RESUMEN
BACKGROUND: For patients with inadequate control of cholesterol using moderate-dose statins in the secondary prevention of cardiovascular diseases (CVD), either doubling the dose of statins or adding ezetimibe should be considered. The cost-effectiveness of them is unknown in the Chinese context. The aim of this study is to compare the cost and effectiveness of the two regimens, and estimate the incremental cost-effectiveness ratio (ICER). METHODS: A Markov model of five health statuses were used to estimate long-term costs and quality-adjusted life-years (QALYs) of the two treatment regimens from the healthcare perspective. The effectiveness data used to calculate the transition probability was based on a previously published randomized trial. The utility data was gathered from literature and the costs were gathered from the electronic medical record system of West China Hospital in Chinese Yuan (CNY) in 2017 price. One-way sensitivity analysis and probabilistic sensitivity analysis were conducted. RESULTS: The ICER for ezetimibe plus moderate-dose rosuvastatin was 47,102.99 CNY per QALY for 20 years simulation, which did not reach the threshold of per capita gross domestic product (GDP) of 59,660 CNY per QALY in 2017 in China. Non-CVD-related mortality and CVD-related mortality contributed most to the ICER. CONCLUSION: Adding ezetimibe to the moderate-dose statin in secondary prevention for CVD is cost-effective, compared with the high-dose statin in the Chinese context whose low-density lipoprotein cholesterol (LDL-c) was not inadequately controlled by moderate-dose statin alone.
Asunto(s)
Anticolesterolemiantes/uso terapéutico , Enfermedades Cardiovasculares/tratamiento farmacológico , Análisis Costo-Beneficio , Ezetimiba/uso terapéutico , Cadenas de Markov , Rosuvastatina Cálcica/uso terapéutico , Prevención Secundaria , Anticolesterolemiantes/administración & dosificación , Anticolesterolemiantes/economía , Enfermedades Cardiovasculares/economía , China , Relación Dosis-Respuesta a Droga , Quimioterapia Combinada , Ezetimiba/administración & dosificación , Ezetimiba/economía , Humanos , Método de Montecarlo , Años de Vida Ajustados por Calidad de Vida , Rosuvastatina Cálcica/administración & dosificación , Rosuvastatina Cálcica/economíaRESUMEN
Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) reduce cardiovascular events in coronary artery disease (CAD). Their costs exceed that of established oral lipid-lowering agents. Previous cost-effectiveness assessments have been inconsistent. Markov cohort state transitions models for stable CAD patients were calculated using information from 1530 participants of the Ludwigshafen Risk and Cardiovascular Health Study (LURIC) with known causes of deaths. Non-fatal to fatal event rates, drug prices, direct treatment costs, and utility weights were from public sources. At an assumed relative risk reduction of 32.5% and an annual drug price of 8500 Euros, QALYs gained were 1.23 and 1.20, savings were 2390 and 2410 Euros, and ICERs were 112,530 and 108,660 Euros in women and men, respectively. When the annual cost of this medication was set at 1600 Euros, corresponding ICERs were 21,180 and 20,450 Euros. PCSK9i treatment is cost-effective in stable CAD at a threshold of 150,000 Euro and annual costs of 8500 Euros. As the broad use of PCSK9i therapy in CAD would have a disruptive impact on the healthcare budget, treatment should be focused on very high risk patients (≥3 comorbidities, annual risk of 10%); alternatively, and for lower risk, significant cost reductions would be needed.
