Contributos para a avaliação económica de medicamentos em Portu

RESUMO: A importância da avaliação económica na área da saúde tem sido crescente ao longo das últimas três décadas. É um campo de análise multi-disciplinar pelo qual se têm vindo a interessar investigadores de todo o mundo e onde, naturalmente, a economia da saúde tem contributos significativos para dar. Contudo, é uma área ainda relativamente inexplorada em termos de investigação metodológica em Portugal. Espera-se com este trabalho colmatar algumas das lacunas existentes e lançar pontes para investigação futura. Neste estudo pretendem-se desenvolver contributos autónomos, numa óptica de resolução de problemas concretos, para a avaliação económica de medicamentos em Portugal. Em primeiro lugar abordou-se a importância da estimação dos custos nos estudos de avaliação económica em saúde. Em segundo lugar determinou-se o custo de um doente com esclerose múltipla, por nível de severidade em Portugal com recurso à metodologia de estudos custo da doença. Em terceiro lugar, aplicando a mesma metodologia, determinou-se o custo de um doente com psoríase, por nível de severidade, em Portugal. Em quarto lugar mediu-se o impacto da psoríase na qualidade de vida relacionada com a saúde dos indivíduos afectados através de dois instrumentos genéricos de medição da qualidade de vida relacionada com a saúde (SF-36 e EQ-5D) e de dois instrumentos específicos (DLQI e PDI). Em quinto lugar, foi feita a adaptação de um modelo sobre a prevenção do tromboembolismo venoso em cirurgia ortopédica ao contexto nacional com recurso a dados recolhidos numa amostra de hospitais portugueses. Foi ainda apresentada uma estimativa do impacto orçamental decorrente da inclusão, ou não, de um novo medicamento na prática nacional. ABSTRACT: The importance of economic evaluation in the health care sector has been growing in the last three decades. It is a multidisciplinary field of research that attracts attention from researchers working all over the world. It is should be noted that health economics can contribute significantly to the development of this area. However, in Portugal is difficult to find methodological contributes in this field of research. With this work one hope to be able to overcome some of the existing shortcomings. This study seeks to develop independent contributions for the economic evaluation of pharmaceuticals in Portugal, aiming to help to solve existing problems. Firstly, one approached the importance of the accurate estimation of costs in economic evaluations of pharmaceuticals. Secondly, the cost of patient with multiple sclerosis was estimated, by severity level, in Portugal, using a cost of illness methodology. In third place, employing the same methodology, the cost of patient with psoriasis by severity level was estimated for Portugal. In fourth place, the impact of psoriasis in the quality of life related to health was ascertained by two generic measures (SF-36 and EQ-5D) and two specific measures (DLQI and PDI). Lastly, a model on the prevention of venous thromboembolism in orthopedic surgery was adapted for Portugal through the inclusion of data collected in a sample of Portuguese hospita

Joint effects of salinity and the antidepressant sertraline on the estuarine decapod Carcinus maenas

Concurrent exposure of estuarine organisms to man-made and natural stressors has become a common occurrence. Numerous interactions of multiple stressors causing synergistic or antagonistic effects have been described. However, limited information is available on combined effects of emerging pharmaceuticals and natural stressors. This study investigated the joint effects of the antidepressant sertraline and salinity on Carcinus maenas. To improve knowledge about interactive effects and potential vulnerability,experiments were performed with organisms from two estuaries with differing histories of exposure to environmental contamination. Biomarkers related to mode of action of sertraline were employed to assess effects of environmentally realistic concentrations of sertraline at two salinity levels. Synergism and antagonism were identified for biomarkers of cholinergic neurotransmission, energy production,anti-oxidant defences and oxidative damage. Different interactions were found for the two study sites highlighting the need to account for differences in tolerance of local ecological receptors in risk evaluations.

Impact of excipients in the chronic toxicity of fluoxetine on the alga Chlorella vulgaris

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) widely used in the treatment of major depression. It has been detected in surface and wastewaters, being able to negatively affect aquatic organisms. Most of the ecotoxicity studies focused only in pharmaceuticals, though excipients can also pose a risk to non-target organisms. In this work the ecotoxicity of five medicines (three generic formulations and two brand labels) containing the same active substance (fluoxetine hydrochloride) was tested on the alga Chlorella vulgaris, in order to evaluate if excipients can influence their ecotoxicity. Effective concentrations that cause 50% of inhibition (EC50) ranging from 0.25 to 15 mg L−1 were obtained in the growth inhibition test performed for the different medicines. The corresponding values for fluoxetine concentration are 10 times lower. Higher EC50 values had been published for the same alga considering only the toxicity of fluoxetine. Therefore, this increase in toxicity may be attributed to the presence of excipients. Thus more studies on ecotoxicological effects of excipients are required in order to assess the environmental risk they may pose to aquatic organisms.

