Browsing by Author "Nathorn Chaiyakunapruk"

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    A retrospective study to evaluate low molecular weight heparin (LMWH) usage and identify risk factors for major bleeding
    (Mahidol University. Mahidol University Library and Knowledge Center, 2010) Narinee Khaisombat; Surakit Nathisuwan; Nathorn Chaiyakunapruk
    หลักฐานจากประเทศตะวันตกแสดงให้เห็นว่าขนาดยา enoxaparin ที่ไม่เหมาะสมเป็นสิ่งที่ พบได้บ่อยและก่อให้เกิดผลเสียโดยตรงต่อผู้ป่วยโรคหลอดเลือดโคโรนารีชนิดเฉียบพลัน โดยเฉพาะเป็น สาเหตุให้เกิดเลือดออก อย่างไรก็ดียังขาดข้อมูลดังกล่าวในคนเอเชีย การศึกษาแบบย้อนหลังนี้จึงมี วัตถุประสงค์เพื่อประเมินการใช้ยา enoxaparin และค้นหาปัจจัยเสี่ยงของการเกิดเลือดออกในผู้ป่วยโรค หลอดเลือดโคโรนารีชนิดเฉียบพลันของโรงพยาบาลรามาธิบดี เก็บข้อมูลผู้ป่วยที่เข้ารับการรักษาตั้งแต่ปี 2549-2551 จำนวน 359 คน จำแนกเป็น ST-elevation myocardial infarction 25.6%, non-ST-elevation myocardial infarction 56.6% และ unstable angina 17.8% ประเมินขนาดยาตามน้ำหนักและการทำงานของ ไตพบเพียง 42.1% ที่ได้รับขนาดยาเหมาะสม พบขนาดยาสูงเกิน 15.6% และต่ำกว่าคำแนะนำ 42.3% พิจารณากลุ่มขนาดยาสูงเกินพบถึง 57.1% ที่ไม่ได้ปรับขนาดยาตามการทำงานของไตที่บกพร่องรุนแรง นอกจากนี้ยังมีสัดส่วนของเพศหญิงมากกว่า อายุเฉลี่ยมากกว่า และน้ำหนักน้อยกว่า เมื่อเทียบกับกลุ่มที่ ขนาดยาเหมาะสม พบเลือดออกที่เกี่ยวเนื่องกับยา enoxaparin 38.7% ความรุนแรง GUSTO ระดับ mild, moderate และ severe พบ 30.9%, 6.6% และ 1.2% ตามลำดับ เกณฑ์ TIMI เป็น minimal, minor และ major พบ 34.7%, 3.5% และ 1.2% ตามลำดับและ TACSR major พบ 8.1% ขนาดยาสูงเกินเสี่ยงต่อเลือดออก โดยรวมเมื่อเทียบกับขนาดยาเหมาะสม อย่างมีนัยสำคัญเมื่อวิเคราะห์หลายตัวแปร (GUSTO: OR, 2.18; 95%CI, 1.18-4.00, TIMI: OR, 2.08; 95%CI, 1.13-3.84) ความเสี่ยงของการเสียชีวิตสัมพันธ์กับความ รุนแรงของอาการเลือดออกและระยะเวลานอนโรงพยาบาลสูงกว่า อย่างมีนัยสำคัญเมื่อเทียบกับผู้ที่ไม่มี เลือดออก การศึกษานี้สนับสนุนว่าการเพิ่มความระมัดระวังในการใช้ enoxaparin และพัฒนามาตรการ จัดการความเสี่ยงอย่างเป็นระบบเพื่อเพิ่มความปลอดภัยให้กับผู้ป่วยเป็นสิ่งที่ควรสนับสนุนให้มีการ
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    Aloe vera and health outcomes: An umbrella review of systematic reviews and meta-analyses
    (2021-02-01) Saranrat Sadoyu; Chidchanok Rungruang; Thitima Wattanavijitkul; Ratree Sawangjit; Ammarin Thakkinstian; Nathorn Chaiyakunapruk; Ramathibodi Hospital; Chulalongkorn University; University of Utah Health; Mahasarakham University
    This umbrella review aims to summarize the effects of Aloe vera on health outcomes and assess the strength of evidence. PubMed, Scopus, Embase, Cochrane database of systematic reviews, CINAHL, and AMED were searched from inception to October, 2019 for systematic reviews and meta-analyses of clinical trials that investigated the effects of Aloe vera on health outcomes. Two independent reviewers extracted data, assessed the methodological quality, and rated the credibility of evidence according to established criteria. Ten articles reporting 71 unique outcomes of Aloe vera were included. Of these, 47 (67%) were nominally statistically significant based on random-effects model (p ≤.05). Only 3 outcomes were supported by highly suggestive evidence, whereas 42 outcomes were supported by weak evidence. The highly suggestive evidence supported benefits of Aloe vera in the prevention of second-degree infusion phlebitis (RR: 0.18, 95% CI: 0.10–0.32, p-value: 1.75 × 10−9) and chemotherapy-induced phlebitis based on overall incidence (OR: 0.13, 95% CI: 0.08–0.20, p-value: 9.68 × 10−20) and incidence of the second degree of severity (OR: 0.10, 95% CI: 0.07–0.14, p-value: 3.41 × 10−35). However, the majority of the evidence were limited by small sample size and poor methodological quality. Therefore, despite the overall favorable effect of Aloe vera, more robust studies are needed.
