Vaccino antinfluenzale stagionale in Italia: misurare l’efficacia sul campo e la sicurezza : Stagione 2015-2016

In Italia, nella stagione influenzale 2015-2016 sono stati condotti dall\u2019Istituto Superiore di Sanit\ue0 (ISS), con il supporto dell\u2019Agenzia Italiana del Farmaco (AIFA), due studi al fine di stimare l\u2019efficacia sul campo (I-MOVE, Influenza - Monitoring Vaccine Effectiveness) e valutare la sicurezza (SVEVA, Studio sulla Valutazione degli Eventi dopo Vaccinazione Antinfluenzale) del vaccino antinfluenzale. Nel complesso hanno aderito 8 Regioni che corrispondono a oltre met\ue0 della popolazione italiana nel 2015 (non tutte le Regioni hanno aderito a entrambi gli obiettivi di studio). Nello studio I-MOVE sono stati reclutati 1.094 casi di ILI (Influenza-Like Illness), dai 64 medici di medicina generale e pediatri di libera scelta partecipanti (506 casi e 498 controlli). I risultati suggeriscono che il vaccino ha conferito una protezione moderata nei confronti del tipo virale A(H1N1)pdm09 e molto bassa per A(H3N2) e B a causa del sostanziale grado di mismatch antigenico osservato, rispetto al ceppo vaccinale. Nello studio SVEVA sono stati monitorati 3.213 soggetti vaccinati e rilevati 854 (26%) eventi dopo 7 giorni dalla vaccinazione, la maggior parte dei quali di lieve entit\ue0. Al fine di ottenere stime di efficacia pi\uf9 solide e descrivere eventi avversi rari, \ue8 necessario tuttavia raggiungere una numerosit\ue0 campionaria maggiore.In Italy, during the 2015/2016 flu season, the National Institute of Health (ISS), with the support of the Italian Drug Agency (AIFA), conducted two studies to estimate vaccine effectiveness (I-MOVE) and evaluate safety (SVEVA) of the flu vaccine. A total of 8 regions, among 21, participated to the study which can correspond to more than 50% of the Italian population in 2015 (not all regions participated to both objectives of the study). For the I-MOVE study, 1094 cases of ILI (506 cases and 498 controls) were recruited by 64 general practitioners and pediatricians. The results indicate that the vaccine gave moderate protection against the virus type A (H1N1) pdm09 and very low protection for A (H3N2) and B due to the antigenic mismatch that was observed, compared to the vaccine strain. For SVEVA study, 3213 vaccinated cases were monitored and 854 (26%) side effects were notified after 7 days of vaccination, the major part were mild. In order to obtain more solid data regarding vaccine effectiveness, and to describe rare adverse events, it is necessary to increase the sample size of both studies

Time to Treatment Intensification in Patients Receiving DPP4 Inhibitors Versus Sulfonylureas as the First Add-On to Metformin Monotherapy: A Retrospective Cohort Study

Background: To verify whether, in patients on metformin (MET) monotherapy for type 2 diabetes (T2D), the add-on of a dipeptidyl peptidase inhibitor (DPP4i) compared to a sulfonylurea (SU) can delay the time to the subsequent treatment intensification (TI). Methods: Population-based administrative data banks from four Italian geographic areas were used. Patients aged ≥18 years on MET monotherapy receiving first DPP4i or SU dispensing between 2008 and 2015 (cohort entry) were followed up to the occurrence of TI (insulin dispensing or add-on of a third non-insulin hypoglicemic >180 days after cohort entry), treatment discontinuation, switch, cancer, death, TI occurrence within, end of data availability, end of study period (31 December 2016), whichever came first. Patients on MET + DPP4i were matched 1:1 with those on MET + SU by sex, age, year of cohort entry, and data bank. Hazard Ratio (HR) and 95% confidence intervals (95%CI) were estimated using multivariable Cox regression model including matching variables and potential confounders measured at baseline. Different sensitivity analyses were performed: i) matching at 180 days after cohort entry, ii) intent to treat (ITT) analysis, iii) matching by duration of MET monotherapy, iv) matching by propensity score. Results: The matched study cohort included 10,600 patients. Overall, 763 TI were observed (4.5/100 person-years; mean follow-up = 1.6 years). The primary analysis showed no difference in time to TI between the two groups (HR = 1.02; 95% CI = 0.88–1.19). Sensitivity analyses confirmed this result, except from the ITT analysis (HR = 1.27; 1.13–1.43). Conclusion: The use of a DPP4i rather than a SU as add-on to MET monotherapy was not associated with a delay in treatment intensification

Patterns and trends of utilization of incretin-based medicines between 2008 and 2014 in three Italian geographic areas

