of hydration of larger helical fragments of nucleic acids of more direct biological interest.