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    Anticoagulation control of pharmacist-managed collaborative care versus usual care in Thailand
    (2012-02-01) Surasak Saokaew; Ubonwan Sapoo; Surakit Nathisuwan; Nathorn Chaiyakunapruk; Unchalee Permsuwan; Chiang Mai University; University of Phayao; Maharat Nakornratchasima Hospital; Mahidol University; Naresuan University; University of Queensland; University of Wisconsin Madison
    Objective There has been a lack of evidence of the effects of pharmacist-managed warfarin therapy (PMWT) in developing countries (e.g. Southeast Asian countries) where the patients' characteristics, genetic make-up, clinical practice and healthcare system are different from the Western world. This study aimed to compare the anticoagulation control and clinical outcomes associated with warfarin therapy provided by PMWT to usual care (UC) in the Thai population. Setting A 1,000-bed tertiary-care hospital in Nakornratchasima province of Thailand. Method A quasi-experimental study comparing PMWT and UC in patients receiving long-term warfarin therapy. For PMWT group, clinical pharmacists optimised the warfarin therapy and suggested recommendations (e.g. dose adjustment, safer alternative drugs, and follow-up time) to physicians. The UC group received the standard care. Main outcome measure Time in therapeutic range (TTR), both actual- and expanded-TTR, bleeding and thromboembolic complications, and physician' acceptance of pharmacist suggestions. Results Of 433 patients enrolled, 220 and 213 were in the PMWT and UC groups respectively. At baseline, patient's characteristics of both groups were comparable. At the end of follow-up period, patients in the PMWT group had significantly higher actual-TTR (48.3% vs. 40.1%; P < 0.001) and expanded-TTR (62.7% vs. 53.9%; P < 0.001) compared to those in the UC group. Rates of major bleeding were 4.4 vs 4.5 events per 100 person-years for the PMWT and UC groups, respectively. Pharmacists performed 284 interventions with an acceptance rate of 80.3% from physicians. Conclusion Pharmacist-managed warfarin therapy resulted in a significantly better anticoagulation control. This study showed that a collaborative approach in anticoagulation management can be successfully implemented in a developing country. Implementation of such care model in other developing countries should be considered. © 2011 CARS.
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    Antithrombotic regimens in patients with percutaneous coronary intervention whom an anticoagulant is indicated: A systematic review and network meta -analysis
    (2018-11-19) Wipharak Bunmark; Peerawat Jinatongthai; Prin Vathesatogkit; Ammarin Thakkinstian; Christopher M. Reid; Wanwarang Wongcharoen; Nathorn Chaiyakunapruk; Surakit Nathisuwan; University of Wisconsin-Madison; Curtin University; Ubon Rajathanee University; Naresuan University; Monash University; Monash University Malaysia; Faculty of Medicine, Ramathibodi Hospital, Mahidol University; Mahidol University; Chiang Mai University
    © 2007 - 2018 Frontiers Media S.A. All Rights Reserved. Background: Patients undergoing percutaneous coronary intervention (PCI) who require anticoagulant therapy are at increased risk of bleeding. The optimal regimen for these patients is uncertain. This study aimed to compare safety and efficacy of antithrombotic regimens used in patients undergoing PCI with concomitant anticoagulant therapy. Methods: A systematic review and network meta-analysis was performed among studies comparing antithrombotic regimens for anticoagulated patients undergoing PCI. The primary outcome of interest was major bleeding. The secondary outcomes were coronary events. The reference intervention was classic triple therapy (aspirin plus clopidogrel plus VKA). Cluster rank incorporating risk (major bleeding) and benefit (all-cause death) was performed to identify the most appropriate regimen(s). Results: There were 3 RCTs (6 interventions) and 29 non-RCTs (8 interventions) that met the inclusion criteria with 22,179 patients. Network meta-analysis of RCTs indicated that dual therapy (DT), either with vitamin K antagonist (VKA) or direct anticoagulant (DOAC) plus an antiplatelet, significantly reduced the risk of major bleeding compared to triple therapy (TT) [pooled RR of 0.51 (0.30-0.87) and 0.68 (0.49-0.94), respectively]. In addition, VKA-DT significantly reduced the risk of all-cause death compared to TT [pooled RR of 0.40 (0.17-0.93)]. Results from network meta-analysis of non-RCT paralleled that of RCTs. No significant differences of coronary events were found. Conclusions: In conclusion, for anticoagulated patients undergoing PCI, dual therapy, either with warfarin or DOAC plus an antiplatelet, should be considered due to its optimal balance on efficacy and safety.
