Cost-effectiveness of adalimumab for rheumatoid arthritis in Germany.

BACKGROUND: In Germany, the clinical use of TNF-α inhibitors in the therapy of rheumatoid arthritis (RA) grew from 2 % of treated patients in 2000 to 20 % in 2008. In 2012, adalimumab was the bestselling drug in the statutory health insurance system with net expenditure of € 581 mio. OBJECTIVES: We aim to analyze the cost-effectiveness of adalimumab for the treatment of RA in Germany. METHODS: We set up an individual patient sampling lifetime model to simulate 10,000 hypothetical patients. The patients' functional status improves according to American College of Rheumatology response criteria. In each 6­month cycle, treatment might be discontinued due to loss of efficacy or adverse events. RESULTS: In the base case, patients gain 7.07 quality-adjusted life years (QALYs) with conventional synthetic therapy and 9.92 QALYs if adalimumab combination therapy is added to the treatment algorithm. The incremental cost-utility ratio (ICUR) is € 24,492 based on German list prices. After deducting mandatory rebates and taxes, the ICUR is € 17,277, comparing favorably to analyses in other countries. Adalimumab combination therapy lowers indirect costs from € 162,698 to € 134,363. The ICUR based on total costs is € 14,550 (€ 7,335 after deducting taxes and rebates). Sensitivity analysis shows that adalimumab combination therapy becomes a dominant treatment option for younger baseline populations, i. e. adalimumab is both more effective and less expensive for baseline age 30 due to savings in indirect costs. CONCLUSIONS: Our complex probabilistic model shows that estimation of cost-effectiveness for RA relies on the incorporation of indirect costs and a sufficiently long simulation horizon to capture the complete range of possible outcomes and the associated long-term benefits of biological treatment.

Src-transformation of mouse fibroblasts induces a Ca(2+)-activated K+, current without changing the T-type Ca2+ current.

Membrane currents of src-transformed NIH3T3 mouse fibroblasts were analyzed in comparison with their non-transformed counterparts using the patch-clamp technique. Normal NIH3T3 cells exhibit two types of Ca2+ currents and a membrane current of ohmic behaviour (current amplitude 135 pA at +30 mV) that can partially be blocked by Cd2+. Src-transformed NIH3T3 cells show an additional membrane current that becomes activated after the establishment of the whole-cell configuration with a maximum amplitude of 1040 pA at +30 mV within 30-60 s. This current then inactivates irreversibly within 5-10 min. The additional current is highly K(+)-selective and Ca(2+)-dependent but voltage-independent. It can be blocked by charybdotoxin (IC50 = 20 nM) and by internal tetraethylammonium (TEA; IC50 = 2.9 mM), but it is not sensitive to external TEA (up to 30 mM). Single-channel analysis revealed only one K+ channel type with a conductance of 37 pS at negative potentials and 18 pS at positive potentials (in symmetrical 145 mM K+ solutions), a voltage-independent open-state probability of 0.6 and the same pharmacological properties as the macroscopic KCa current. The properties of the KCa current and the underlying channels of src-transformed NIH3T3 cells are identical to those observed in ras-transformed NIH3T3 cells. In contrast, src- or ras-transformation affects differently the voltage-dependent, transient (T-type) Ca2+ current. While ras-transformation of NIH3T3 cells suppresses their T-type Ca2+ current, this current remains unchanged in src-transformed NIH3T3 cells.

Lysophospholipids induce membrane hyperpolarization in microglia by activation of IKCa1 Ca(2+)-dependent K(+) channels.

Effects of the lysophospholipids sphingosine-1-phosphate and lysophosphatidic acid were studied in cultured murine microglia using the patch-clamp and video imaging techniques. Both lysophospholipids induced transient membrane hyperpolarization and K(+) current activation. The lysophospholipid-induced K(+) current was blocked by charybdotoxin or iberiotoxin, but was unaffected by apamin. In recordings with 1 microM intracellular free Ca(2+), Ca(2+)-dependent K(+) currents of microglia showed a similar pharmacological profile to lysophospholipid-induced currents. The Ca(2+)-dependent K(+) channels activated in microglia by lysophospholipids are most likely encoded by the IKCa1 channel gene. The presence of IKCa1 mRNA in microglia was demonstrated by reverse transcriptase-polymerase chain reaction studies. Ca(2+) imaging experiments revealed increases in the intracellular free Ca(2+) concentration of microglia to a mean value of about 400 nM after application of 1 microM sphingosine-1-phosphate or 1 microM lysophosphatidic acid. We suggest that the transient membrane hyperpolarization seen in microglia following exposure to sphingosine-1-phosphate or lysophosphatidic acid is caused by activation of IKCa1 Ca(2+)-dependent K(+) channels. Increases in the concentration of intracellular free Ca(2+) evoked by the lysophospholipids are sufficient to activate microglial Ca(2+)-dependent K(+) channels.