Toxicity screening of Diclofenac, Propranolol, Sertraline and Simvastatin using Danio rerio and Paracentrotus lividus embryo bioassays

Early life-stage bioassays have been used as an alternative to short-term adult toxicity tests since they are cost-effective. A single couple can produce hundreds or thousands of embryos and hence can be used as a simple high-throughput approach in toxicity studies. In the present study, zebrafish and sea urchin embryo bioassays were used to test the toxicity of four pharmaceuticals belonging to different therapeutic classes: diclofenac, propranolol, simvastatin and sertraline. Simvastatin was the most toxic tested compound for zebrafish embryo, followed by diclofenac. Sertraline was the most toxic drug to sea urchin embryos, inducing development abnormalities at the ng/L range. Overall, our results highlight the potential of sea urchin embryo bioassay as a promising and sensitive approach for the high-throughput methods to test the toxicity of new chemicals, including pharmaceuticals, and identify several drugs that should go through more detailed toxicity assays.

Aplicação da Abordagem Kaizen Lean no Departamento de Logística no HGSA

O presente relatório de Dissertação surge no âmbito da unidade curricular Dissertação/Projeto/Estágio do 2º ano do Mestrado em Engenharia Mecânica – Ramo Gestão Industrial do Instituto Superior de Engenharia do Porto. O objetivo principal do projeto foi a aplicação das metodologias Kaizen-Lean no departamento de logística do Hospital Geral de Santo António, tendo em vista a melhoria contínua nestas duas áreas distintas: - gestão do produto farmacêutico, desde que é identificada a sua necessidade no armazém central até à reposição pelo fornecedor e respetiva distribuição e entrega nos serviços clínicos utilizadores. Aqui estão também incluídos os processos de negociação e encomenda. - gestão do serviço de transportes incluindo os transportes de doentes, produtos e profissionais de saúde. Este projeto surgiu no seguimento de projetos anteriores desenvolvidos pelo Kaizen Institute Portugal, empresa de consultoria de melhoria contínua, no Centro Hospitalar do Porto – Hospital Geral de Santo António. Durante o trabalho recorreu-se à aplicação de ferramentas Kaizen Lean nomeadamente metodologias e ferramentas associadas ao TFM – Total Flow Management e ao TSM – Total Service Management, ferramentas estas integradas no Kaizen Management System. De salientar também a aplicação do Kaizen Change Management, com uma componente muito forte de aplicação do Kaizen Diário. O resultado final da aplicação destas ferramentas resultou na concretização dos objectivos traçados que foram propostos. Tais como o desenvolvimento de uma cultura de melhoria contínua nas equipas de trabalho, organização dos postos de trabalho e redução dos stocks nos produtos farmacêuticos do Armazém de Produtos Farmacêuticos (APF).

Sulphonamide-imprinted sol–gel materials as ionophores in potentiometric transduction

This work proposes different kind of solid-contact graphite-based electrodes for the selective determination of sulphonamides (SPHs) in pharmaceuticals, biological fluids and aquaculture waters. Sulfadiazine (SDZ) and sulfamethoxazole (SMX) were selected for this purpose for being the most representative compounds of this group. The template molecules were imprinted in sol–gel (ISG) and the resulting material was used as detecting element. This was made by employing it as either a sensing layer or an ionophore of PVC-based membranes and subsequent potentiometric transduction, a strategy never reported before. The corresponding non-imprinted sol–gel (NISG) membranes were used as blank. The effect of plasticizer and kind/charge of ionic lipophilic additive was also studied. The best performance in terms of slope, linearity ranges and signal reproducibility and repeatability was achieved by PVC membranes including a high dielectric constant plasticizer and 15 mg of ISG particles. The corresponding average slope was −51.4 and −52.4 mV/decade, linear responses were 9.0 × 10−6 and 1.7 × 10−5 M, and limits of detection were 0.74 and 1.3 μg/mL for SDZ and for SMX, respectively. Good selectivity with log Kpot < −0.3 was observed for carbonate, chloride, fluoride, hydrogenocarbonate, nitrate, nitrite, phosphate, cyanide, sulfate, borate, persulphate, citrate, tartrate, salicylate, tetracycline, ciprofloxacin, sulphamerazine, sulphatiazole, dopamine, glucose, galactose, cysteine and creatinine. The best sensors were successfully applied to the analysis of real samples with relative errors ranging from −6.8 to + 3.7%.

