Pentoxifylline use in dermatology.

Pentoxifylline is methylxanthine derivative which is used in microcirculatory disorders as a vasoactive drug. Novel immunomodulatory properties of pentoxifylline have been reported including the down regulation of tumour necrosis factor-α synthesis and other inflammatory cytokines. Studies have shown that pentoxifylline might be efficacious in a wide spectrum of skin diseases. This article focuses on the use of pentoxifylline which is a safe and cheap drug in various dermatological disorders.

Headache rate and cost of care following lumbar puncture at a single tertiary care hospital.

BACKGROUND: American Academy of Neurology guidelines recommend the use of noncutting needles because of lower rates of headache following lumbar puncture in randomized trials. We sought to determine the rate of headache using cutting needles and the potential cost savings of switching to noncutting needles. METHODS: We retrospectively reviewed the charts of all patients who had a lumbar puncture in the outpatient neurology clinic at a single institution between January 2004 and December 2005. Outcome data included occurrence of headache, back pain, or epidural hematomas within 2 weeks of the procedure. Costs associated with the use of the current system were compared with the projected costs of switching to a noncutting needle system. RESULTS: A total of 274 patients underwent lumbar puncture (62% women, mean age 53 ± 17 years, average weight 178 ± 43 pounds). Of these, 38 (14%) had a post-lumbar puncture headache. Eight patients (3%) reported back pain. No patients had an epidural hematoma. Twelve patients were admitted for a total of 18 hospital days, mainly for headache. Predictors of headache were younger age and no prior aspirin use. The rate of headache associated with the noncutting needle according to published literature is 4%. The estimated cost savings would have been approximately $20,000 per year (or approximately $73 per person). CONCLUSIONS: In this single-institution study, use of a noncutting needle would have potentially been associated with less adverse events and less cost. Further studies are warranted, including the possibility of premedication with aspirin.

Burden of pulmonary arterial hypertension in Germany.

This study aimed to describe health care provision, resource consumption and related costs, as well as treatment patterns and quality of life in adult patients with pulmonary arterial hypertension (PAH) in Germany. Data for this retrospective and prospective cost-of-illness-study were derived from hospitals, general practitioners and patients. Costs were evaluated from the perspective of third party payer and patient. Quality of life data were collected by using three validated instruments. A total of 167 patients were enrolled at 10 hospitals. Time period from first occurrence of symptoms to confirmed diagnosis of PAH was 2.3 years on average. Mean number of GP visits was 1.5 per patient per month, and within 15 months, inpatient stays were reported for 50% of patients. The ratio of combination therapy to single-drug therapy for endothelin receptor antagonists, phosphodiesterase-5-inhibitor and prostacyclin analogues increased significantly during 15 months. Treatment costs were, on average, euro47,400 per patient per year, arising mainly from drugs. Compared to the general population, quality of life of PAH patients was considerably impaired. This is the first study which evaluated aspects of the medical and economic consequences of PAH based on a large cohort of PAH patients in Germany.

[Erectile dysfunction after radical prostatectomy : patient information, contact persons, postoperative proerectile therapy]. / Erektile Dysfunktion nach radikaler Prostatektomie : Aufklärung, Ansprechpartner, postoperative proerektile Therapie.

BACKGROUND: Postoperative erectile dysfunction (ED) is one of the potential after-effects of radical prostatectomy. The aim of this study was to learn which caregivers inform the patients prior to the intervention about the risk of ED, which individuals the patients discuss this issue with, and whether the patients preoperatively consider use of a PDE5 inhibitor for proerectile therapy after the operation. METHODS: Using the IIEF-5 questionnaire, the preoperative erectile function of 110 patients was evaluated after the hospital admission interview. The patients were asked who had informed them about the risk of postoperative ED. They were also asked in whom they had confided to discuss this issue and whether they were prepared to undergo postoperative proerectile therapy with a PDE5 inhibitor. The patients were subsequently assigned to one of two groups: group I, consisting of those with a preoperative IIEF score > or = 21, or group II, those with a preoperative IIEF score <21. RESULTS: The answers given by groups I and II did not differ significantly. The median patient age was the same, 68, in both groups. In addition to being informed about postoperative ED by the hospital doctor on admission (100%), the patients were informed about this by the following individuals (results for group II in parentheses): board-certified urologist, 81.8% (74%); general practitioner (GP), 27.3%; partner, 12.1% (11.7%); self-help groups, 0% (2.6%); and friends, 3% (6.5%). Patients also discussed the risk of postoperative ED with the following individuals (results for group II in parentheses): local urologist, 66.7% (63.4%); partner, 45.5% (42.9%); hospital doctor, 39.4% (42.9%); GP, 21.2% (23.4%); friends, 9.1% (14.3); or no one, 3% (5.2%). Regarding whether patients were willing to undergo postoperative therapy using a PDE5 inhibitor, 36.4% in group I and 32.5% in group II said yes, 12.1% in group I and 11.7% in group II said no, and 51.5% in group I and 55.8% in group II were undecided. CONCLUSION: Irrespective of the patient's erectile status, the hospital doctor and the local urologist informed the patients about the risk of postoperative ED. Satisfactory information delivered by at least two people occurred in over 70% of all cases. The most frequent confidant of the patient for discussing this issue was his local urologist. Fewer than 50% of the patients discussed this topic with their partners. Possible reasons for underestimating the importance of sexual function could be the frequent taboo status of sexuality as a discussion topic in relationships, as well as preoperative distress. These circumstances should be taken into account by offering sufficient information, including that on the availability of postoperative proerectile therapy, for both the patient and his partner as early as possible, i.e., at the stage of choosing a treatment option.