Asunto(s)
Anticolesterolemiantes/administración & dosificación , Anticolesterolemiantes/economía , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Enfermedad de la Arteria Coronaria/economía , Costos de los Medicamentos , Hiperlipidemias/tratamiento farmacológico , Hiperlipidemias/economía , Inhibidores de PCSK9 , Inhibidores de Serina Proteinasa/administración & dosificación , Inhibidores de Serina Proteinasa/economía , Anciano , Anticolesterolemiantes/efectos adversos , Biomarcadores/sangre , Colesterol/sangre , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/epidemiología , Ahorro de Costo , Análisis Costo-Beneficio , Esquema de Medicación , Femenino , Alemania/epidemiología , Humanos , Hiperlipidemias/sangre , Hiperlipidemias/epidemiología , Masculino , Cadenas de Markov , Persona de Mediana Edad , Modelos Económicos , Proproteína Convertasa 9/metabolismo , Años de Vida Ajustados por Calidad de Vida , Medición de Riesgo , Factores de Riesgo , Inhibidores de Serina Proteinasa/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
The present investigation was aimed to study the effect of detoxification on the nutrients and antinutrients of wild apricot kernel followed by its hypocholesterolemic effect in male Wistar albino rats. The results revealed a non-significant (p > 0.05) effect of detoxification on the proximate composition except total carbohydrates and protein content. However, detoxification led to a significant (p < 0.05) decrease in l-ascorbic acid (76.82%), ß-carotene (25.90%), dietary fiber constituents (10.51-28.92%), minerals (4.76-31.08%) and antinutritional factors (23.92-77.05%) (phenolics, tannins, trypsin inhibitor activity, saponins, phytic acid, alkaloids, flavonoids, oxalates) along with the complete removal (100%) of bitter and potentially toxic hydrocyanic acid (HCN). The quality parameters of kernel oil indicated no adverse effects of detoxification on free fatty acids, lipase activity, acid value and peroxide value, which remained well below the maximum permissible limit. Blood lipid profile demonstrated that the detoxified apricot kernel group exhibited significantly (p < 0.05) increased levels of HDL-cholesterol (48.79%) and triglycerides (15.09%), and decreased levels of total blood cholesterol (6.99%), LDL-C (22.95%) and VLDL-C (7.90%) compared to that of the raw (untreated) kernel group. Overall, it can be concluded that wild apricot kernel flour could be detoxified efficiently by employing a simple, safe, domestic and cost-effective method, which further has the potential for formulating protein supplements and value-added food products.
Asunto(s)
Anticolesterolemiantes/análisis , Antimetabolitos/análisis , Contaminación de Alimentos/prevención & control , Manipulación de Alimentos , Alimentos Especializados/análisis , Prunus armeniaca/química , Semillas/química , Animales , Anticolesterolemiantes/efectos adversos , Anticolesterolemiantes/economía , Anticolesterolemiantes/uso terapéutico , Antimetabolitos/efectos adversos , Contaminación de Alimentos/economía , Ingredientes Alimentarios/efectos adversos , Ingredientes Alimentarios/análisis , Ingredientes Alimentarios/economía , Industria de Procesamiento de Alimentos/economía , Alimentos Especializados/efectos adversos , Alimentos Especializados/economía , Humanos , Cianuro de Hidrógeno/efectos adversos , Cianuro de Hidrógeno/análisis , Hipercolesterolemia/sangre , Hipercolesterolemia/prevención & control , Residuos Industriales/efectos adversos , Residuos Industriales/análisis , Residuos Industriales/economía , Masculino , Valor Nutritivo , Tamaño de la Partícula , Prunus armeniaca/efectos adversos , Prunus armeniaca/crecimiento & desarrollo , Distribución Aleatoria , Ratas Wistar , Reproducibilidad de los Resultados , Semillas/efectos adversos , Semillas/crecimiento & desarrollo , Vida Silvestre , beta Caroteno/análisis , beta Caroteno/uso terapéuticoRESUMEN
BACKGROUND: Simvastatin plus ezetimibe reduced the risk of cardiovascular events in the IMProved Reduction of Outcomes: Vytorin Efficacy International (IMPROVE-IT) study. The aim of this study is to investigate the cost-effectiveness of adding ezetimibe to simvastatin treatment for patients with ACS based on the recently completed IMPROVE-IT trial. METHODS: We constructed a Markov state-transition model to evaluate the costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness (ICER) associated with co-therapy compared with simvastatin alone from a health care perspective. We ran separate base-case analyses assuming a trial-length and longer term follow-up. One-way sensitivity analyses were used to explore uncertainty in model parameters. RESULTS: In the trial-length model, the ICERs compared with simvastatin alone were $114,400 per QALY for the combination therapy. In 5- and 10-year time horizons, the ICERs remained above the cost-effectiveness threshold of $50,000 per QALY. In the lifetime horizon model, The ICER was $45,046 per QALY for combination treatment compared with simvastatin alone. The combination therapy is cost-effective at an 80% decrease in the current branded simvastatin and ezetimibe cost. Probabilistic sensitivity analysis suggested simvastatin and ezetimibe co-therapy would be a cost-effective alternative to simvastatin monotherapy 60.7% of the time. CONCLUSIONS: In our trial-length, 5-year, and 10-year models, the co-therapy was not a cost-effective alternative; however, as follow-up was extended to lifetime, the co-therapy became a cost-effective treatment compared with the simvastatin monotherapy in patients with histories of ACS.