Ciprofloxacin-imprinted polymeric receptors as ionophores for potentiometric transduction

A 3D-mirror synthetic receptor for ciprofloxacin host–guest interactions and potentiometric transduction is presented. The host cavity was shaped on a polymeric surface assembled with methacrylic acid or 2-vinyl pyridine monomers by radical polymerization. Molecularly imprinted particles were dispersed in 2-nitrophenyl octyl ether and entrapped in a poly(vinyl chloride) matrix. The sensors exhibited a near-Nernstian response in steady state evaluations. Slopes and detection limits ranged from 26.8 to 50.0 mV decade−1 and 1.0 × 10−5 to 2.7 × 10−5 mol L−1, respectively. Good selectivity was observed for trimethoprim, enrofloxacin, tetracycline, cysteine, galactose, hydroxylamine, creatinine, ammonium chloride, sucrose, glucose, sulphamerazine and sulfadiazine. The sensors were successfully applied to the determination of ciprofloxacin concentrations in fish and in pharmaceuticals. The method presented offered the advantages of simplicity, accuracy, applicability to colored and turbid samples and automation feasibility, as well as confirming the use of molecularly imprinted polymers as ionophores for organic ion recognition in potentiometric transduction.

Development of a SPE–UHPLC–MS/MS methodology for thedetermination of non-steroidal anti-inflammatory and analgesicpharmaceuticals in seawaterPaula

An analytical methodology for the simultaneous determination of seven pharmaceuticals and two metabolites belonging to the non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics therapeutic groups was developed based on off-line solid-phase extraction and ultra-high performance liquid chromatography coupled to tandem mass spectrometry (SPE–UHPLC–MS/MS). Extraction conditions were optimized taking into account parameters like sorbent material, sample volume and sample pH. Method detection limits (MDLs) ranging from 0.02 to 8.18 ng/L were obtained. This methodology was successfully applied to the determination of the selected pharmaceuticals in seawater samples of Atlantic Ocean in the Northern Portuguese coast. All the pharmaceuticals have been detected in the seawater samples, with pharmaceuticals like ibuprofen, acetaminophen, ketoprofen and the metabolite hydroxyibuprofen being the most frequently detected at concentrations that can reach some hundreds of ng/L.

Contaminantes emergentes em cemitérios: avaliação exploratória

A constituição dos solos, as condições que reúnem e o seu conteúdo microbiológico permitem que a matéria orgânica enterrada se degrade, sendo estas várias das muitas razões para a utilização dos solos como cemitério. Com o desenvolvimento tecnológico, o crescente número de unidades cemiteriais e o aumento da preocupação ambiental e da saúde pública, realizaram-se estudos com o objetivo de caraterizar e quantificar quais os poluentes existentes e avaliar o seu impacto no meio ambiente. Este trabalho, que vem no seguimento dessa crescente preocupação visa caraterizar e quantificar tanto em amostras de solo como em amostras de águas, quais os elementos poluentes existentes no cemitério de Paranhos. De maneira a identificar estes elementos poluentes realizou-se uma campanha de amostragem no cemitério onde se retiraram tanto amostras de solo como amostras de água, procedendo ao seu tratamento e à sua análise em laboratório, utilizando os métodos de fluorescência de raios X e espectrometria de massa respetivamente. Após o tratamento e a análise concluiu-se que nas amostras de solo, todos os metais detetados estão em maior quantidade no solo do cemitério excetuando o ferro sendo que ainda se aferiu a existência de fármacos nas amostras de água, nomeadamente a sertraline e carbamazepina.

Price linkages in pharmaceutical markets

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Economics from the NOVA – School of Business and Economics