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    Assessing clinical evidence of drug interactions between citrus juices and cyclosporine
    (2013-08-01) Pakawadee Sermsappasuk; Nathorn Chaiyakunapruk; Manupat Lohitnavy; Chagriya Kitiyakara; Naresuan University; University of Queensland; University of Wisconsin Madison; Mahidol University
    Background: Previous studies have demonstrated that grapefruit juice increased the bioavailability of cyclosporine;however, the results from the literature are inconsistent. Other citrus fruits such as pomelo or orange juice had variable effects on the bioavailability of cyclosporine.Objective: To assess the effect of grapefruit juice and other types of citrus juice on oral bioavailability of cyclosporine in humans using meta-Analysis.Methods: We conducted a meta-Analysis of placebo-controlled studies evaluating the effects of citrus juices on bioavailability of cyclosporine. The studies were identified in PubMed, Cochrane CENTRAL, CINAHL, ISI Web of Knowledge, Psych Info International, Pharmaceutical Abstract (IPA), and reference lists of relevant papers. The weighted-mean difference (WMD) was calculated for net changes in the area under the curve (AUC) of cyclosporine. All studies conducted as placebo-controlled crossover studies in humans to compare the effect of citrus juices and control (drinking water) on AUC of cyclosporine and/or Cmin,ss were reviewed. All studies included were evaluated and extracted independently, and discrepancies were resolved through discussion.Results: Eighteen studies were identified. A subgroup analysis suggested that grapefruit juice significantly increased AUC of cyclosporine (WMD = 1762.5 ng·h/ml, 95%CI = 1178.9-2346.0 ng·h/ml, p > 0.001). While a meta-Analysis of all other types of citrus juices (tangerine juice, Seville orange juice, sweet orange juice, and citrus soda) except pomelo juice revealed no effect on the AUC of cyclosporine (WMD = -181.0 ng·h/ml,95%CI = -582.8-220.9 ng·h/ml, p > 0.5), a study of pomelo juice indicated a significant increase in the AUC of cyclosporine.Conclusions: Grapefruit juice intake increases oral bioavailability of cyclosporine in both healthy volunteers and renal transplant patients, whereas all other types of citrus juices may not have an influence on the oral bioavailability of cyclosporine. Current evidence suggests that pomelo juice may be able to increase cyclosporine oral bioavailability.
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    Assessing evidence of interaction between smoking and warfarin: A systematic review and meta-analysis
    (2011-05-01) Surakit Nathisuwan; Piyameth Dilokthornsakul; Nathorn Chaiyakunapruk; Tatiya Morarai; Thararat Yodting; Nichakorn Piriyachananusorn; Mahidol University; Naresuan University; University of Queensland; University of Wisconsin Madison
    Background: Chronic smoking, theoretically, can interfere with warfarin metabolism through enzyme-inducing effects of polycyclic aromatic hydrocarbons. However, clinical evidence of interactions between warfarin and smoking are inconclusive. This study aimed to systematically review all relevant clinical evidence of this interaction. Methods: We performed a systematic search using computerized databases, including PubMed, Embase, Cochrane Central Register of Controlled Trials, CINAHL, Allied and Complementary Medicine, PsycINFO, International Pharmaceutical Abstracts, and ClinicalTrials.gov from 1966 to December 2008. Keywords included "warfarin" with "smoking," "tobacco," "cigarette," and "polycyclic aromatic hydrocarbons." Original articles reporting interaction between warfarin and smoking were included. All articles were reviewed independently by two investigators for study design, population, outcomes, and quality of evidence. Results: Of the 1,240 studies retrieved, one experimental pharmacokinetic study and 12 crosssectional studies were included. The pooled analyses of multivariate studies suggested that smoking was associated with a 12.1 3% (95% CI, 6.999-17.265; P < .001) increase in warfarin dosage requirement and an additional 2.26 mg (95% CI, 2.529-7.042; P=5.355) per week compared with nonsmoking. Additional sensitivity analysis of four multivariate studies with adjustment for pharmacogenomic factors suggested that smoking was associated with a 13.21% (95% CI, 8.59%-17.83%; P < .001) increase in warfarin dosage requirement compared with nonsmokers. Results of an experimental pharmacokinetic study lend theoretical support to the findings. Conclusions: Evidence suggests that smoking may potentially cause significant interaction with warfarin by increasing warfarin clearance, which leads to reduced warfarin effects. Close monitoring of warfarin therapy should be instituted when there is a change in smoking status of patients requiring warfarin therapy. © 2011 American College of Chest Physicians.
