Cost-Effectiveness Analysis of Nintedanib Versus Pirfenidone in Idiopathic Pulmonary Fibrosis in Belgium.

BACKGROUND: Nintedanib (Ofev®) and pirfenidone (Esbriet®) are recommended by international guidelines as treatment options for idiopathic pulmonary fibrosis (IPF). OBJECTIVES: To compare the cost-effectiveness of nintedanib with that of pirfenidone for the treatment of IPF from a Belgian healthcare payer perspective. METHODS: The economic analysis used a Markov model that calculated outcomes over patient lifetime. Overall survival was assumed to be the same for the two comparators. Data from a network meta-analysis were used for loss of lung function, acute exacerbation events, safety and treatment discontinuation (for any reason). The health-state utility estimates in the model were calculated from EQ-5D scores collected in nintedanib studies. The assumed resource use for background care was also based on patient-level data that were categorised to fit the health states in the model and synthesised with costs and tariffs from Belgian national databases. RESULTS: Treatment with nintedanib resulted in an estimated total cost of €102,315, which was less than the total cost of treatment with pirfenidone (€113,313). Given the similarities in the survival and progression outcomes obtained with nintedanib and pirfenidone, the model predicted near equivalence in total QALYs (3.353 QALYs for the nintedanib arm and 3.318 for the pirfenidone arm). Results were largely driven by model assumptions underlying mortality, acute exacerbations and treatment discontinuation. CONCLUSIONS: After performing a synthesis of the most recently published evidence for IPF patients and assuming a Belgian healthcare payer perspective, we found nintedanib to be more cost-saving than pirfenidone.

Novel Aspects in the Pathogenesis of Nonalcoholic Steatohepatitis.

Nonalcoholic steatohepatitis (NASH) is a progressive form of nonalcoholic fatty liver disease, characterized by inflammation, hepatocyte injury and fibrogenesis. Overall mortality, and liver-related mortality, are both increased in NASH patients. Considering that nonalcoholic fatty liver disease is the most prevalent hepatic abnormality in the Western world, understanding the mechanisms leading to NASH and its progression to cirrhosis is critical for a better management of these patients. Moreover, a more detailed knowledge of this condition may be helpful to identify those subjects which are more susceptible to develop progressive liver disease. Emerging data indicate that NASH progression results from parallel events originating from the liver as well as from the adipose tissue, and the gastrointestinal tract. In this review we highlight some of the most recent findings reported on the pathogenesis of NASH and its fibrogenic progression to cirrhosis, in an effort to identify possible targets for treatment or biomarkers of disease progression.

Effects of maximally tolerated oral therapy on the six-minute walking test in patients with chronic congestive heart failure secondary to either ischemic or idiopathic dilated cardiomyopathy.

In patients with heart failure, therapy with "maximally tolerated" oral doses of diuretics, vasodilators, and digitalis results in a significant increase in the distance walked during the 6-minute walking test, compared with conventional therapy at "standard" doses, indicating an improvement in exercise tolerance. The 6-minute walk test is a simple, inexpensive, and well-tolerated test to measure changes in exercise tolerance induced by pharmacologic interventions, even on a short-term basis.

Inhibition by pentoxifylline of extracellular signal-regulated kinase activation by platelet-derived growth factor in hepatic stellate cells.

1. It has been proposed that pentoxifylline (PTF) acts an antifibrogenic agent by reducing the synthesis of extracellular matrix components, and this possibility has been confirmed in animal models of hepatic fibrosis. In this study the effects of PTF on the proliferation of extracellular matrix producing cells induced by platelet-derived growth factor (PDGF) were evaluated. The study was performed on hepatic stellate cells, currently indicated as the major source of extracellular matrix in fibrotic liver. 2. PTF caused a dose-dependent reduction of PDGF-induced mitogenesis with an IC50 of 170 microM, identical to the EC50 for the increase in intracellular cyclic AMP levels. Preincubation with PTF did not affect either PDGF-receptor autophosphorylation or phosphotidylinositol 3-kinase activity, whereas it markedly reduced PDGF-stimulated extracellular signal-regulated kinase (ERK) activity and ERK isoform phosphorylation. PTF also reduced PDGF-induced c-fos mRNA expression, which is dependent on activation of the RAS/ERK pathway. In addition, the PDGF-induced increase in cytsolic-free calcium was almost completely prevented by pretreating the cells with PTF. 3. The results of the present study indicate that PTF, in addition to its effect on collagen deposition and degradation, may exert an antifibrogenic effect by reducing the PDGF-induced proliferation of extracellular matrix producing cells. This effect appears to be mediated by a reduction of PDGF-stimulated ERK activity as well as of other intracellular signalling pathways such as the PDGF-induced elevation of cytosolic-free calcium.