Economic analysis in health care regulation : three essays

ABSTRACT - It is the purpose of the present thesis to emphasize, through a series of examples, the need and value of appropriate pre-analysis of the impact of health care regulation. Specifically, the thesis presents three papers on the theme of regulation in different aspects of health care provision and financing. The first two consist of economic analyses of the impact of health care regulation and the third comprises the creation of an instrument for supporting economic analysis of health care regulation, namely in the field of evaluation of health care programs. The first paper develops a model of health plan competition and pricing in order to understand the dynamics of health plan entry and exit in the presence of switching costs and alternative health premium payment systems. We build an explicit model of death spirals, in which profitmaximizing competing health plans find it optimal to adopt a pattern of increasing relative prices culminating in health plan exit. We find the steady-state numerical solution for the price sequence and the plan’s optimal length of life through simulation and do some comparative statics. This allows us to show that using risk adjusted premiums and imposing price floors are effective at reducing death spirals and switching costs, while having employees pay a fixed share of the premium enhances death spirals and increases switching costs. Price regulation of pharmaceuticals is one of the cost control measures adopted by the Portuguese government, as in many European countries. When such regulation decreases the products’ real price over time, it may create an incentive for product turnover. Using panel data for the period of 1997 through 2003 on drug packages sold in Portuguese pharmacies, the second paper addresses the question of whether price control policies create an incentive for product withdrawal. Our work builds the product survival literature by accounting for unobservable product characteristics and heterogeneity among consumers when constructing quality, price control and competition indexes. These indexes are then used as covariates in a Cox proportional hazard model. We find that, indeed, price control measures increase the probability of exit, and that such effect is not verified in OTC market where no such price regulation measures exist. We also find quality to have a significant positive impact on product survival. In the third paper, we develop a microsimulation discrete events model (MSDEM) for costeffectiveness analysis of Human Immunodeficiency Virus treatment, simulating individual paths from antiretroviral therapy (ART) initiation to death. Four driving forces determine the course of events: CD4+ cell count, viral load resistance and adherence. A novel feature of the model with respect to the previous MSDEMs is that distributions of time to event depend on individuals’ characteristics and past history. Time to event was modeled using parametric survival analysis. Events modeled include: viral suppression, regimen switch due virological failure, regimen switch due to other reasons, resistance development, hospitalization, AIDS events, and death. Disease progression is structured according to therapy lines and the model is parameterized with cohort Portuguese observational data. An application of the model is presented comparing the cost-effectiveness ART initiation with two nucleoside analogue reverse transcriptase inhibitors (NRTI) plus one non-nucleoside reverse transcriptase inhibitor(NNRTI) to two NRTI plus boosted protease inhibitor (PI/r) in HIV- 1 infected individuals. We find 2NRTI+NNRTI to be a dominant strategy. Results predicted by the model reproduce those of the data used for parameterization and are in line with those published in the literature.

HPV : devem os rapazes ser vacinados?

RESUMO - A infecção por Vírus do Papiloma Humano (Human Papillomavirus - HPV) é uma das doenças de transmissão sexual mais frequentes em todo o mundo. A descoberta de que esta infecção é responsável pelo carcinoma do colo do útero impulsionou o desenvolvimento de vacinas contra o HPV. Em Portugal, a vacina tetravalente contra o HPV faz parte do Plano Nacional de Vacinação, sendo administrada apenas a raparigas aos 13 anos de idade como medida profiláctica do carcinoma do colo do útero. Nos Estados Unidos da América, em Dezembro de 2010, a Food and Drugs Administration (FDA) aprovou o uso da vacina tetravalente na prevenção de lesões pré-cancerígenas e cancerígenas do ânus, tanto em rapazes como em raparigas, dos 9 aos 26 anos. A 25 de Outubro de 2011, o Advisory Committee on Immunization Practices (ACIP) recomendou que todos os rapazes de 11 e 12 anos sejam vacinados contra o HPV com a vacina tetravalente. Partindo desta realidade, o que se pretende com o presente trabalho é compilar evidência científica suficiente que permita ponderar mais aprofundadamente acerca das implicações, a partir de dados epidemiológicos e económicos, de se vacinar ou não os rapazes contra o HPV em Portugal. Em primeiro lugar recolheu-se evidência científica acerca da relação entre a infecção por HPV e o desenvolvimento de carcinomas de diversas regiões anatómicas. Em segundo lugar compilaram-se dados epidemiológicos sobre a incidência e sobrevivência associada aos diferentes tipos de tumores potencialmente associados à infecção por HPV, dando especial ênfase à realidade portuguesa. Em terceiro lugar enquadrou-se sucintamente a história da vacinação contra o HPV em Portugal e as vacinas existentes para prevenir esta infecção. Em quarto lugar foram revistos estudos de avaliação económica da vacinação contra o HPV quer em mulheres quer em homens, após uma introdução ao conceito de avaliação económica do medicamento. Em quinto lugar, foi feita uma estimativa dos custos com a vacinação dos rapazes contra o HPV durante os próximos 20 anos. Por último, procurou-se reflectir acerca das implicações de se alargar ou não a vacinação contra o HPV aos rapazes em Portugal.

Toxicological effects of a pharmaceutical, simvastatin, in Gammarus locusta: histopathological evaluation

Dissertação para obtenção do Grau de Mestre em Engenharia do Ambiente

Catastrophic health care expenditures in Portugal between 2000-2010: Assessing impoverishment, determinants and policy implications

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Economics from the NOVA – School of Business and Economics

Operating profitability in branded pharmaceutical firms

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Management from the NOVA – School of Business and Economics