Clinical and cost-effectiveness of epoprostenol, iloprost, bosentan, sitaxentan and sildenafil for pulmonary arterial hypertension within their licensed indications: a systematic review and economic evaluation.

OBJECTIVE(S): To investigate the clinical and cost-effectiveness of epoprostenol, iloprost, bosentan, sitaxentan and sildenafil for the treatment of adults with pulmonary arterial hypertension (PAH) within their licensed indications. DATA SOURCES: Major electronic databases (including the Cochrane Library, MEDLINE and EMBASE) were searched up to February 2007. Further data were obtained from dossiers submitted to NICE by the manufacturers of the technologies. REVIEW METHODS: The systematic clinical and economic reviews were conducted according to accepted procedures. Model-based economic evaluations of the cost-effectiveness of the technologies from the perspective of the UK NHS and personal social services were carried out. RESULTS: In total, 20 randomised controlled trials (RCTs) were included in this assessment, mostly of 12-18 weeks duration and comparing one of the technologies added to supportive treatment with supportive treatment alone. Four published economic evaluations were identified. None produced results generalisable to the NHS. There was no consensus in the industry submissions on the most appropriate model structure for the technology assessment. Improvement in 6-minute walk distance (6MWD) was seen with intravenous epoprostenol in primary pulmonary hypertension (PPH) patients with mixed functional class (FC) (mainly III and IV, licensed indication) compared with supportive care (58 metres; 95% CI 6-110). For bosentan compared with supportive care, the pooled result for improvement in 6MWD for FCIII patients with mixed PAH (licensed indication) was 59 metres (95% CI 20-99). For inhaled iloprost, sitaxentan and sildenafil no stratified data for improvement in 6MWD were available. The odds ratio (OR) for FC deterioration at 12 weeks was 0.40 (95% CI 0.13-1.20) for intravenous epoprostenol compared with supportive care. The corresponding values for inhaled iloprost (FCIII PPH patients; licensed indication), bosentan, sitaxentan (FCIII patients with mixed PAH; licensed indication) and sildenafil (FCIII patients with mixed PAH; licensed indication) were 0.29 (95% CI 0.07-1.18), 0.21 (95% CI 0.03-1.76), 0.18 (95% CI 0.02-1.64) and [Commercial-in-confidence information has been removed] respectively. The incremental cost-effectiveness ratios (ICERs) for the technologies plus supportive care compared with supportive care alone, determined by independent economic evaluation, were 277,000 pounds/quality-adjusted life-year (QALY) for FCIII and 343,000 pounds/QALY for FCIV patients for epoprostenol, 101,000 pounds/QALY for iloprost, 27,000 pounds/QALY for bosentan and 25,000 pounds/QALY for sitaxentan. For the most part sildenafil plus supportive care was more effective and less costly than supportive care alone and therefore dominated supportive care. In the case of epoprostenol the ICERs were sensitive to the price of epoprostenol and for bosentan and sitaxentan the ICERs were sensitive to running the model over a shorter time horizon and with a lower cost of epoprostenol. Two RCTs directly compared the technologies against each other with no significant differences observed between the technologies. Combinations of technologies were investigated in four RCTs, with some showing conflicting results. CONCLUSION(S): All five technologies when added to supportive treatment and used at licensed dose(s) were more effective than supportive treatment alone in RCTs that included patients of mixed FC and types of PAH. Current evidence does not allow adequate comparisons between the technologies nor for the use of combinations of the technologies. Independent economic evaluation suggests that bosentan, sitaxentan and sildenafil may be cost-effective by standard thresholds and that iloprost and epoprostenol may not. If confirmed, the use of the most cost-effective treatment would result in a reduction in costs for the NHS. Long-term, double-blind RCTs of sufficient sample size that directly compare bosentan, sitaxentan and sildenafil, and evaluate outcomes including survival, quality of life, maintenance on treatment and impact on the use of resources for NHS and personal social services are needed.

