The cost of teriflunomide in the treatment of relapsing-remitting multiple sclerosis.

Aims: Teriflunomide, used globally to treat multiple sclerosis (MS) and widely subsidised for this indication including in Australia and New Zealand, is the main metabolite of leflunomide, an older immune-modulating drug. Leflunomide therefore represents a potential alternative therapy for MS. Teriflunomide is about 50-500 times more expensive than leflunomide, depending on prices in each jurisdiction.

Effect of medical thromboprophylaxis on mortality from pulmonary embolus and major bleedingy.

Background: Several studies have failed to discover a beneficial effect of medical thromboprophylaxis on mortality.

Aims: To examine the relative influence of acute fatal pulmonary embolism (PE) and fatal major haemorrhage on overall mortality in medical patients treated with low molecular weight heparin (LMWP) for prophylaxis.

Methods: The author compared deaths from the above factors using data from a recent Cochrane Collaboration meta-analysis.

Potential cost to Western Australia of proposed patient co-payments according to healthcare organisational structure: A preliminary analysis.

Background: The Australian federal government has proposed an AUD $7 patient co-payment for a general practitioner (GP) consultation. One effect of the co-payment may be that patients will seek assistance at public hospital emergency departments (EDs), where currently there is no user charge.

Aims: We studied the possible financial impact of patient diversion on the Western Australia (WA) health budget.

Current state of medical thromboprophylaxis in Australia.

Background: Australia has two published national guidelines for general medical thromboprophylaxis (MT), but the two differ in detail and the basis for patient selection remains uncertain. Several aspects of current guidelines are controversial, as is the proposed design of a dedicated prescribing box in the National Inpatient Medication Chart.

Aim: To discuss and comment on the current standing of medical thromboprophylaxis in Australia.

Measures of risk and their relationship to the relative size of a high-risk group: application to medical thromboprophylaxis.

Background: The aim of this study was to establish the meaning of "high-risk" when the subgroup so defined by risk factor analysis is a substantial proportion of the population. This is clinically important when patients, deemed to be at high risk as a result of risk factor analysis, become eligible for a clinical intervention to decrease the risk, especially if the intervention has adverse effects. One example in clinical practice is the assessment of eligibility for medical thromboprophylaxis.

Eligibility for medical thromboprophylaxis based on risk-factor weights, and clinical thrombotic event rates.

Objectives: To measure eligibility for medical thromboprophylaxis using two Australasian guidelines - the Australia and New Zealand Working Party Guidelines [WPG] and the National Health and Medical Research Council Guidelines [NHMRCG]) - and proposed new guidelines based on risk-factor weights; and to measure the incidence of clinical venous thromboembolism (VTE) events in medical patients ("ensuing VTE").

Design, Setting And Patients: Prospective case-note audit in an acute medical ward of Southland Hospital, a regional hospital in Invercargill, New Zealand, among all 595 patients who were discharged consecutively from 21 November 2010 to 7 March 2011. Of these, 245 were excluded on clinical grounds or because they were under the care of the authors.

The Cockroft and Gault formula for estimation of creatinine clearance: a friendly deconstruction.

Aims: To review the derivation of the Cockroft and Gault formula for estimating creatinine clearance from serum creatinine in a historical context.

Method: The derivation described by Cockroft and Gault was reviewed, and an alternative formula was sought using the data reported in the paper.

Results: Cockroft and Gault used 24 hour urine creatinine data expressed as mg/kg body weight and mathematical manipulation of a linear regression equation which introduced body weight as an independent variable into the formula.

A pilot randomized controlled trial of deprescribing.

Objective: Polypharmacy and adverse drug reactions are frequent and important among older people. Few clinical trials have evaluated systematic withdrawal of medications among older people. This small, open, study was conducted to determine the feasibility of a randomized controlled deprescribing trial.

Genesis of medical thromboprophylaxis guidelines in Australia: a need for transparency and standardisation in guideline development.

Clinical guidelines are recommendations based on systematic identification and synthesis of the best available scientific evidence. The National Health and Medical Research Council (NHMRC) has published standards for guideline development. According to the NHMRC standards, guideline development must be a transparent and independent process, with full disclosure of any potential competing interests.

Rational thromboprophylaxis in medical inpatients: not quite there yet.

Routine thromboprophylaxis in hospitalised medical patients is based on trials that predominantly use asymptomatic deep vein thrombosis (DVT) as the endpoint. As asymptomatic DVT is 10-30-fold more common than symptomatic DVT, this exaggerates estimates of benefit and cost-effectiveness. Based on symptomatic disease, the number needed to treat per venous thromboembolism (VTE) prevented is high (150-1600), and the true cost-effectiveness of thromboprophylaxis for symptomatic event reduction is uncertain.

The national inpatient medication chart: critical audit of design and performance at a tertiary hospital.

Objective: To compare the national inpatient medication chart (NIMC) with the chart previously used at Royal Perth Hospital (RPH) in Western Australia, and with charts used at 13 other hospitals across Australia; and to audit NIMC performance in practice and to assess its design characteristics.

Design: Audit of patient prescribing documents extended to include a comparison with aggregated pilot study data and the previous RPH chart. Assessment of design features by inspection, based on their likely effect on medication safety.

Cost effectiveness of trastuzumab in the adjuvant treatment of early breast cancer: a lifetime model.

Background: Recent randomised trials have demonstrated a statistically significant effect of trastuzumab on disease-free survival when used as adjuvant therapy for human epidermal growth factor receptor 2 protein (HER2)-positive resectable early stage breast cancer, with a treatment course lasting either 9 or 52 weeks. However, the cost effectiveness of adjuvant trastuzumab with respect to mortality remains uncertain, especially in an Australian setting.

Objective: To estimate the cost effectiveness of trastuzumab in Australia, in a cohort of 50-year-old patients with HER2-positive breast cancer over a lifetime, using (i) disease-free survival and cardiotoxicity data from recent randomised trials; (ii) information on long-term survival of patients with treated primary breast cancer; and (iii) costs of treating local and distant relapses and disease from causes other than breast cancer.