Asunto(s)
Síndrome Coronario Agudo/tratamiento farmacológico , Isquemia Encefálica/prevención & control , Ezetimiba/administración & dosificación , Predicción , Infarto del Miocardio/prevención & control , Simvastatina/administración & dosificación , Síndrome Coronario Agudo/complicaciones , Síndrome Coronario Agudo/diagnóstico , Anticolesterolemiantes/administración & dosificación , Anticolesterolemiantes/economía , Isquemia Encefálica/epidemiología , Isquemia Encefálica/etiología , Análisis Costo-Beneficio , Relación Dosis-Respuesta a Droga , Quimioterapia Combinada , Ezetimiba/economía , Femenino , Estudios de Seguimiento , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Inhibidores de Hidroximetilglutaril-CoA Reductasas/economía , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Infarto del Miocardio/etiología , Estudios Prospectivos , Años de Vida Ajustados por Calidad de Vida , Arabia Saudita/epidemiología , Simvastatina/economía , Resultado del TratamientoRESUMEN
We used the Archimedes Model, a mathematical simulation model (Model) to estimate the clinical- and cost-effectiveness of using LDL particle concentration (LDL-P) as an adjunct or alternative to LDL cholesterol (LDL-C) to guide statin therapy. LDL-P by NMR has been shown to be a better measure of cardiovascular disease (CVD) risk than LDL-C, and may therefore be a better gauge of the need for and response to statin treatment. Using the Model, we conducted a virtual clinical trial comparing the use of LDL-C alone, LDL-P alone, and LDL-C and LDL-P together to guide treatment in the general adult population, and in high-risk, dyslipidemic subpopulations. In the general population, the 5-year major adverse cardiovascular event (MACE) relative risk reduction (RRR) of LDL-P alone compared to the control arm (LDL-C alone) was 5.0% (95% CI, 4.7-5.3; p < .0001); using both LDL-C and LDL-P (dual markers) led to 3.0% RRR compared to the control arm (95% CI, 2.8-3.3; p < .0001). For individuals with diabetes, the RRR was 7.3% (95% CI, 6.4-8.2; p < .0001) for LDL-P alone and 6.9% for dual markers (95% CI, 6.1-7.8; both, p < .0001). In the general population, the costs per quality-adjusted life year (QALY) associated with the use of LDL-P alone were $76,052 at 5 years and $8913 at 20 years and $142,825 at 5 years and $25,505 at 20 years with the use of both markers. In high-risk subpopulations, the use of LDL-P alone was cost-saving at 5 years; whereas the cost per QALY for the use of both markers was $14,250 at 5 years and $859 at 20 years for high-risk dyslipidemics, $19,192 at 5 years and $649 at 20 years for diabetics, and $9030 at 5 years and $7268 at 20 years for patients with prior CHD. In conclusion, the model estimates that using LDL-P to guide statin therapy may reduce the risk of CVD events to a greater extent than does the use of LDL-C alone and maybe cost-effective or cost-saving for high-risk patients.
Asunto(s)
Anticolesterolemiantes/uso terapéutico , Simulación por Computador , Dislipidemias/tratamiento farmacológico , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Lipoproteínas LDL/sangre , Modelos Cardiovasculares , Resonancia Magnética Nuclear Biomolecular/métodos , Adulto , Anticolesterolemiantes/economía , Atorvastatina , Enfermedades Cardiovasculares/economía , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/prevención & control , Comorbilidad , Ahorro de Costo , Análisis Costo-Beneficio , Diabetes Mellitus/sangre , Costos de los Medicamentos , Sustitución de Medicamentos , Dislipidemias/sangre , Dislipidemias/dietoterapia , Dislipidemias/economía , Ácidos Heptanoicos/administración & dosificación , Ácidos Heptanoicos/uso terapéutico , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/economía , Hipercolesterolemia/sangre , Hipercolesterolemia/dietoterapia , Hipercolesterolemia/tratamiento farmacológico , Hipercolesterolemia/economía , Estilo de Vida , Medicare/economía , Pirroles/administración & dosificación , Pirroles/uso terapéutico , Años de Vida Ajustados por Calidad de Vida , Riesgo , Conducta de Reducción del Riesgo , Simvastatina/administración & dosificación , Simvastatina/uso terapéutico , Resultado del Tratamiento , Estados UnidosRESUMEN
SCOPE: Olive products are rich in phenolic compounds, which are natural antioxidants in vitro. We tested the in vivo effects of alperujo, an olive production by-product, as well as hydroxytyrosol and 3,4-dihydroxyphenylglycol (DHPG) isolated from alperujo, on indices and pathways of oxidative and metabolic stress in a vitamin E-deficient rat model. METHODS AND RESULTS: Rats were fed a vitamin E-deficient diet for 10 weeks, followed by this diet supplemented with either 100 mg/kg diet dα-tocopherol, alperujo extract, hydroxytyrosol, or 10 mg/kg diet DHPG, for a further 2 weeks. We detected alperujo phenolics in tissues and blood, indicating they are bioavailable. Alperujo extract partially ameliorated elevated plasma levels of thiobarbituric acid reactive substances and also lowered plasma cholesterol levels, whereas hydroxytyrosol increased plasma triglyceride levels. Proteomics and subsequent network analysis revealed that hepatic mitochondrial aldehyde dehydrogenase (ALDH2), of which protein and activity levels were regulated by dα-tocopherol and olive phenolics, represents a novel central regulatory protein hub affected by the dietary interventions. CONCLUSION: The in vivo free radical scavenging properties of olive phenolics appear relatively modest in our model. But alternative mechanisms, including regulation of ALDH2, may represent relevant antioxidant mechanisms by which dietary olive phenolics could have beneficial impact on cardiovascular health.