Identification and targeting policies for computer-controlled infusion pumps.

In this article a series of useful techniques is presented to improve the adaptation capabilities of computer-controlled infusion pumps: an identification algorithm for the time constant of the effect compartment, a smoothing technique for estimation based on noisy data, and an infusion policy to target any effect site concentration with no overshoot.

Artifact-tolerant controllers for automatic drug delivery in anesthesia.

This article presents a method for treating measurement artifacts in model-based control systems. A nonlinear modification to the usual observer structure is introduced to prevent the measurement artifacts from winding up the controller states. It is shown how stability of the closed loop system can be analyzed and an example of a successful application in a clinical study is provided.

Ascites and hepatorenal syndrome.

Ascites is a frequent complication of chronic liver disease with severe portal hypertension. Moreover, in the presence of tense ascites, renal dysfunction and hepatorenal syndrome may occur. Unfortunately, there is no explanation that thoroughly describes the complex relationship between the liver and kidney in either physiological or pathological conditions. Nevertheless, available evidence indicates that early sodium and water retention precedes decompensation, characterized by hyperdynamic circulation. The best approach to the treatment of these patients should be aimed at the prevention of ascites formation. An accurate sequential treatment is indicated in patients with ascites. In the case of hepatorenal syndrome, the only definitive approach is liver transplantation.

Update on ascites and hepatorenal syndrome.

Ascites is the most common complication occurring during liver cirrhosis. Even if a significant decrease in renal clearance may be observed in the first step of chronic active liver disease, renal impairment, at times complicated by the typical signs of hepatorenal syndrome, occurs only in patients with ascites, especially when tense and refractory. Experimental and clinical data seem to suggest a primary sodium and water retention in the pathogenesis of ascites, in the presence of an intrahepatic increase of hydrostatic pressure, which, by itself, physiologically occurs during digestion. Abnormal sodium and water handling leads to plasma volume expansion, followed by decreased peripheral vascular resistance and increased cardiac output. This second step is in agreement with the peripheral arterial vasodilation hypothesis, depicted by an increase in total blood volume, but with a decreased effective arterial blood volume. This discrepancy leads to the activation of the sympathetic nervous and renin-angiotensin-aldosterone systems associated with the progressive activation of the renal autacoid systems, especially, that of the arachidonic acid. During advanced cirrhosis, renal impairment becomes more sustained and renal autacoid vasodilating substances are less available, possibly due to a progressive exhaustion of these systems. At the same time ascites becomes refractory inasmuch as it is no longer responsive to diuretic treatment. Various pathogenetic mechanisms leading to refractory ascites are mentioned. Finally, several treatment approaches to overcome the reduced effectiveness of diuretic therapy are cited. Paracentesis, together with simultaneous administration of human albumin or other plasma expanders is the main common approach to treat refractory ascites and to avoid a further decrease in renal failure. Other effective tools are: administration of terlipressin together with albumin, implantation of the Le Veen shunt, surgical porto-systemic shunting or transjugular intrahepatic portosystemic stent-shunt, or orthotopic liver transplantation, according to the conditions of the individual patient.

Modeling and closed-loop control of hypnosis by means of bispectral index (BIS) with isoflurane.