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    Association of non-alcoholic fatty liver disease and all-cause mortality in hospitalized cardiovascular disease patients: A systematic review and meta-analysis
    (2021-02-05) Surasak Saokaew; Sukrit Kanchanasurakit; Kanitta Thawichai; Prommanee Duangprom; Monnapha Wannasri; Sirintip Khankham; Chayanis Kositamongkol; Nathorn Chaiyakunapruk; Pochamana Phisalprapa; University of Phayao; The University of Utah; Monash University Malaysia; Faculty of Medicine Siriraj Hospital, Mahidol University; Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN; Center of Health Outcomes Research and Therapeutic Safety (Cohorts; School of Pharmacy; Division of Pharmacy Practice; Phrae Hospital
    BACKGROUND: Controversy remains concerning the association of the all-cause mortality risk of hospitalized cardiovascular disease (CVD) patients with non-alcoholic fatty liver disease (NAFLD). This study investigated the risks of all-cause mortality among hospitalized CVD patients with NAFLD. METHODS: We used related keywords to search for studies in 3 electronic databases: PubMed, EMBASE, and Cochrane Library. All eligible studies published up to April 2020 were reviewed. The findings of those studies reporting the mortality outcomes of hospitalized CVD patients with and without NAFLD were examined, and the various study results were pooled and analyzed using a random-effects model. A quality assessment using the Newcastle-Ottawa scale was performed on the studies selected for inclusion in a meta-analysis. RESULTS: A total of 2135 studies were found, of which 3 were included in this meta-analysis. All studies were considered good quality. The mean age of the patients in the analysis was 73 years, and about half of them were men. The comorbidities reported were hypertension, diabetes mellitus, and dyslipidemia. The results showed that hospitalized CVD patients with NAFLD were at a significantly higher risk of all-cause mortality than non-NAFLD patients (adjusted hazard ratio of 2.08 [95% confidence interval, 1.56-2.59], P < .001). The included studies showed low heterogeneity (I2 = 0.0%, P = .473), and Begg and Egger tests revealed no apparent publication bias (P = .327 and P = .682, respectively). CONCLUSIONS: Hospitalized CVD patients with NAFLD were at a higher risk of all-cause mortality than those without NAFLD. More studies that further explore this association are needed.
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    Attributable Cost and Length of Stay for Patients with Enoxaparin-Associated Bleeding
    (2012-05-01) Surasak Saokaew; Narinee Khaisombat; Nathorn Chaiyakunapruk; Khanchit Likittanasombat; Surakit Nathisuwan; Naresuan University; University of Phayao; Mahidol University; University of Queensland; University of Wisconsin Madison
    Patients receiving enoxaparin are at risk of bleeding. The study of the economic impact of enoxaparin-associated bleeding in Asian population, however, is limited. This study aimed to estimate the attributable costs and length of stay (LOS) of patients experiencing enoxaparin-associated bleeding compared with nonbleeding patients in the setting of acute coronary syndrome. We conducted a retrospective cohort study of hospitalized patients with acute coronary syndrome who received enoxaparin in a large university-affiliated hospital. Cost and LOS were compared among three groups of patients according to the status of bleeding event. The attributable cost and LOS were estimated by using multiple linear regressions with log-transformed model and adjusted by confounders. The adjusted means of cost and LOS estimates were retransformed to their natural values by using Duan's smearing estimator. The differences of costs and LOS were presented as mean with 95% confidence intervals (CIs).Out of 346 patients, 134 experienced enoxaparin-associated bleeding (28 and 106 patients experienced major and minor bleeding, respectively). The average age and gender in both groups were similar. Compared to the nonbleeding group, the attributable cost and LOS were 108,226 Thai baht (95% CI: 87,068-129,386) and 8 days (95% CI: 7.1-9.0) for major bleeding and 72,997 Thai baht (95% CI: 57,822-88,172) and 3.1 days (95% CI: 2.5-3.7) for minor bleeding, respectively. Bleeding is significantly associated with increased cost and LOS among enoxaparin users. These findings suggest that strategies aiming to reduce bleeding events may potentially help reduce the cost of care among patients with acute coronary syndrome receiving enoxaparin therapy. © 2012 International Society for Pharmacoeconomics and Outcomes Research (ISPOR).