Investigation on the protective value of breathing masks in farmer's lung using an inhalation provocation test.

Six subjects with farmer's lung underwent double inhalation challenge tests, each lasting 60 min, using natural antigen exposure. Subjects underwent the tests first without and then with protection by a particle-filtering half mask. Our purpose was to determine whether and to what extent the use of such masks reduced or prevented symptoms in affected patients. Clinical assessment included general and pulmonary symptoms, HR, temperature, WBC count, R, ITGV, VC, TLC, PO2, DCO, and chest x-ray film. The unprotected challenge provoked late responses characteristic of extrinsic allergic alveolitis. In the challenge using the mask, all six patients reported to be completely free of symptoms. Compared with the test without a mask, a statistically significant reduction in the rise of temperature, WBCs, HR, R, TLC, and PO2 was observed. Compared with the initial values, a statistically significant reduced increase of temperature and leukocytes was demonstrated in the test using the mask. Pulmonary and systemic alterations were significantly reduced but not completely prevented by the application of the particle-filtering half mask.

Effect of K+ channel blockers on the alpha 2-adrenoceptor-coupled regulation of electrically evoked noradrenaline release in hippocampus.

The question whether presynaptic alpha 2-adrenoceptors regulating noradrenaline release in hippocampus directly couple to tetraethylammonium chloride (TEA) or alpha-dendrotoxin (alpha-DTX)-sensitive K+ channels was investigated. Hippocampal slices, prelabelled with [3H] noradrenaline, were superfused in the presence of (+)-oxaprotiline and electrically stimulated with 4 pulses delivered at 100 Hz, in order to avoid autoinhibition due to released noradrenaline. TEA enhanced the evoked [3H]noradrenaline release in rabbit hippocampus in a concentration-dependent manner, yielding an approximately 4-fold increase at 30 mmol/l, whereas the spontaneous outflow of tritium was only slightly affected at this concentration. The alpha 2-adrenoceptor agonist clonidine, at 10-100 nmol/l inhibited the evoked [3H]noradrenaline release between 77% and 96%. The inhibitory effect of the alpha 2-agonist was distinctly diminished in the presence of 30 mmol/l TEA but was restored in low Ca2+/high Mg2+ buffer. Therefore, the diminution of the alpha 2-agonist effect by TEA observed in experiments with normal Ca2+ can be explained by an increase of the Ca2+ availability for the release process due to the prolongation of action potentials. In rabbit hippocampus alpha-DTX (10-200 nmol/l) did neither affect the evoked release of [3H]noradrenaline nor its alpha 2-agonist-induced modulation. However, in rat hippocampus alpha-DTX significantly increased the evoked transmitter release and diminished the effect of clonidine. Taken together, the present data for the rabbit hippocampus exclude the possibility that activation of presynaptic alpha 2-adrenoceptors inhibits depolarization-evoked [3H]noradrenaline release by inducing an outward K+ current through TEA- or alpha-DTX-sensitive K+ channels.(ABSTRACT TRUNCATED AT 250 WORDS)

Activation of a Ca2+-dependent K+ current in mouse fibroblasts by lysophosphatidic acid requires a pertussis toxin-sensitive G protein and Ras.

Lysophosphatidic acid (LPA) is a bioactive lipid that acts through G protein-coupled plasma membrane receptors and mediates a wide range of cellular responses. Here we report that LPA activates a K+ current in NIH3T3 mouse fibroblasts that leads to membrane hyperpolarization. The activation occurs with an EC50 value of 1.7 nM LPA. The K+ current is Ca2+-dependent, voltage-independent, and completely blocked by the K+ channel blockers charybdotoxin, margatoxin, and iberiotoxin with IC50 values of 1.7, 16, and 62 nM, respectively. The underlying K+ channels possess a single channel conductance of 33 pS in symmetrical K+ solution. Pretreatment of cells with pertussis toxin (PTX), Clostridium sordellii lethal toxin, or a farnesyl protein transferase inhibitor reduced the K+ current amplitude in response to LPA to about 25% of the control value. Incubation of cells with the protein tyrosine kinase inhibitor genistein or microinjection of the neutralizing anti-Ras monoclonal antibody Y13-259 reduced it by more than 50%. In contrast, the phospholipase C inhibitor U-73122 and the protein kinase A activator 8-bromo-cAMP had no effect. These results indicate that the K+ channel activation by LPA is mediated by a signal transduction pathway involving a PTX-sensitive G protein, a protein tyrosine kinase, and Ras. LPA is already known to activate Cl- channels in various cell types, thereby leading to membrane depolarization. In conjunction with our results that demonstrate LPA-induced membrane hyperpolarization by activation of K+ channels, LPA appears to be significantly involved in the regulation of the cellular membrane potential.