A model-based closed-loop control system is presented to regulate hypnosis with the volatile anesthetic isoflurane. Hypnosis is assessed by means of the bispectral index (BIS), a processed parameter derived from the electroencephalogram. Isoflurane is administered through a closed-circuit respiratory system. The model for control was identified on a population of 20 healthy volunteers. It consists of three parts: a model for the respiratory system, a pharmacokinetic model and a pharmacodynamic model to predict BIS at the effect compartment. A cascaded internal model controller is employed. The master controller compares the actual BIS and the reference value set by the anesthesiologist and provides expired isoflurane concentration references to the slave controller. The slave controller maneuvers the fresh gas anesthetic concentration entering the respiratory system. The controller is designed to adapt to different respiratory conditions. Anti-windup measures protect against performance degradation in the event of saturation of the input signal. Fault detection schemes in the controller cope with BIS and expired concentration measurement artifacts. The results of clinical studies on humans are presented.

Purification, kinetic properties and primary structure of bovine erythrocyte acylphosphatase.

An erythrocyte isoenzyme of acylphosphatase was purified from bovine red cells. The protein was characterized as regards the kinetic parameters and amino acid sequence. A simple and rapid sequencing strategy, based on a few experiments, was used for reconstructing the primary structure of the enzyme, since the purification procedure gave a very low yield. The length of the polypeptide chain is 100 residues. Comparison with the analogous human isoenzyme indicates that the primary structure is about 90% conserved. The presence of two additional residues at the acetylated N-terminus confirms the hypervariability for this region found in other acylphosphatases.

Prevalence of diagnosed and undiagnosed diabetes mellitus and impaired fasting glucose in Sardinia.

We aimed at updating the prevalence of impaired fasting glucose (IFG) and of undiagnosed (UD) and diagnosed diabetes (DD) among the Sardinian population. The survey was carried out from 2002 to 2005 on 4.737 subjects aged 20-80+ years. IFG was diagnosed when blood glucose was 110-125 mg/dl; UD when it was >or=126 mg/dl in the absence of personal history of diabetes; DD when personal history was positive, irrespective of blood glucose value. Prevalence rates (%) were adjusted for age by direct method to the Italian 2001 population. IFG was diagnosed in 11% of the sample (9.88% in females and 12.24% in males); UD was found in 5.65% (5.20 and 6.15%, females and males, respectively), DD in 8.72% (6.74 and 10.05%); and total diabetes (TD), i.e. the sum of UD + DD, was 14.37% (12.93 and 15.07%, females and males, respectively). In Sardinia, in about 5 years there was an increase of IFG (+61.8%), UD (+56.9%), DD (+55.7%), and TD (+57.9%). Thus Sardinia participates in the worldwide increase in prevalence of diabetes and its microvascular, macrovascular, and socioeconomic consequences.

Phosphatidylinositol-3 kinase and extracellular signal-regulated kinase mediate the chemotactic and mitogenic effects of insulin-like growth factor-I in human hepatic stellate cells.

BACKGROUND/AIM: Several studies have shown that proliferation of hepatic stellate cells is stimulated by insulin-like growth factor-I. The aim of this study was to investigate the effect of insulin-like growth factor-I on human hepatic stellate cells chemotaxis and the intracellular pathways involved in both mitogenic and chemotactic effects. METHODS/RESULTS: Insulin-like growth factor-I, at the concentration of 100 ng/ml, was able to induce a 2- to 3-fold increase in human hepatic stellate cells migration in a modified Boyden chamber system. This effect was associated with a marked activation of phosphatidylinositol 3-kinase by insulin-like growth factor-I, as evaluated by measurement of phosphatidylinositol 3-kinase activity in phosphotyrosine immunoprecipitates In order to establish a functional link between these observations, we then performed experiments employing two selective phosphatidylinositol 3-kinase inhibitors, namely wortmannin and LY294002. These compounds blocked activation of phosphatidylinositol 3-kinase and inhibited insulin-like growth factor-I-induced hepatic stellate cells migration. Since phosphatidylinositol 3-kinase activation has been shown to be necessary for platelet-derived growth factor-induced mitogenesis in hepatic stellate cells, we verified the effects of phosphatidylinositol 3-kinase inhibition on insulin-like growth factor-I-induced DNA synthesis. Incubation with either wortmannin or LY294002, dose-dependently reduced the mitogenic potential of insulin-like growth factor-I. Since phosphatidylinositol 3-kinase is involved, at least in part, in the activation of the Ras/extracellular signal-regulated kinase pathway in hepatic stellate cells, the role of extracellular signal-regulated kinase activation in mediating the biological effects of insulin-like growth factor-I was explored. Insulin-like growth factor-I induced mitogenesis and chemotaxis were markedly reduced by pre-incubation of hepatic stellate cells with PD-98059, a selective inhibitor of MEK. CONCLUSIONS: Activation of phosphatidylinositol 3-kinase and extracellular signal-regulated kinase is required for both insulin-like growth factor-I-dependent hepatic stellate cells proliferation and chemotaxis. Insulin-like growth factor-I, together with other soluble mediators, may contribute to the hepatic wound-healing response by modulating hepatic stellate cells migration and proliferation.