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    Characterization of statin-associated myopathy case reports in thailand using the health product vigilance center database
    (2013-09-01) Pornwalai Boonmuang; Surakit Nathisuwan; Nathorn Chaiyakunapruk; Wimon Suwankesawong; Pattreya Pokhagul; Nattawat Teerawattanapong; Pairin Supsongserm; Prince of Songkla University; Mahidol University; Naresuan University; University of Queensland; University of Wisconsin Madison; The Food and Drug Administration, Thailand Ministry of Public Health
    Background: HMG-CoA reductase inhibitors [statins], a widely prescribed cholesterol-lowering therapy, are associated with muscle-related adverse events. While characteristics of such events are well documented in Western countries, little data exists for the Thai population. Objective: The aim of this study was to determine the characteristics of patients, type and dosing of statin, and to identify patterns of drug use that may be associated with such adverse events using the national pharmacovigilance database known as Thai Vigibase. Method: Muscle-related adverse events involving statins in the Thai Vigibase from 1996 to December 2009 were identified. For each report, the following information was extracted: patient demographics, co-morbidities, detailed information of adverse event, detailed information of suspected drug, treatment and outcome, as well as causality assessment and quality of reports. Descriptive statistics were performed for all study variables. Results: A total of 198 cases of statin-associated muscle-related adverse events were identified. Mean age was 61.4 ± 12.4 years of age and 59.6 % were female. Simvastatin, atorvastatin, rosuvastatin and cerivastatin were implicated as the suspected drug in 163 (82.3 %), 24 (12.1 %), 10 (5.1 %) and 1 (0.5 %) cases, respectively. Rhabdomyolysis accounted for 55.6 % of all muscle-related adverse events. Drug interactions known to enhance such toxicity of statins were identified in 40.9 % of the total set of reports. Similar to studies from Western countries, fibrates, HIV protease inhibitors, non-dihydropyridine calcium channel blockers, azole antifungals and macrolides were commonly found in such cases. Interestingly, colchicine has been identified as the second most common drug interaction in our database. Case fatality rates were 0.9, 1.6 and 16.7 %, when there were 0, 1 and ≥2 interacting drugs, respectively. Conclusions: Characteristics of muscle-related adverse events with statins in the Thai population showed some similarities and differences compared with Western countries. Such similarities included advanced age, female sex, certain co-morbidities and drug interactions. While the majority of interacting drugs are well known, a big proportion of cases of statin-colchicine interaction attributed to long-term use of colchicine in Thailand was noted and should be further investigated. Based on these results, an attempt to avoid dangerous and well-known drug interactions among statin users should be implemented nationwide. © 2013 Springer International Publishing Switzerland.
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    Coffee Consumption and Non-alcoholic Fatty Liver Disease: An Umbrella Review and a Systematic Review and Meta-analysis
    (2021-12-13) Chayanis Kositamongkol; Sukrit Kanchanasurakit; Chiraphong Auttamalang; Nutkamon Inchai; Thanatchaporn Kabkaew; Sarunporn Kitpark; Nathorn Chaiyakunapruk; Acharaporn Duangjai; Surasak Saokaew; Pochamana Phisalprapa; Siriraj Hospital; University of Phayao; Monash University Malaysia; University of Utah Health; Phrae Hospital
    Background: The effects of coffee consumption on hepatic outcomes are controversial. This study investigated the associations between coffee consumption and the incidence of non-alcoholic fatty liver disease (NAFLD) in the general population and the reduction of liver fibrosis among patients with NAFLD. Methods: The study consisted of two parts: an umbrella review and a systematic review and meta-analysis (SRMA). The searches for each part were performed separately using PubMed, EMBASE, Cochrane, Scopus, and CINAHL databases. All articles published up to September 2021 were reviewed. To be eligible, studies for the umbrella review were required to report outcomes that compared the risks of NAFLD in the general population and/or liver fibrosis in patients with NAFLD who did and did not drink coffee. Our SRMA included primary studies reporting the effects of coffee consumption on NAFLD-related outcomes. The outcomes were pooled using a random-effects model and reported in both qualitative and quantitative terms (pooled risk ratio, odds ratio, and weighted mean difference). Results: We identified four published SRMAs during the umbrella review. Most studies showed that individuals in the general population who regularly drank coffee were significantly associated with a lower NAFLD incidence than those who did not. Our SRMA included nine studies on the effects of coffee consumption on NAFLD incidence. Pooled data from 147,875 subjects showed that coffee consumption was not associated with a lower NAFLD incidence in the general population. The between-study heterogeneity was high (I2, 72–85%). Interestingly, among patients with NAFLD (5 studies; n = 3,752), coffee consumption was significantly associated with a reduction in liver fibrosis (odds ratio, 0.67; 95% CI, 0.55 to 0.80; I2, 3%). There were no differences in the coffee consumption of the general population and of those with NAFLD (4 studies; n = 19,482) or by patients with no/mild liver fibrosis and those with significant fibrosis (4 studies; n = 3,331). Conclusions: There are contrasting results on the effects of coffee on NAFLD prevention in the general population. Benefits of coffee consumption on liver fibrosis were seen among patients with NAFLD. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021226607, identifier CRD42021226607
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    Community pharmacy-based implementation and evaluation of an Osteoporosis Self-Assessment Tool for Asians
    (2006-01-01) Nathorn Chaiyakunapruk; Ampuscha Laowakul; Saree Karnchanarat; Nisakorn Pikulthong; Boonsong Ongphiphadhanakul; Naresuan University; Paolo Memorial Hospital; Pharcare; Drugs House; Mahidol University
    Objectives: To implement an osteoporosis screening and referral program in community pharmacies and evaluate the use of the Osteoporosis Self-Assessment Tool for Asians (OSTA) as the screening instrument. Design: Uncontrolled study. Setting: Three community pharmacies in Bangkok, Thailand. Patients: 51 women aged 50 years or older without prior diagnosis of osteoporosis; three community pharmacists; six hospital-based physicians. Intervention: OSTA assessment by community pharmacists of the risks of osteoporosis in patients; counseling of patients about diet and exercise; referral of patients at high risk (OSTA index value less than -4) to hospitals where pharmacists had made arrangements in advance; and assessment of satisfaction and opinions of participating patients and physicians. Results: Of the 51 patients, 32 (62.7%) were categorized as low risk (OSTA index value > -1) and 19 (37.3%) as intermediate risk (OSTA index value range, -4 to -1). The majority of patients (97%) were satisfied with the program and the knowledge gained. Even though no high-risk patients were identified and referred for medical care, all six participating physicians agreed with having risk assessment service in community pharmacies and the prearranged referral system, and five of six physicians believed that OSTA results were valuable in the management of osteoporosis. Conclusion: Community pharmacy-based osteoporosis risk assessment services using OSTA were well accepted by the patients and participating physicians. Public health benefits may result from the provision of osteoporosis risk screening services in community pharmacies in Thailand and other Asian countries.