Asunto(s)
Antioxidantes/uso terapéutico , Hígado/metabolismo , Metoxihidroxifenilglicol/análogos & derivados , Olea/química , Estrés Oxidativo , Alcohol Feniletílico/análogos & derivados , Extractos Vegetales/uso terapéutico , Aldehído Deshidrogenasa/metabolismo , Aldehído Deshidrogenasa Mitocondrial , Animales , Anticolesterolemiantes/economía , Anticolesterolemiantes/metabolismo , Anticolesterolemiantes/uso terapéutico , Antioxidantes/economía , Antioxidantes/metabolismo , Dieta/efectos adversos , Suplementos Dietéticos/economía , Modelos Animales de Enfermedad , Industria de Procesamiento de Alimentos/economía , Frutas/química , Hipolipemiantes/economía , Hipolipemiantes/metabolismo , Hipolipemiantes/uso terapéutico , Residuos Industriales/análisis , Residuos Industriales/economía , Absorción Intestinal , Hígado/enzimología , Masculino , Metoxihidroxifenilglicol/metabolismo , Metoxihidroxifenilglicol/uso terapéutico , Proteínas Mitocondriales/metabolismo , Alcohol Feniletílico/metabolismo , Alcohol Feniletílico/uso terapéutico , Extractos Vegetales/economía , Extractos Vegetales/metabolismo , Distribución Aleatoria , Ratas , Deficiencia de Vitamina E/sangre , Deficiencia de Vitamina E/etiología , Deficiencia de Vitamina E/metabolismo , Deficiencia de Vitamina E/fisiopatologíaRESUMEN
BACKGROUND: Expanding insurance coverage, while necessary, may not be sufficient to ensure high-quality care for adults with cardiovascular disease. We sought to examine the association between having a usual source of care (USOC) and receiving medication treatment of hypertension and hypercholesterolemia. METHODS: Using the 2003-2006 National Health and Nutrition Examination Survey, we categorized USOC (a place to go when sick or need medical advice) and insurance status in adults >or=35 years old with an indication for medication treatment of hypertension (n = 3,142) and hypercholesterolemia (n = 1,134), determined using the Joint National Committee 7 and Adult Treatment Panel III recommendations, respectively. Multivariable logistic regression modeling was used to determine the independent effect of USOC on receiving treatment of hypertension and hypercholesterolemia, controlling for age, sex, race/ethnicity, insurance status, and comorbidities. Separate multivariable models were examined stratified by insurance status. RESULTS: Among subjects with an indication for treatment of hypertension and hypercholesterolemia, 32.4% and 42.0% were untreated, respectively. When compared with adults with a USOC, adults without a USOC were more likely to be untreated for hypertension (adjusted prevalence ratio [aPR] 2.43, 95% CI 1.88-2.85) and hypercholesterolemia (aPR 1.79, 95% CI 1.31-2.13). In stratified analyses among subjects with insurance, no USOC remained associated with being untreated (hypertension, aPR 2.58, 95% CI 1.88-3.08; hypercholesterolemia, aPR 1.65, 95% CI 0.97-2.18). CONCLUSIONS: Absence of a USOC was associated with being untreated for hypertension and hypercholesterolemia, even among individuals with insurance, suggesting that efforts to improve chronic disease management should also facilitate access to a regular source of care.