Characterization and regulation of insulin-like growth factor binding proteins in human hepatic stellate cells.

Cultured hepatic stellate cells (HSCs), the cell type primarily involved in the progression of liver fibrosis, secrete insulin-like growth factor-I (IGF-I) and IGF binding protein (IGFBP) activity. IGF-I exerts a mitogenic effect on HSCs, thus potentially contributing to the fibrogenic process in an autocrine fashion. However, IGF-I action is modulated by the presence of specific IGFBPs that may inhibit and/or enhance its biologic effects. Therefore, we examined IGFBP-1 through IGFBP-6 mRNA and protein expression in HSCs isolated from human liver and activated in culture. Regulation of IGFBPs in response to IGF-I and other polypeptide growth factors involved in the hepatic fibrogenic process was also assessed. RNase protection assays and ligand blot analysis demonstrated that HSCs express IGFBP-2 through IGFBP-6 mRNAs and release detectable levels of IGFBP-2 through IGFBP-5. Because IGF-I, platelet-derived growth factor-BB (PDGF-BB), and transforming growth factor-beta (TGF-beta) stimulate HSC proliferation and/or matrix production, we tested their effect on IGFBPs released by HSCs. IGF-I induced IGFBP-3 and IGFBP-5 proteins in a time-dependent manner without an increase in the corresponding mRNAs. IGFBP-4 protein levels decreased in response to IGF-I. TGF-beta stimulated IGFBP-3 mRNA and protein but decreased IGFBP-5 mRNA and protein. In contrast, PDGF-BB failed to regulate IGFBPs compared with controls. Recombinant human IGFBP-3 (rhIGFBP-3) was then tested for its effect on IGF-I-induced mitogenesis in HSCs. rhIGFBP-3 inhibited IGF-I-stimulated DNA synthesis in a dose-dependent manner, with a peak effect observed at 25 nM IGFBP-3. Because TGF-beta is highly expressed in cirrhotic liver tissue, we determined whether IGFBP-3 mRNA expression is increased in liver biopsies obtained from patients with an active fibroproliferative response due to viral-induced chronic active hepatitis. In the majority of these samples, IGFBP-3 mRNA was increased compared with normal controls. These findings indicate that human HSCs, in their activated phenotype, constitutively produce IGFBPs. IGF-I and TGF-beta differentially regulate IGFBP-3, IGFBP-4, and IGFBP-5 expression, which, in turn, may modulate the in vitro and in vivo action of IGF-I.

PI-3-kinase and MAPK regulate mesangial cell proliferation and migration in response to PDGF.

