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Microsoft word - seminar june 18 ce and personalized medicine.docx

TWO PAPERS ON THE COST EFFECTIVENESS OF GENETIC
TESTS FOR DETERMINING TREATMENT FOR PATIENTS
WITH ACUTE CORONORY SYNDROMES (ACS)
The use of genetic tests to guide treatments is a promising area of personalized medicine. The cost effectiveness of using a genetic test to guide treatment depends both on the frequency of the genetic marker in the relevant population and the rate of adverse health events avoided. Two recent studies look at the cost effectiveness of genetic testing for CYP2C19 variants to guide treatment for patients with ACS using two different data sets. Both results will be presented at this seminar. TIME 12:30
Pharmacy Building
Paper 1: “Personalised thienopyridine therapy: the cost effectiveness of genetic testing for CYP2C19 variants to guide treatment in patients with acute coronary syndromes” Laura Panattoni, University of Auckland
Paper 2: “Ticagrelor versus Genotype-Driven Antiplatelet Therapy for Secondary Prevention after Acute Coronary Syndrome: A Cost-Effectiveness Analysis” Dan Crespin, University of North Carolina
For more information, contact Paul Brown on pm_brown@unc.edu or ext. 3-3002. “Personalised thienopyridine therapy: the cost effectiveness of genetic testing for
CYP2C19 variants to guide treatment in patients with acute coronary syndromes”

Laura Panattoni, Paul M Brown, Braden Te Ao, Mark Webster, Patrick Gladding
Background: Patients with acute coronary syndromes and the reduced function allele
CYP2C19*2 (*2 allele) treated with thienopyridines have an increased risk of adverse cardiac
events with clopidogrel, but not with prasugrel. This study evaluated, in the New Zealand
setting, the cost effectiveness of generic clopidogrel in all patients, compared with prasugrel for
all patients, and also compared with the guided use of prasugrel in *2 allele patients.
Method
s: Clinical outcome data comparing clopidogrel and prasugrel from the TRITON-TIMI
38 trial was combined with rates of the*2 allele in Maori (24%), Pacific Islanders (45%), Asian
(29%), and New Zealand Europeans (15%). National hospital DRG discharge codes were used
to determine the incidence and costs of hospitalizations for stroke, MI, bleeding, stent
thrombosis, and cardiovascular death during the 15 months after patients presented with an
acute coronary syndrome. Decision tree modeling and Monte Carlo simulations were used.

Results:
The cost of medications and hospitalizations during the 15 months post ACS was
estimated to be $403 and $16,717, respectively, for each patient in New Zealand, with 8.5
QALYs. Treating all with patients with prasugrel was associated with higher cost and lower
QALYs, but use of a genetic test to guide the selected use of prasugrel was cost effective in the
New Zealand population (NZ$ 8,542/QALY), particularly for Maori (NZ$ 7,211/QALY) and
Pacific Islanders ($NZ 6,966/QALY). Prasugrel is less cost effective than clopidogrel when
used in all patients.

Conclusions:
Use of a genetic test to guide thienopyridine treatment in patients with acute
coronary syndromes is a cost effective treatment strategy, especially for Maori and Pacific
Islanders.
“Ticagrelor versus Genotype-Driven Antiplatelet Therapy for Secondary Prevention after
Acute Coronary Syndrome: A Cost-Effectiveness Analysis”

Daniel J. Crespin, Jerome J. Federspiel, Andrea K. Biddle, Daniel E. Jonas, Joseph S. Rossi,
Objective: To determine the cost-effectiveness of ticagrelor compared with a genotype-driven
selection of antiplatelet agents.

Background
: Clopidogrel’s effectiveness is likely reduced significantly for prevention of
thrombotic events after acute coronary syndrome (ACS) in patients exhibiting a decreased
ability to metabolize clopidogrel into its active form. A genetic mutation responsible for this
reduced effectiveness is detectable by genotyping. Ticagrelor is not dependent on gene-based
metabolic activation and demonstrated greater clinical efficacy than clopidogrel in a recent
secondary prevention trial. In 2011, clopidogrel will lose its patent protection and likely will be
substantially less expensive than ticagrelor.

Methods
: A hybrid decision tree/Markov model was used to estimate the 30-year medical costs
(in 2009 US$) and outcomes for a cohort of ACS patients of age 66 receiving either genotype-
driven or ticagrelor-only treatment. Outcomes included life years and quality-adjusted life years
(QALYs) gained. Data comparing the clinical performance of ticagrelor and clopidogrel were
derived from the Platelet Inhibition and Patient Outcomes trial.

Results
: The incremental cost-effectiveness ratio (ICER) for universal ticagrelor was $9,161 per
QALY compared to genotype-driven treatment, and was most sensitive to the price of ticagrelor
and the hazard ratio for death for ticagrelor compared with clopidogrel. The ICER remained
below $50,000 per QALY until a monthly ticagrelor price of $755 or a 0.93 hazard ratio for
death for ticagrelor relative to clopidogrel. In probabilistic analyses, universal ticagrelor was
below $50,000 per QALY in 97.4% of simulations.

Conclusion
: Prescribing ticagrelor universally increases quality-adjusted life years for ACS
patients at a cost below a typically accepted threshold.

Source: http://econ.duke.edu/uploads/assets/Workshop%20Papers/June18_THEW.pdf

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