Asunto(s)
Anticolesterolemiantes/uso terapéutico , Antihipertensivos/uso terapéutico , Encuestas Epidemiológicas , Hipercolesterolemia/tratamiento farmacológico , Hipertensión/tratamiento farmacológico , Cobertura del Seguro/estadística & datos numéricos , Encuestas Nutricionales , Evaluación de Resultado en la Atención de Salud , Adulto , Anciano , Anticolesterolemiantes/economía , Antihipertensivos/economía , Análisis Costo-Beneficio , Femenino , Estudios de Seguimiento , Humanos , Hipercolesterolemia/economía , Hipertensión/economía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados UnidosRESUMEN
BACKGROUND: Despite the importance of secondary prevention, nonadherence rates for patients with myocardial infarction (MI) range from 13% to 60% for prescribed, evidence-based medicines. Although rates and consequences of discontinuance vary for different medications, the existing literature provides little insight into reasons for discontinuance. OBJECTIVE: To address this gap, we explored clopidogrel and cholesterol-lowering therapy (CLT) discontinuance after an MI to understand patients' reasons for stopping these 2 medications. METHODS: In this qualitative descriptive study, 2 groups of patients who stopped a heart medication-either clopidogrel or CLT-were recruited from a prospective MI registry. Patients who discontinued CLT (n = 29) or clopidogrel (n = 11) were interviewed within 18 months of hospitalization. Patients were recruited and interviewed until data saturation was achieved. The Health Belief Model was used as an organizing framework in analyzing and coding the narrative data. The codes were then summarized for each group and compared to identify similarities and differences in reasons for CLT and clopidogrel discontinuance. RESULTS AND CONCLUSIONS: The most common reason for CLT discontinuance was adverse effects that were painful and interfered with daily life. Less common reasons for discontinuance were prescription confusion, cost, mistrust in medicines/healthcare system, and preference for alternative therapies. Reasons for clopidogrel discontinuance were duration confusion, adverse effects, and cost. Although doctors stopped patients' clopidogrel in preparation for surgery, doctors conceded to discontinuance of CLT for patients who experienced adverse effects after trying 2 to 3 different CLTs. Patients who discontinued CLT were more likely to believe that they did not need the treatment than do patients who discontinued clopidogrel. Clinicians should be aware that reasons may vary across patients and medication class for prematurely stopping therapy; thus, proactive interventions should be targeted to address these differences. Identifying at-risk patients for targeted interventions to prevent premature cardiac medication discontinuation is vital.
Asunto(s)
Cumplimiento de la Medicación/psicología , Motivación , Infarto del Miocardio/tratamiento farmacológico , Infarto del Miocardio/psicología , Anciano , Anticolesterolemiantes/efectos adversos , Anticolesterolemiantes/economía , Clopidogrel , Femenino , Humanos , Masculino , Cumplimiento de la Medicación/estadística & datos numéricos , Persona de Mediana Edad , Modelos Psicológicos , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Narración , Evaluación en Enfermería , Investigación Metodológica en Enfermería , Educación del Paciente como Asunto , Inhibidores de Agregación Plaquetaria/efectos adversos , Inhibidores de Agregación Plaquetaria/economía , Investigación Cualitativa , Medición de Riesgo , Encuestas y Cuestionarios , Ticlopidina/efectos adversos , Ticlopidina/análogos & derivados , Ticlopidina/economía , Estados Unidos/epidemiologíaRESUMEN
The effects of ingestion of flaxseed gum on blood glucose and cholesterol, particularly low-density lipoprotein cholesterol, in type 2 diabetes were evaluated. Flaxseed gum was incorporated in wheat flour chapattis. Sixty patients of type 2 diabetes were fed a daily diet for 3 months, along with six wheat flour chapattis containing flaxseed gum (5 g), as per the recommendations of the American Diabetic Association. The control group (60 individuals) consumed an identical diet but the chapattis were without gum. The blood biochemistry profiles monitored before starting the study and at monthly intervals showed fasting blood sugar in the experimental group decreased from 154 ± 8 mg/dl to 136 ± 7 mg/dl (P=0.03) while the total cholesterol reduced from 182 ± 11 mg/dl to 163 ± 9 mg/dl (P=0.03). Results showed a decrease in low-density lipoprotein cholesterol from 110 ± 8 mg/dl to 92 ± 9 mg/dl (P=0.02). The study demonstrated the efficacy of flax gum in the blood biochemistry profiles of type 2 diabetes.