Background: The incretin-based medicines GLP1 analogues (GLP1a) and dipeptidyl peptidase-4 inhibitors (DPP4i) are hypoglycaemic agents licensed for the treatment of type 2 diabetes mellitus (T2DM). Although these drugs possess comparable efficacy and low risk of hypoglycaemia, differences in terms of route of administration (subcutaneous versus oral), effect on body weight and gastrointestinal tolerabily can impact their actual use in clinical practice. This study aimed to describe the real-world utilization of incretin-based medicines in the Italian clinical practice. Methods: A multi-database, population-based, descriptive, cohort study was performed using administrative data collected between 2008 and 2014 from three Italian geographic areas. Subjects aged 6518 were selected. New users were defined as those with 651 dispensing of GLP1a or DPP4i during the year of interest and none in the past. Trends of cumulative annual incidence of use in the general adult population were observed. New users of GLP1a or DPP4i were respectively described in terms of demographic characteristics and use of antidiabetic drugs during 1 year before and after the first incretin dispensing. Results: The overall study population included 4,943,952 subjects. A total of 7357 new users of GLP1a and 41,907 of DPP4i were identified during the study period. Incidence of use increased between 2008 (0.2\u2030 for both GLP1a and DPP4i) and 2011 (GLP1a = 0.6\u2030; DPP4i = 2.5\u2030) and slightly decreased thereafter. In 2014, 61% of new GLP1a users received once-daily liraglutide while 52% of new DPP4i users received metformin/DPP4i in fixed-dose. The percentage of new DPP4i users older than 65 years of age increased from 30.9 to 62.6% during the study period. Around 12% of new users had not received any antidiabetic before starting an incretin. Conclusions: During the study period, DPP4i rapidly became the most prescribed incretin-based medicine, particularly among older new user. The choice of the specific incretin-based medicine at first prescription appeared to be directed towards those with higher convenience of use (e.g. oral DPP4i rather than subcutaneous GLP1a, once-daily liraglutide rather than twice-daily exenatide). The non-negligibile use of incretin-based medicines as first-line pharmacotherapy for T2DM warrants further effectiveness and safety evaluations to better define their place in therapy

Patterns and trends of utilization of incretin-based medicines between 2008 and 2014 in three Italian geographic areas

Background: The incretin-based medicines GLP1 analogues (GLP1a) and dipeptidyl peptidase-4 inhibitors (DPP4i) are hypoglycaemic agents licensed for the treatment of type 2 diabetes mellitus (T2DM). Although these drugs possess comparable efficacy and low risk of hypoglycaemia, differences in terms of route of administration (subcutaneous versus oral), effect on body weight and gastrointestinal tolerabily can impact their actual use in clinical practice. This study aimed to describe the real-world utilization of incretin-based medicines in the Italian clinical practice. Methods: A multi-database, population-based, descriptive, cohort study was performed using administrative data collected between 2008 and 2014 from three Italian geographic areas. Subjects aged ≥18 were selected. New users were defined as those with ≥1 dispensing of GLP1a or DPP4i during the year of interest and none in the past. Trends of cumulative annual incidence of use in the general adult population were observed. New users of GLP1a or DPP4i were respectively described in terms of demographic characteristics and use of antidiabetic drugs during 1 year before and after the first incretin dispensing. Results: The overall study population included 4,943,952 subjects. A total of 7357 new users of GLP1a and 41,907 of DPP4i were identified during the study period. Incidence of use increased between 2008 (0.2‰ for both GLP1a and DPP4i) and 2011 (GLP1a = 0.6‰; DPP4i = 2.5‰) and slightly decreased thereafter. In 2014, 61% of new GLP1a users received once-daily liraglutide while 52% of new DPP4i users received metformin/DPP4i in fixed-dose. The percentage of new DPP4i users older than 65 years of age increased from 30.9 to 62.6% during the study period. Around 12% of new users had not received any antidiabetic before starting an incretin. Conclusions: During the study period, DPP4i rapidly became the most prescribed incretin-based medicine, particularly among older new user. The choice of the specific incretin-based medicine at first prescription appeared to be directed towards those with higher convenience of use (e.g. oral DPP4i rather than subcutaneous GLP1a, once-daily liraglutide rather than twice-daily exenatide). The non-negligibile use of incretin-based medicines as first-line pharmacotherapy for T2DM warrants further effectiveness and safety evaluations to better define their place in therapy

How Are the Interests of Incapacitated Research Participants Protected through Legislation? An Italian Study on Legal Agency for Dementia Patients