Activation of a Ca2+-dependent K+ current in mouse fibroblasts by sphingosine-1-phosphate involves the protein tyrosine kinase c-Src.

Sphingosine-1-phosphate (S1P) is a phospholipid that acts through G-protein-coupled plasma membrane receptors and induces a broad spectrum of cellular responses, including proliferation, migration, differentiation and apoptosis. Here we report that in NIH3T3 and C3H10T1/2 mouse fibroblasts S1P activates a Ca2+-dependent, voltage-independent K+ current (EC50-value 113 nM) that is blocked by the K+ channel blockers charybdotoxin, margatoxin, and iberiotoxin. The K+ current activation by S1P is transient and leads to a large membrane hyperpolarization. Recently, we showed that lysophosphatidic acid (LPA), a serum lipid with similar biological effects compared to those of S1P, can activate a Ca2+-dependent K+ current in NIH3T3 cells that has identical properties compared to the one that is activated by S1P. When applied consecutively, both S1P and LPA induced a K+ current response in NIH3T3 cells, which indicates that the K+ current activation is not subjected to cross-desensitization between S1P and LPA. In C3H10T1/2 mouse fibroblasts that overexpress the nonreceptor protein tyrosine kinase c-Src, the amplitude of the S1P-induced K+ current was almost doubled compared to the one that we found in control cells. Expression of a non-myristylated c-Src mutant led to a further increase in the K+ current response to S1P, whereas expression of a kinase-defective c-Src mutant reduced it to about 40% compared to the control value. Our data show that S1P activates Ca2+-dependent K+ channels in mouse fibroblasts via an intracellular signalling pathway that involves the non-receptor protein tyrosine kinase c-Src.

Activation of a Ca2+-dependent K+ current by the oncogenic receptor protein tyrosine kinase v-Fms in mouse fibroblasts.

We investigated the effects of the receptor-coupled protein tyrosine kinase (RTK) v-Fms on the membrane current properties of NIH3T3 mouse fibroblasts. We found that v-Fms, the oncogenic variant of the macrophage colony-stimulating factor receptor c-Fms, activates a K+ current that is absent in control cells. The activation of the K+ current was Ca2+-dependent, voltage-independent, and was completely blocked by the K+ channel blockers charybdotoxin, margatoxin and iberiotoxin with IC50 values of 3 nM, 18 nM and 76 nM, respectively. To identify signalling components that mediate the activation of this K+ current, NIH3T3 cells that express different mutants of the wild-type v-Fms receptor were examined. Mutation of the binding site for the Ras-GTPase-activating protein led to a complete abolishment of the K+ current. A reduction of 76% and 63%, respectively, was observed upon mutation of either of the two binding sites for the growth factor receptor binding protein 2. Mutation of the ATP binding lobe, which disrupts the protein tyrosine kinase activity of v-Fms, led to a 55% reduction of the K+ current. Treatment of wild-type v-Fms cells with Clostiridium sordellii lethal toxin or a farnesyl protein transferase inhibitor, both known to inhibit the biological function of Ras, reduced the K+ current amplitude to 17% and 6% of the control value, respectively. This is the first report showing that an oncogenic RTK can modulate K+ channel activity. Our results indicate that this effect is dependent on the binding of certain Ras-regulating proteins to the v-Fms receptor and is not abolished by disruption of its intrinsic protein tyrosine kinase activity. Furthermore, our data suggest that Ras plays a key role for K+ channel activation by the oncogenic RTK v-Fms.

Bacillus intermedius ribonuclease as inhibitor of cell proliferation and membrane current.