Phosphodiesterase type 5 inhibitors for the management of erectile dysfunction: preference and adherence to treatment.

Erectile dysfunction (ED) is a common medical condition that has a negative impact on men and their partners. The field has revolutionised over the last two decades and more treatment options are available now for the treatment of ED than ever before. Among available treatment options, the most commonly prescribed therapies are oral phosphodiesterase type 5 (PDE5) inhibitors. The first drug in this class, sildenafil citrate, generally provides patients and their partners with efficacious, safe, and discreet treatment that rapidly has become the first-line treatment option. Its successful introduction into clinical practice was soon followed by the launch of two other PDE5 inhibitors: tadalafil and vardenafil. The existence of these drugs has resulted in an increase in their marketing. However, the abundance of choices made the question "which PDE-5 inhibitor?" relevant for clinicians, patients and their partners. It is widely accepted that there are no significant differences in their safety and efficacy, a fact that has led to the initiation of studies aiming to evaluate them regarding patient preference. Nevertheless, the results are rather conflicting. Also a significant percentage of men initiating treatment switch between inhibitors or discontinue therapy. This article examines the peer-reviewed published data addressing patient's preference and adherence to ED treatment with PDE5 inhibitors. It also examines strategies to improve compliance and satisfaction with treatment.

The use of sulfasalazine and pentoxifylline (low-cost antitumour necrosis factor drugs) as adjuvant therapy for the treatment of pemphigus vulgaris: a comparative study.

BACKGROUND: Pemphigus vulgaris (PV) represents a potentially life-threatening autoimmune blistering disease in which IgG autoantibodies are directed against cell-cell adhesion molecules. Tumour necrosis factor (TNF)-alpha has been suggested to have a possible role in the mechanism underlying acantholysis. OBJECTIVES: This comparative double-blinded study was carried out to estimate the use of both sulfasalazine (SSZ) and pentoxifylline (PTX) (low-cost anti-TNF drugs) as an adjuvant therapy for PV. METHODS: The study included 64 patients with PV: 42 patients received the full treatment regimen (with SSZ and PTX) and 22 patients followed the same regimen except they received placebo instead of PTX and SSZ. Five healthy subjects were included as controls. Serum samples were taken to measure TNF-alpha levels in the control group and before starting treatment in both the patient groups and this was repeated every 2 weeks for 8 weeks; a clinical assessment was made every week for all the patients. RESULTS: The serum level of TNF-alpha was statistically higher in both groups of patients than in the healthy individuals. There was a statistically significant decrease in the serum levels of TNF-alpha in patients in group 1 compared with those in group 2 at 6 and 8 weeks. There was also a significant clinical improvement in patients in group 1 compared with those in group 2. CONCLUSION: The use of PTX and SSZ as adjuvant therapy in the treatment of PV induced a faster and more significant decrease in the serum level of TNF-alpha, and this decrease was associated with rapid clinical improvement.

The impact of formulary replacement of sildenafil by vardenafil at a local VA hospital.

The National Veterans Administration (VA) changed its formulary agent for the treatment of erectile dysfunction from sildenafil to vardenafil in January 2006 for economic reasons. The objective of this study was to assess the impact of this formulary change on the patients at a local VA hospital. All non-formulary requests for sildenafil between January 2006 and September 2006 were reviewed. A total of 169 non-formulary requests were made for sildenafil while 7657 patients filled vardenafil prescriptions. Overall, the formulary change from sildenafil to vardenafil appeared to be well tolerated by the vast majority of patients at this local VA hospital. The substantial cost savings to the VA seem to be justified by the minimal adverse effects on men treated for erectile dysfunction.

Is sex only for the healthy and wealthy?