Patients with dementia may have limited capacity to give informed consent to participate in clinical research. One possible way to safeguard the patients' interests in research is the involvement of a proxy in the recruitment process. In Italy, the system of proxy is determined by the courts. In this study we evaluate the timing for appointment of a legal proxy in Italy and identify predictive variables of appointment.Subjects were recruited among the outpatients seeking medical advice for cognitive complaints at the Centre for Research and Treatment of Cognitive Dysfunctions, University of Milan, "Luigi Sacco" Hospital. The Centre was participating to the AdCare Study, a no-profit randomised clinical trial coordinated by the Italian National Institute of Health. The requirement that informed consent be given by a legal representative dramatically slowed down the recruitment process in AdCare, which was prematurely interrupted. The Centre for Research and Treatment of Cognitive Dysfunctions collected data on the timing required to appoint the legal representatives. Patients diagnosed with dementia and their caregivers were provided information on the Italian law on legal agency (law 6/2004). At each scheduled check-up the caregiver was asked whether she/he had applied to appoint a legal proxy for the patient and the time interval between the presentation of the law, the registration of the application at the law court chancellery and the sentence of appointment was registered. The study involved 169 demented patients. Seventy-eight patients (46.2%) applied to appoint a legal proxy. These subjects were usually younger, had been suffering from dementia for a longer time, had less than two children and made more use of memantine. The mean interval time between the presentation of the law and the patients' application to the law court chancellery was two months. The mean interval time between the patient's application to the law court chancellery and the sentence of appointment was four months.In Italy the requirement that legal representatives be appointed by the courts slows down subjects' participation in research. Other procedures for legal agency of the incapacitated patients may be adopted, taking as examples other EU countries' systems

The geographic relationship between the use of antimicrobial drugs and the pattern of resistance for Streptococcus pneumoniae in Italy.

OBJECTIVES: A temporal relationship between the increasing use of antibiotics and the increasing levels of antibiotic resistance has been established for Streptococcus pneumoniae. There are also data that support the presence of a geographic correlation between the level of resistance and the pattern of use among different countries and even within the same country. The aim of this study was to evaluate the potential geographic correlation between the use of beta-lactams and erythromycin in different Italian regions and the resistance of these antibiotics to invasive strains of S. pneumoniae during the period 1999-2000. METHODS: Ecological study. RESULTS: In Italy the mean level of resistance for penicillin and erythromycin was 11.4% and 28.9%, respectively. The highest level of resistance for both antibiotics was observed in central and southern regions (i.e. Campania, Lazio and the combined regions of Calabria, Puglia and Sicilia). These regions were also those with the highest consumption of antibiotics. A strong correlation was found between the prevalence of resistance to erythromycin and the regional use of macrolides (r=0.93, P=0.001) and beta-lactams (r=0.84, P=0.002). With regard to penicillin resistance, the greatest correlation was observed for oral penicillin (r=0.85, P=0.002). CONCLUSION: Our study provides further evidence of the association between regional level of antibiotic use and prevalence of antibiotic resistance

La valutazione dell'uso e della sicurezza dei farmaci: esperienze in Italia

Consiglio Nazionale delle Ricerche (CNR). Biblioteca Centrale / CNR - Consiglio Nazionale delle RichercheSIGLEITItal

9. Seminario nazionale. La valutazione dell'uso e della sicurezza dei farmaci: esperienze in Italia Riassunti

Objective of the workshop is to present and discuss some of the main issues relevant to drug use and adverse drug reactions in Italy. The first session is related to adverse drug reactions surveillance and the second session to the appropriateness of drug use and regulatory activities. Italian experiences on adverse drug reaction studies in emergency departments, in children and during vaccination campaigns are presented. At the end of the workshop the activities of the National Center for drug evaluation are illustratedConsiglio Nazionale delle Ricerche - Biblioteca Centrale - P.le Aldo Moro, 7, Rome Istituto Superiore di Sanita' - Viale Regina Elena, 299, Rome / CNR - Consiglio Nazionale delle RichercheSIGLEITItal

The association between multidose vaccinations and death: comparing case series methods when the first exposure changes the general risk of an event

Many case-control studies have shown a protective effect of vaccinations on the risk of sudden unexplained death (SUD). In this paper we compare the properties of different statistical methods in this situation, when the first vaccination appears to reduce the overall risk of an event (SUD). The first method is the self controlled case series (SCCS) method, which considers only subjects with an event during the observation time. This method yields unbiased estimates in the situation of non-censoring events. We show by simulation studies that the second method considered, the adjusted SCCS method, underestimates the parameter of interest, the effect of the first dose, when the general risk of SUD is lower in control periods after the first vaccination than in the period before vaccination. This type of bias could be eliminated by considering only cases who had received at least one vaccination. Additionally, we compare the adjusted SCCS method with the Cox model as a third method. Cox regression can take into account the time before the first vaccination, and this method yields unbiased estimates at modest effect sizes and short risk periods. We applied the SCCS method and Cox regression to data from the German study on sudden infant death (GeSID) and to a case series study from Italy (the HERA study) examining sudden unexpected deaths and vaccinations during the first 2 years of life. We show that the adjusted SCCS analysis with all cases underestimates the vaccination effect, as expected from the simulation analyses. Using Cox regression, we examined the general risk reduction after vaccination, as was the focus of the above mentioned studies. With a relative incidence of 0.8, our results were less pronounced than in the case-control analysis of the GeSID study (adjusted odds ratio: 0.51). SCCS analyses of both the GeSID and HERA studies yielded very similar estimates for the first and second vaccine doses