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    Comparative effectiveness of chemopreventive interventions for colorectal cancer: Protocol for a systematic review and network meta-analysis of randomised controlled trials
    (2016-08-01) Sajesh K. Veettil; Surasak Saokaew; Kean Ghee Lim; Siew Mooi Ching; Pochamana Phisalprapa; Nathorn Chaiyakunapruk; International Medical University; Monash University Malaysia; University of Phayao; Naresuan University; Universiti Putra Malaysia; Mahidol University; University of Queensland; University of Wisconsin Madison
    Background: Colorectal cancer (CRC) is the third most common cancer worldwide and is associated with substantial socioeconomic burden. Despite considerable research, including numerous randomised controlled trials (RCTs) and systematic reviews assessed the effect of various chemopreventive interventions for CRC, there remains uncertainty regarding the comparative effectiveness of these agents. No network meta-analytic study has been published to evaluate the efficacies of these agents for CRC. Therefore, the aim of this study is to summarise the direct and indirect evidence for these interventions to prevent CRC in average-high risk individuals, and to rank these agents for practical consideration. Methods: We will acquire eligible studies through a systematic search of MEDLINE, EMBASE, the Cochrane Central Registry of Controlled Trials, CINAHL plus, IPA and clinicaltrials.gov website. The Cochrane Risk of Bias Tool will be used to assess the quality of included studies. The primary outcomes are the incidence of CRC, the incidence/recurrence of any adenoma or change in polyp burden (number or size). Quantitative synthesis or meta-analysis will be considered. We will also construct a network meta-analysis (NMA) to improve precision of the comparisons among chemo-preventive interventions by combining direct and indirect evidence. The probability of each treatment being the best and/or safest, the number-neededto- treat [NNT; 95% credible interval (CrIs)], and the number-needed-to-harm (NNH; 95% CrIs) will be calculated to provide measures of treatment efficacy. The GRADE approach will be used to rate the quality of evidence of estimates derived from NMA. Results: This protocol has been registered (registration number: CRD42015025849) with the PROSPERO (International Prospective Register of Systematic Reviews). The procedures of this systematic review and NMA will be conducted in accordance with the PRISMA-compliant guideline. The results of this systematic review and NMA will be submitted to a peer-reviewed journal for publication. Conclusions: To the best of our knowledge, this study will be the first NMA to identify the comparative effectiveness of interventions for the prevention of CRC. The results of our study will update evidence for chemoprevention of CRC, identify key areas for future research, and provide a framework for conducting large systematic reviews involving indirect comparisons.
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    Comparative efficacy and safety of warfarin care bundles and novel oral anticoagulants in patients with atrial fibrillation: a systematic review and network meta-analysis
    (2020-12-01) Siok Shen Ng; Nai Ming Lai; Surakit Nathisuwan; Nowrozy Kamar Jahan; Piyameth Dilokthornsakul; Khachen Kongpakwattana; William Hollingworth; Nathorn Chaiyakunapruk; Taylor's University Malaysia; University of Utah; Naresuan University; Monash University Malaysia; University of Bristol, Faculty of Medicine and Dentistry; Mahidol University; Hospital Melaka
    © 2020, The Author(s). Warfarin care bundles (e.g. genotype-guided warfarin dosing, patient’s self-testing [PST] or patient’s self-management [PSM] and left atrial appendage closure) are based on the concept of combining several interventions to improve anticoagulation care. NOACs are also introduced for stroke prevention in atrial fibrillation (SPAF). However, these interventions have not been compared in head-to-head trials yet. We did a network meta-analysis based on a systematic review of randomized controlled trials comparing anticoagulant interventions for SPAF. Studies comparing these interventions in adults, whether administered alone or as care bundles were included in the analyses. The primary efficacy outcome was stroke and the primary safety outcome was major bleeding. Thirty-seven studies, involving 100,142 patients were assessed. Compared to usual care, PSM significantly reduced the risk of stroke (risk ratio [RR] 0.24, 95% CI 0.08–0.68). For major bleeding, edoxaban 60 mg (0.80, 0.71–0.90), edoxaban 30 mg (0.48, 0.42–0.56), and dabigatran 110 mg (0.81, 0.71–0.94) significantly reduced the risk of major bleeding compared with usual warfarin care. Cluster rank plot incorporating stroke and major bleeding outcomes indicates that some warfarin care bundles perform as well as NOACs. Both interventions are therefore viable options to be considered for SPAF. Additional studies including head-to-head trials and cost-effectiveness evaluation are still warranted.