Asunto(s)
Anticolesterolemiantes/uso terapéutico , Diabetes Mellitus Tipo 2/dietoterapia , Lino/química , Hipoglucemiantes/uso terapéutico , Gomas de Plantas/uso terapéutico , Mucílago de Planta/uso terapéutico , Semillas/química , Anticolesterolemiantes/administración & dosificación , Anticolesterolemiantes/economía , Anticolesterolemiantes/aislamiento & purificación , Pan/análisis , Pan/economía , LDL-Colesterol/sangre , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/complicaciones , Dieta/etnología , Femenino , Preferencias Alimentarias/etnología , Alimentos Formulados/análisis , Alimentos Formulados/economía , Industria de Procesamiento de Alimentos/economía , Humanos , Hipercolesterolemia/complicaciones , Hipercolesterolemia/prevención & control , Hipoglucemiantes/administración & dosificación , Hipoglucemiantes/economía , Hipoglucemiantes/aislamiento & purificación , India , Residuos Industriales/análisis , Residuos Industriales/economía , Masculino , Medicina Ayurvédica , Persona de Mediana Edad , Proyectos Piloto , Gomas de Plantas/administración & dosificación , Gomas de Plantas/economía , Gomas de Plantas/aislamiento & purificación , Mucílago de Planta/administración & dosificación , Mucílago de Planta/economía , Mucílago de Planta/aislamiento & purificaciónRESUMEN
Rosuvastatin, a new hydrophilic 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin), is approved as an adjunct to diet in patients with primary hypercholesterolemia, mixed dyslipidemia, or Fredrickson type IV hypercholesterolemia. Because of its increased affinity for the reductase, rosuvastatin reduces the low-density lipoprotein cholesterol (LDL) level more than atorvastatin, simvastatin, and pravastatin do, without additional adverse effects. In addition, cytochrome P450 isoenzymes do not extensively metabolize rosuvastatin, and inhibitors of these isoenzymes do not substantially affect it. Rosuvastatin could be a first-line option for patients requiring a reduction of 50% or more to reach the LDL goal of the National Cholesterol Education Program Adult Treatment Panel III. Rosuvastatin monotherapy may allow patients to achieve this LDL goal earlier, and it may help them avoid combination therapy or potential adverse effects of high-dose statin therapy. However, because cardiovascular disease morbidity and mortality data are lacking for rosuvastatin (but available for all other marketed statins) and because its postmarketing data are limited, rosuvastatin should be reserved for patients requiring an LDL reduction of 50% or less who cannot reach the recommended goal with other statins because of adverse effects, drug interactions, or cost.
Asunto(s)
Anticolesterolemiantes/uso terapéutico , Fluorobencenos/uso terapéutico , Hipercolesterolemia/tratamiento farmacológico , Pirimidinas/uso terapéutico , Sulfonamidas/uso terapéutico , Anticolesterolemiantes/efectos adversos , Anticolesterolemiantes/economía , Ensayos Clínicos como Asunto , Interacciones Farmacológicas , Fluorobencenos/efectos adversos , Fluorobencenos/economía , Humanos , Pirimidinas/efectos adversos , Pirimidinas/economía , Rosuvastatina Cálcica , Sulfonamidas/efectos adversos , Sulfonamidas/economíaRESUMEN
Although the National Cholesterol Education Program Adult Treatment Panel III (ATP III) guidelines stress the importance of nonpharmacologic lipid modification interventions such as diet and exercise, the guidelines also recognize that many patients will require drug therapy to achieve low-density lipoprotein cholesterol (LDL-C) target goals. Currently available lipid-modifying drugs include bile acid sequestrants (or resins), fibrates, nicotinic acid, and statins, with each class exerting different effects on the lipid profile. In addition, nonprescription agents such as plant stanols and sterols have been shown to be effective in modifying plasma lipids. Of these agents, the statins are the most effective, most widely prescribed, and best-tolerated form of lipid-lowering drug therapy. New formulations of other drugs, such as niacin and bile acid sequestrants, can also improve treatment regimes and reduce side effects, thereby improving patient compliance with these therapies. In patients who have high levels of LDL-C and triglycerides together with low concentrations of high-density lipoprotein cholesterol (HDL-C), combination therapy may be required. Ezetimibe, a selective cholesterol absorption inhibitor, is the first of a new class of lipid-lowering agents and provides a new agent for the management of patients with dyslipidemia. Data from the ezetimibe clinical development program suggests that this agent can be used alone or in combination with statins to reduce LDL-C, improve compliance, and bring more patients to ATP III target goal.