Proliferation and migration are important biological responses of mesangial cells to injury. Platelet-derived growth factor (PDGF) is a prime candidate to mediate these responses in glomerular disease. PDGF and its receptor (PDGFR) are upregulated in the mesangium during glomerular injury. We have recently shown that PDGF activates phosphatidylinositol 3-kinase (PI-3-kinase) in cultured mesangial cells. The role of this enzyme and other more distal signaling pathways in regulating migration and proliferation of mesangial cells has not yet been addressed. In this study, we used two inhibitors of PI-3-kinase, wortmannin (WMN) and LY-294002, to investigate the role of this enzyme in these processes. Pretreatment of mesangial cells with WMN and LY-294002 dose-dependently inhibited PDGF-induced PI-3-kinase activity assayed in antiphosphotyrosine immunoprecipitates. WMN pretreatment also inhibited the PI-3-kinase activity associated with anti-PDGFR beta immunoprecipitates prepared from mesangial cells treated with PDGF. Pretreatment of the cells with different concentrations of WMN resulted in a dose-dependent inhibition of PDGF-induced DNA synthesis. Both WMN and LY-294002 inhibited PDGF-stimulated migration of mesangial cells in a dose-dependent manner. It has recently been shown that PI-3-kinase physically interacts with Ras protein. Because Ras is an upstream regulator of the kinase cascade leading to the activation of mitogen-activated protein kinase (MAPK), we determined whether activation of PI-3-kinase is necessary for activation of MAPK. Pretreatment of mesangial cells with WMN and LY-294002 significantly inhibited PDGF-induced MAPK activity as measured by immune complex kinase assay of MAPK immunoprecipitates. Furthermore, PD-098059, an inhibitor of MAPK-activating kinase inhibited PDGF-induced MAPK activity and resulted in significant reduction of mesangial cell migration in response to PDGF. These data indicate that MAPK is a downstream target of PI-3-kinase and that both these enzymes are involved in regulating proliferation and migration of mesangial cells.

Transforming growth factor-beta 1 regulates platelet-derived growth factor receptor beta subunit in human liver fat-storing cells.

Activated liver fat-storing cells (FSC) are known to play a key role in the development of liver fibrosis. An important element in FSC activation process is the increased expression of receptors for platelet-derived growth factor (PDGF), a potent mitogen for FSC. The aim of the present study was to evaluate the expression PDGF-receptor alpha and beta subunits in cultured human FSC and their regulation induced by transforming growth factor-beta 1 (TGF-beta), a cytokine potentially involved in an autocrine loop. TGF-beta induced a significant increase of the mitogenic effect of PDGF-BB and did not affect the mitogenicity of PDGF-AA and PDGF-AB, suggesting a selective action of the PDGF-receptor-beta subunit. This hypothesis was confirmed by regulation experiments showing selective and time-dependent upregulation of the messenger (m)RNA encoding for the PDGF-receptor-beta subunit and the relative protein induced by TGF-beta. In addition, binding studies showed a parallel increase of PDGF-BB binding sites after incubation of human FSC with TGF-beta. These studies provide evidence for an additional mechanism leading to the perpetuation of FSC activation and proliferation and contribute to a better understanding of the role of TGF-beta and PDGF in the development of liver fibrosis.

Stimulation of lipid peroxidation or 4-hydroxynonenal treatment increases procollagen alpha 1 (I) gene expression in human liver fat-storing cells.

Hepatic fat-storing cells (FSC) play a key role in the development of fibrosis as a major source of collagen and other extracellular matrix (ECM) proteins in the injured liver. Both experimental and clinical studies have shown that lipid peroxidation is often associated with the development of liver fibrosis. Here we report that exposure of cultured human liver FSC to the pro-oxidant system ascorbate/iron results in an early induction of lipid peroxidation, as monitored in terms of MDA and fluorescent aldehyde/protein adducts production, and in a significant increase of the constitutive expression of procollagen type I mRNA paralleled by the accumulation of the protein in cell culture media. This fibrogenic effect is almost completely abolished by pretreatment of FSC cultures with the antioxidants alpha-tocopherol (Vitamin E) or diphenylphenylendiamine (DPPD). Moreover, treatment of FSC with 1.0 microM 4-hydroxynonenal (HNE), a highly reactive aldehydic end-product of lipid peroxidation, results in a significant stimulation of procollagen type I gene expression and synthesis, suggesting that this aldehyde also exerts profibrogenic activity. These findings indicate that oxidative reactions can directly influence procollagen I gene expression and synthesis in FSC, thus contributing to the development of liver fibrosis.