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    Comparative efficacy of interventions on nonalcoholic fatty liver disease (NAFLD): A PRISMA-compliant systematic review and network meta-analysis
    (2016-08-01) Ratree Sawangjit; Bunchai Chongmelaxme; Pochamana Phisalprapa; Surasak Saokaew; Ammarin Thakkinstian; Kris V. Kowdley; Nathorn Chaiyakunapruk; Mahasarakham University; Monash University Malaysia; Naresuan University; Mahidol University; University of Phayao; Swedish Medical Center; University of Wisconsin Madison; University of Queensland
    Copyright © 2016 the Author(s). Published by Wolters Kluwer Health, Inc. All rights reserved. Background: The prevalence of nonalcoholic fatty liver disease (NAFLD) has significantly increased over the last decades. Despite existence of several interventions, there remains unclear which interventions work the best. Methods: A systematic review and network meta-analysis of randomized trials comparing efficacy of all treatment options in NAFLD were performed to determine comparative efficacy and safety of interventions in the management of NAFLD. Several electronic databases were searched up to Nov 15, 2015. Outcomes include liver histological outcomes (i.e., fibrosis), all-cause mortality, cirrhosis, and safety. A network meta-analysis was applied to estimate pooled risk ratios (RR). Quality of evidence was assessed using GRADE criteria. Results: A total of 44 studies (n = 3802) were eligible. When compared with placebo, obeticholic acid (OCA) was the only intervention that significantly improved fibrosis with RR (95% CI) of 1.91 (1.15, 3.16), while pentoxyfylline (PTX) demonstrated improved fibrosis without statistical significance with RR (95% CI) of 2.27 (0.81, 6.36). Only thiazolidinedione (TZD) and vitamin E use resulted in significant increase in resolution of NASH, while OCA, TZD, and vitamin E significantly improved other outcomes including NAS, steatosis, ballooning, and inflammation outcomes. Quality of evidence varied from very low (i.e., metformin, PTX on mean change of ballooning grade) to high (OCA, TZD, vitamin E on improving histological outcomes). Limitations of this study were lack of relevant long-term outcomes (e.g., cirrhosis, death, safety), possible small study effect, and few head-to-head studies. Conclusions: Our study suggests potential efficacy of OCA, TZD, and vitamin E in improving histologic endpoints in NAFLD. These findings are however based on a small number of studies. Additional studies are awaited to strengthen this network meta-analysis.
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    Compliance and persistence with Alzheimer’s disease treatment: a retrospective analysis of multiregional hospital databases in Thailand
    (2019-01-02) Khachen Kongpakwattana; Piyameth Dilokthornsakul; Charungthai Dejthevaporn; Oraluck Pattanaprateep; Nathorn Chaiyakunapruk; Naresuan University; Monash University Malaysia; Faculty of Medicine, Ramathibodi Hospital, Mahidol University
    © 2018, © 2018 Informa UK Limited, trading as Taylor & Francis Group. Aims: Due to the lack of studies evaluating compliance or persistence with Alzheimer’s Disease (AD) treatment outside High-Income Countries (HICs), this study aimed to assess compliance, persistence, and factors associated with non-compliance and non-persistence by utilizing existing “real-world” information from multiregional hospital databases in Thailand. Materials and methods: Study subjects were retrospectively identified from databases of five hospitals located in different regions across Thailand. AD patients aged ≥60 years who were newly-prescribed with donepezil, galantamine, rivastigmine, or memantine between 2013 and 2017 were eligible for analysis. The Medication Possession Ratio (MPR) was used as a proxy for compliance, while the Kaplan–Meier survival analysis was employed to estimate persistence. Logistic and Cox regressions were used to assess determinants of non-compliance and non-persistence, adjusted for age and gender. Results: Among 698 eligible patients, mean (SD) MPR was 0.83 (0.25), with 70.3% of the patients compliant to the treatment (having MPR ≥ 0.80). Half of the patients discontinued their treatment (having a treatment gap >30 days) within 177 days with a 1-year persistence probability of 21.1%. The patients treated in the university-affiliated hospital were more likely to be both non-compliant (OR = 1.71; 95% CI = 1.21–2.42) and non-persistent (HR = 1.33; 95% CI = 1.12–1.58). In addition, non-compliance was higher for those prescribed with single AD treatment (OR = 2.52; 95% CI = 1.35–4.69), while non-persistence was higher for those unable to reimburse for AD treatment (HR = 1.34; 95% CI = 1.11–1.62). Limitations: By using retrospective databases, a difficulty in validating whether the medications are actually taken after being refilled may over-estimate the levels of compliance and persistence. Meanwhile, possible random coding errors may under-estimate the strength of association findings. Conclusions: This study reveals the situation of compliance and persistence on AD treatment for the first time outside HICs. The determinants of non-compliance and non-persistence underline key areas for improvement.