OBJECTIVE: To study reasons for Sildenafil (a phosphodiesterase type 5 inhibitor) treatment abortion in erectile dysfunction (ED), with special regard to the relation between cost and use. METHODS: Men (N = 132) with ED, where treatment with Sildenafil was instituted between 1998 and 2000, were mailed a questionnaire in February 2003, regarding their current ED treatment, including frequency of use, reasons for change or discontinuation, effect on partner relations, and total income of the household. RESULTS: The response rate was 69%. Nearly every second man (47%) still used Sildenafil at least twice per month. The remaining 53% had aborted oral ED treatment: 10% due to return of normal erections, 43% due to (either alone or in combination): cost of treatment, impaired health, loss of efficacy, change to another ED treatment, or side-effects. Cost was the most common cause (48%) for discontinuation. In low-income households, rationing of treatment or abortion due to the cost was reported significantly (P < 0001) more often (86%) than in high-income households (35%). CONCLUSION: Just under half of all the patients (47%) used Sildenafil for more than 2 years after initiation of treatment. The cost of the treatment is an important factor for patient compliance in households with a low income, despite the fact that the treatment is highly effective and improves the partner relationship.

Comorbid conditions in men with ED before and after ED diagnosis: a retrospective database study.

Although erectile dysfunction (ED) has been considered a complication of other medical conditions, clinicians and researchers suggest that ED may serve as a clinical marker of vascular health. This retrospective claims study examined the prevalence of predefined comorbid conditions in men with ED (N=301 994) in the 12 months before and the 6 months following ED diagnosis. Consistent with previous research, comorbid conditions were prevalent among men with ED. Comorbid conditions were most often diagnosed before an ED diagnosis, although new diagnoses in the 6 months following an ED diagnosis were common and occured more frequently than new diagnoses in a matched sample of men without ED during the same period. Differences by age, region and insurance coverage for ED medications were also examined. Findings support previous research that suggests ED may serve as a marker for previously undetected comorbid conditions.

The costs of caring for erectile dysfunction in a managed care setting: evidence from a large national claims database.

PURPOSE: We examined the direct costs of erectile dysfunction (ED) empirically. MATERIALS AND METHODS: A naturalistic cohort study was done in 285,436 patients with ED and 51 health plans that covered 28 million lives nationwide from 1999 through 2001. Based on claims that had an ED related diagnosis code, procedure code or medication code we categorized the cost structure of ED care and calculated the annual costs of ED care per patient with ED, per user and per member monthly for individual and for all categories of ED care. RESULTS: A patient with ED in a health plan spent about an average of 83.91 dollars in 1999, 95.41 dollars in 2000 and 119.26 dollars in 2001 for ED care. In 2001, 37.08% of ED care costs per patient with ED were spent on phosphodiesterase type 5 (PDE-5) inhibitor therapy, 14.36% were spent on physician office visits, 10.19% were spent on diagnosis procedures, 8.45% were spent on testosterone hormone therapy, 3.85% were spent on penile prosthesis implantation, 4.41% were spent on intracavernous injection, 2.68% were spent on alprostadil pellet insertion and 0.81% was spent on vacuum erection devices. Of the 7 commonly used ED treatments PDE-5 inhibitor therapy has the lowest annual cost per user. CONCLUSIONS: In 2001 ED imposed a 122,669 dollars annual burden to a health plan with 100,000 members, that is or 0.108 dollars per member monthly. Each patient with ED spent 119.26 dollars annually for all ED related services or treatments. Of the 7 commonly used treatments PDE-5 inhibitor therapy had the lowest annual cost per user.

A study of the management of erectile dysfunction in general practice.

BACKGROUND AND OBJECTIVES: The Department of Health issued guidelines for the NHS treatment of erectile dysfunction (ED) with phosphodiesterase type 5 inhibitors (PDE 5 inhibitors) in 1999. There has been an increasing trend in the prescribing of PDE 5 inhibitors within Bebington and West Wirral Primary Care Trust (PCT) over the 3-year period from February 2001 to January 2004. The objective of the study was to investigate implementation of Government guidelines on prescribing of PDE 5 inhibitors for ED and the cost of prescribing outside these guidelines. METHODS: Practice data were collected for all patients prescribed a PDE 5 inhibitor in 16 surgeries within Bebington and West Wirral Primary Care Trust, from November 2002 to December 2003. The data were evaluated with respect to adherence to UK Government guidelines. Analysis was made on the cost to the PCT with respect to treatment provided outside the guidelines. RESULTS AND DISCUSSION: Prescribing for 78% of patients was within Government guidelines. With respect to frequency of prescribing, 89% of patients in the PCT received less than or equal to the recommended frequency of one tablet per week. The percentage range for practices was 67-100%. The cost to the PCT for PDE 5 inhibitor treatment provided outside the guidelines was 19,060 pounds sterling over the period of study. CONCLUSION: Prescribers generally follow Government guidelines, however, stricter adherence to guidelines could result in more efficient use of National Health Service resources.