Asunto(s)
Alilamina/análogos & derivados , Anticolesterolemiantes/uso terapéutico , Hiperlipidemias/tratamiento farmacológico , Alilamina/uso terapéutico , Anticolesterolemiantes/economía , Ácidos y Sales Biliares/antagonistas & inhibidores , LDL-Colesterol/antagonistas & inhibidores , LDL-Colesterol/sangre , Clorhidrato de Colesevelam , Gemfibrozilo/uso terapéutico , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Lipotrópicos/uso terapéutico , Ácidos Nicotínicos/uso terapéutico , Fitosteroles/uso terapéutico , Fitoterapia , Guías de Práctica Clínica como AsuntoRESUMEN
OBJECTIVE: To compare the results and cost-effectiveness of a cholesterol lowering protocol implemented by registered dietitians with cholesterol lowering advice by physicians. DESIGN: Six month randomized controlled trial, cost-effectiveness analysis. Subjects included 90 ambulatory care patients (60 men, 30 women), age range 21 to 65 years, with hypercholesterolemia and not taking hypolipidemic drugs. Patients were randomly assigned to receive medical nutrition therapy (MNT) from dietitians using a NCEP based lowering protocol or usual care (UC) from physicians. Outcome measures were plasma lipid profiles, dietary intake, weight, activity, patient satisfaction, and costs of MNT. Changes from baseline for each variable of interest were compared between treatment groups using analysis of covariance controlling for baseline value of the variable and gender. RESULTS: MNT achieved a 6% decrease in total and LDL cholesterol levels at 3 and 6 months compared with a 1% increase and a 2% decrease in both values at 3 and 6 months with UC (P<.001 and P<.05, respectively). Weight loss (1.9 vs 0 kg, P<.001) and dietary intake of saturated fat (7% of energy vs 10%, P<.001) were better in the MNT than the UC group. The additional costs of MNT were $217 per patient to achieve a 6% reduction in cholesterol and $98 per patient to sustain the reduction. The cost-effectiveness ratio for MNT was $36 per 1% decrease in cholesterol and LDL level. APPLICATIONS/CONCLUSIONS: MNT from registered dietitians is a reasonable investment of resources because it results in significantly better lipid, diet, activity, weight, and patient satisfaction outcomes than UC.
Asunto(s)
Dieta con Restricción de Grasas/economía , Servicios Dietéticos/economía , Hipercolesterolemia/dietoterapia , Evaluación de Resultado en la Atención de Salud , Satisfacción del Paciente , Adulto , Anciano , Análisis de Varianza , Anticolesterolemiantes/economía , Anticolesterolemiantes/uso terapéutico , Peso Corporal/efectos de los fármacos , HDL-Colesterol/sangre , LDL-Colesterol/sangre , Análisis Costo-Beneficio , Grasas de la Dieta/administración & dosificación , Ejercicio Físico , Conducta Alimentaria , Femenino , Humanos , Hipercolesterolemia/tratamiento farmacológico , Hipercolesterolemia/economía , Estilo de Vida , Lípidos/sangre , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
This study was designed to evaluate whether medical nutrition therapy administered by registered dietitians could lead to a beneficial clinical and cost outcome in men with hypercholesterolemia. Ninety-five subjects participating in a cholesterol-lowering drug study took part in an 8-week nutrition intervention program before initiating treatment with a cholesterol-lowering medication, Patient records were reviewed via a retrospective chart review to determine plasma lipid levels at the beginning and end of the program and the number and length of sessions with a dietitian. Complete information was available for 74 subjects aged 60.8 n+/- 9.8 years (mean +/- SD). Medical nutrition therapy lowered total serum cholesterol levels 13% (P < .001), low-density lipoprotein cholesterol (LDL-C) 15% (P < .0001), triglyceride 11% (P < .05), and high-density lipoprotein-cholesterol (HDL-C) 4% (P < .05). Total dietitian intervention time was 144 +/- 21 minutes (range = 120 to 180 minutes) in 2.8 +/- 0.7 sessions (range = 2 to 4) during 6.81 +/- 0.7 weeks of medical nutrition therapy (range = 6 to 8 weeks). Analysis of covariance was conducted to examine whether mean change in LDL-C differed by number of dietitian visits. Results showed a marginal difference between the number of dietitian visits and change in LDL-C (f = 2.6, P < .084). However, the magnitude of LDL-C reduction was significantly higher with 4 dietitian visits (180 minutes) than with 2 visits (120 minutes) (21.9% vs 12.1%; P = .027). Lipid drug eligibility was obviated in 34 of 67 (51%) subjects per the National Cholesterol Treatment Program guidelines algorithm. The estimated annualized cost savings from the avoidance of lipid medications was $60,561.68. Therefore, we conclude that 3 or 4 individualized dietitian visits of 50 minutes each over 7 weeks are associated with a significant serum cholesterol reduction and a savings of health care dollars.