The antiproliferative action of the guanine-specific ribonuclease secreted by Bacillus intermedius (binase) was studied in different chicken and mouse cell lines. The proliferation rate of chicken embryo fibroblasts, either normal or Rous sarcoma virus-transformed, was significantly reduced by binase treatment. Among mouse fibroblasts, v-ras-transformed NIH3T3 cells were sensitive to binase, whereas the growth of non-transformed, v-src-transformed or v-fms-transformed NIH3T3 cells was not affected. A 48 h treatment with binase inhibited the Ca2+-dependent K+ current of v-ras-transformed NIH3T3 cells but had no effect on this membrane current in non-transformed and in v-src- or v-fms-transformed NIH3T3 cells. Our results suggest that mammalian cells expressing the ras-oncogene are a potential target for the antiproliferative action of binase.

Present status of kidney transplantation.

Kidney transplantation today is the method of choice to treat end-stage renal disease (ESRD) in more than 50% of the ESRD-population. Due to major improvements in surgical handling, immunosuppressive therapy, and infection control, the one-year survival for patients and first grafts has reached nearly 90% in the recent years. In contrast no comparable achievements have been made in long-term graft survival. A constant number of grafts is lost yearly after the first postoperative year. In addition an increasing number of well functioning grafts is lost due to the death of the recipients caused mainly by cardiovascular and malignant disorders. The extension of kidney transplantation to all suitable recipients is nearly exclusively hampered by the organ shortage, which is further enhanced by failing grafts. This urges us to further improve the prognosis for patient and graft. This must include organ sharing on the basis of improved HLA-typing to achieve highly compatible grafts. The tools for differential diagnosis of acute and chronic graft dysfunction have to be improved. New immunosuppressive agents with higher immunosuppressive power and specificity but fewer nephrotoxic, metabolic and hemodynamic side effects are required at least for chronic rejection. The risk of infectious and malignant complications must be limited.

Kidney transplantation in Alport's syndrome: long-term outcome and allograft anti-GBM nephritis.

Anti-glomerular basement membrane (anti-GBM) nephritis occurring in kidneys transplanted in patients with Alport's syndrome (AS) has been reported repeatedly. Therefore, we studied graft survival and course of renal function in all 30 AS patients grafted at Hannover Medical School and compared them with non-diabetic, age and sex matched patients, transplanted on the date closest to the transplantation of the AS patient. Serum creatinine, proteinuria, urinary sediment and anti-GBM antibodies were examined in all AS patients with functioning grafts. Cases of patient or graft loss in the AS group were analyzed retrospectively. One- and five-year patient survival was 100 and 91% in AS and 89 and 78% in controls (p > 0.05, respectively). One- and five-year first graft survival was 79 and 66% in both groups. Graft histology was available in 34 biopsies obtained from 21 kidneys in 15 AS patients. Anti-GBM nephritis was not detected in any of the biopsies. No graft was lost due to anti-GBM nephritis. Anti-GBM antibodies were detectable temporarily only in one AS patient. He also had linear IgG staining in his graft GBM, but no other signs of anti-GBM nephritis. We conclude that patient survival and graft survival in AS patients following kidney transplantation is not different from non-AS patients. Allograft anti-GBM nephritis is a rare complication in patients with Alport's syndrome.

Sulfonylurea-sensitive K+ channels and their probable role for the membrane potential of mouse motor nerve endings.

We studied the effect of the KATP channel blockers tolbutamide and glibenclamide on presynaptic membrane currents in the mouse M. triangularis sterni preparation using the perineural recording technique. Both sulfonylureas blocked part of the fast K+ component within 2 min after application. The block was much more pronounced under glucose-free conditions and was completely reversible by washing. Addition of glucose to glucose-free bath solution also reduced the K+ component. A further effect of the sulfonylureas was observed under glucose-free conditions. With a delay of 5 to 10 min, the nodal Na+ component began to diminish and disappeared within 30 min. This was associated with a dramatic increase in spontaneous quantal transmitter release suggesting that the block of sulfonylurea-sensitive K+ channels causes depolarization of motor nerve terminals and fibres thus inactivating Na+ channels. Tetraethylammonium (TEA) which blocks ATP-dependent K+ channels in high concentrations caused, under glucose-free conditions, the same delayed effect as the sulfonylureas. This delayed effect was fully reversible by washing with glucose-containing, but not with glucose-free solution. Our findings strongly suggest that KATP channels exist in mammalian motor nerve endings and that under hypoglycemic conditions these channels open and become essential for the maintenance of the membrane potential.