Asunto(s)
Anticolesterolemiantes/uso terapéutico , Colesterol/sangre , Servicios Dietéticos/economía , Hipercolesterolemia/dietoterapia , Adulto , Anciano , Anticolesterolemiantes/economía , California , Costos de la Atención en Salud , Hospitales de Veteranos , Humanos , Hipercolesterolemia/tratamiento farmacológico , Hipercolesterolemia/economía , Masculino , Persona de Mediana Edad , Niacina/economía , Niacina/uso terapéutico , Estudios Retrospectivos , VeteranosRESUMEN
OBJECTIVE: Recognising the importance of treating hyperlipidaemia, the National Cholesterol Education Program (NCEP) has established widely accepted treatment goals for low density lipoprotein cholesterol (LDL-C). Medications used most commonly to achieve these LDL-C goals are HMG-CoA reductase inhibitors. The relative resource utilisation and cost associated with the use of reductase inhibitors of different LDL-C lowering efficacy are unknown, but are major health and economic concerns. The objective of this study was to determine the mean total cost of care to reach NCEP goals with various reductase inhibitors. DESIGN: In a randomised, 54-week, 30-centre controlled trial we compared resources used and costs associated with treating patients to achieve NCEP goals using 4 reductase inhibitors: atorvastatin, simvastatin, lovastatin and fluvastatin. PATIENTS AND PARTICIPANTS: The trial studied 662 patients; 318 had known atherosclerotic disease. INTERVENTIONS: Reductase inhibitor therapy was initiated at recommended starting doses and increased according to NCEP guidelines and package insert information. For patients who did not reach the goal at the highest recommended dose of each reductase inhibitor, the resin colestipol was added. MAIN OUTCOME MEASURES AND RESULTS: Patients treated with atorvastatin, compared-with other reductase inhibitors, were more likely to reach NCEP goals during treatment (p < 0.05), required fewer office visits (p < 0.001) and less adjuvant colestipol therapy (p = 0.001). Consequently, the mean total cost of care (1996 values) to reach NCEP goals was lower with atorvastatin [$US1064; 95% confidence interval (CI): $US953 to $US1176] compared with simvastatin ($US1471, 95% CI: $US1304 to $US1648), lovastatin ($US1972; 95% CI: $US1758 to $US2186) and fluvastatin ($US1542; 95% CI: $US1384 to $US1710). Results were similar for patients with or without known atherosclerotic disease. CONCLUSIONS: In patients requiring drug therapy for hypercholesterolaemia, NCEP LDL-C goals are achieved significantly more often using fewer resources with atorvastatin compared with simvastatin, lovastatin or fluvastatin.
Asunto(s)
Anticolesterolemiantes/economía , Ácidos Grasos Monoinsaturados/economía , Política de Salud/economía , Ácidos Heptanoicos/economía , Hipercolesterolemia/economía , Indoles/economía , Lovastatina/economía , Pirroles/economía , Simvastatina/economía , Anciano , Anticolesterolemiantes/uso terapéutico , Atorvastatina , Análisis Costo-Beneficio , Ácidos Grasos Monoinsaturados/uso terapéutico , Femenino , Fluvastatina , Ácidos Heptanoicos/uso terapéutico , Humanos , Hipercolesterolemia/tratamiento farmacológico , Indoles/uso terapéutico , Lovastatina/uso terapéutico , Masculino , Persona de Mediana Edad , Pirroles/uso terapéutico , Simvastatina/uso terapéutico , Estados UnidosRESUMEN
BACKGROUND: Decision makers in the field of health services are increasingly forced to identify and realise the grounds for spendings and savings. Therefore, preventive measures of cardiovascular diseases are becoming more and more scrutinized. The present analysis is answering the question: Is secondary preventive lipid-lowering therapy with a cholesterol-synthesis-enzyme-(CSE-)inhibitor in patients with manifest coronary heart disease cost-effective in comparison to other already proven medical interventions? METHODS: The cost-effectiveness-analysis with the endpoint costs per life years saved had been chosen as a form of evaluation. The study is a retrospective analysis. The clinical data have been taken from the already published double blinded, randomised, placebo controlled PLAC-I- and -II-studies as well as from the PLAC-Meta-Analysis. The cost estimate (costs of myocardial infarction, stroke and cost therapy with pravastatin) were based on the perspective of the German statutory sick funds. RESULTS: With the reduced probability of a fatal myocardial infarction or a stroke in the group treated with pravastatin there are cost offsets of DM 2,400. This figure is opposed to an additional expenditure of about DM 6,900, -for the CSE-inhibitor. The calculation of the effectiveness resulted in an additional life expectancy of 0.28 years in the pravastatin cohorts in comparison with the group treated with placebo over an observation period of 3 years. The costs per life year saved are approximately DM 16,000,-. CONCLUSION: The preventive use of pravastatin in patients with coronary heart disease can be estimated as cost-effective as compared with other medical interventions.