[Persistent skin reaction and Raynaud phenomenon after a sting by Echiichthys draco (great weever fish)]. / Persistierende Hautreaktion und Raynaud-Syndrom nach einem Stich durch den Fisch Echiichthys draco (Petermännchen).

A 54-year-old recreational angler was stung in his right forefinger by Echiichthys draco. Within a few seconds he developed severe swelling with extreme pain sensation at the sting site, accompanied by dizziness and chill. Even under morphine therapy the pain symptoms were only slightly reduced. During the subsequent weeks, an erythema with marginate medium-sized scaling developed at the sting site and the patient experienced a approximately 50% reduced bending capacity of the forefinger and permanent numbness in this region. After 4 months, Raynaud phenomenon developed limited to the right forefinger. Great weever fishes (Echiichthys spp.) are the most venomous fishes in European waters. In humans, life-threatening sting reactions occur only in exceptional cases. As a commercial antiserum is not available, the therapy is mainly empiric (General measures of first aid and emergency medicine, the wound should be thoroughly washed). Patients should be informed that reduced motion ability, swelling or Raynaud's phenomenon can persist for several months.

Potassium single-channel properties in normal and Rous sarcoma virus-transformed chicken embryo fibroblasts.

Ion channels in normal and Rous sarcoma virus (RSV)-transformed chicken embryo fibroblasts (CEFs) were examined by using the patch-clamp technique. Three different types of ion channels were observed with single-channel conductances in symmetrical 140 mM KCl (with frequencies of occurrence in parentheses) of 186 pS (70%), 110 pS (10%), and 65 pS (20%), which are identical in normal and RSV-transformed CEFs. The total channel density in both cell types is about 0.13 per micron2. All three types of channels are highly selective for K+ ions, they are Ca(2+)- and voltage-dependent, and they can be completely blocked by external tetraethylammonium (10 mM) in both normal and RSV-transformed cells. Some channel properties, however, are different in normal and RSV-transformed CEFs. The K186 channel of normal CEFs is almost completely activated in the presence of about 1 nM free internal Ca2+ and is insensitive to charybdotoxin (100 nM). In contrast, the K186 channel of RSV-transformed CEFs has an EC50 value for activation by internal Ca2+ of about 100 nM and is highly sensitive to charybdotoxin (IC50 = 9 nM). In normal CEFs, the K186 channel activity starts at membrane potentials more positive than -50 mV and reaches a high open state probability of 0.94 at +50 mV. In RSV-transformed CEFs, the threshold of K186 channel activity is also -50 mV but the maximal open state probability is only 0.70 at +50 mV membrane potential. Averages of current traces of K186 channels show the typical features of the macroscopic K+ currents described previously for normal and RSV-transformed CEFs.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of standardized hay exposure of healthy probands and patients with farmer's lung with special reference to bronchoalveolar lavage]. / Der Einfluss einer standardisierten Heuexposition auf Gesunde und Farmerlungenkranke unter besonderer Berücksichtigung der bronchoalveolären Lavage.

Ten farmers with farmer's lung disease, and 15 healthy subjects who had not previously been exposed to hay, were exposed to hay for one hour. Over a period of twenty-four hours, the symptoms, number of leukocytes, temperature and pulmonary functional-analytical parameters were recorded. In all the cases with farmer's lung, and in seven of the healthy test subjects, broncho-alveolar lavages (BAL) were carried out prior to and 48 hours after the exposure to hay. In the patients with farmer's lung, a systemic, statistically significant reaction associated with an increase in the number of leukocytes to about 7,400/cmm, together with an increase in temperature of about 1.6 degrees C, occurred 8 hours after the initiation of the provocative test. In addition, a primary reaction developed, with a statistically significant decrease in vital capacity (VC) by 700 ml, of the total lung capacity (TLC) of 500 ml, and of the oxygen partial pressure of 14 mmHg. Four hours after the start of the provocation, the resistance increased, on average, by 0.5 cm H2O/l/s (p less than 0.05). In the case of the farmers with farmer's lung disease, a comparison of the cell composition of the BAL fluid prior to and after the provocative test revealed a decrease in the percentage of macrophages from 84.6 +/- 9.1% to 46.8 +/- 15.7% (p less than 0.003), an increase in the percentage of lymphocytes from 10.8 +/- 6.6% to 26.4 +/- 23.4% (p less than 0.04), and an increase in the percentage of polymorphs from 4.3 +/- 5.7% to 26.4 +/- 20.0% (p less than 0.004).(ABSTRACT TRUNCATED AT 250 WORDS)