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    Correction to: Weight Reduction and Pioglitazone are Cost-Effective for the Treatment of Non-alcoholic Fatty Liver Disease in Thailand (PharmacoEconomics, (2019), 37, 2, (267-278), 10.1007/s40273-018-0736-0)
    (2019-02-13) Bunchai Chongmelaxme; Pochamana Phisalprapa; Ratree Manthaisong; Piyameth Dilokthornsakul; Nathorn Chaiyakunapruk; Naresuan University; Monash University Malaysia; Faculty of Medicine, Siriraj Hospital, Mahidol University; Mahasarakham University; University of Wisconsin
    © 2018, Springer Nature Switzerland AG. Weight Reduction is Cost-Effective for the Treatment of Non-alcoholic Fatty Liver Disease in Thailand.
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    Cost utility analysis of reduced intensity hematopoietic stem cell transplantation in adolescence and young adult with severe thalassemia compared to hypertransfusion and iron chelation program
    (2013-02-07) Rosarin Sruamsiri; Nathorn Chaiyakunapruk; Samart Pakakasama; Somtawin Sirireung; Nintita Sripaiboonkij; Udomsak Bunworasate; Suradej Hongeng; Naresuan University; University of Queensland; University of Wisconsin Madison; Jeffrey Cheah School of Medicine and Health Sciences; Mahidol University; Chulalongkorn University
    Background: Hematopoieticic stem cell transplantation is the only therapeutic option that can cure thalassemia disease. Reduced intensity hematopoietic stem cell transplantation (RI-HSCT) has demonstrated a high cure rate with minimal complications compared to other options. Because RI-HSCT is very costly, economic justification for its value is needed. This study aimed to estimate the cost-utility of RI-HSCT compared with blood transfusions combined with iron chelating therapy (BT-ICT) for adolescent and young adult with severe thalassemia in Thailand. Methods. A Markov model was used to estimate the relevant costs and health outcomes over the patients' lifetimes using a societal perspective. All future costs and outcomes were discounted at a rate of 3% per annum. The efficacy of RI-HSCT was based a clinical trial including a total of 18 thalassemia patients. Utility values were derived directly from all patients using EQ-5D and SF-6D. Primary outcomes of interest were lifetime costs, quality adjusted life-years (QALYs) gained, and the incremental cost-effectiveness ratio (ICER) in US ($) per QALY gained. One-way and probabilistic sensitivity analyses (PSA) were conducted to investigate the effect of parameter uncertainty. Results: In base case analysis, the RI-HSCT group had a better clinical outcomes and higher lifetime costs. The incremental cost per QALY gained was US $ 3,236 per QALY. The acceptability curve showed that the probability of RI-HSCT being cost-effective was 71% at the willingness to pay of 1 time of Thai Gross domestic product per capita (GDP per capita), approximately US $ 4,210 per QALY gained. The most sensitive parameter was utility of severe thalassemia patients without cardiac complication patients. Conclusion: At a societal willingness to pay of 1 GDP per capita, RI-HSCT was a cost-effective treatment for adolescent and young adult with severe thalassemia in Thailand compared to BT-ICT. © 2013 Sruamsiri et al.; licensee BioMed Central Ltd.
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    Cost-effectiveness analysis of chlorhexidine gluconate compared with povidone-iodine solution for catheter-site care in Siriraj Hospital, Thailand
    (2006-11-01) Ratree Maenthaisong; Nathorn Chaiyakunapruk; Visanu Thamlikitkul; Naresuan University; Mahidol University
    Background: Catheter-related bloodstream infections (CRBSI) are an important cause of patient morbidity, mortality, and increased health care costs. Use of an antiseptic solution for skin disinfection at the catheter insertion site helps prevent catheter-related infections. In Thailand, povidone-iodine solution is the most commonly used agent for this purpose. However, the results of several studies including a meta-analysis indicated that the use of chlorhexidine gluconate is more effective than the use of povidone-iodine as an antiseptic for preventing CRBSI. This study evaluated the cost-effectiveness of chlorhexidine gluconate versus povidone-iodine for catheter-site care using the Siriraj Hospital perspective. Material and Method: We used a decision analytic modeling for estimating the cost-effectiveness of antiseptic solutions. The CRBSI rate was obtained from the Center for Nosocomial Infection Control at Siriraj Hospital, while the efficacy of cholorhexidine compared to povidone-idone was based on a meta-analysis. The cost of managing infections was derived from the Thai Drug Related Group (DRG). A series of sensitivity analyses were performed. Since the time horizon of the analysis was less than 1 year, there was no need for discounting. Results: We found that the use of chlorhexidine, rather than povidone iodine, for central catheter site care resulted in a 1.61 % decrease in the incidence of CRBSI, a 0.32 % decrease in the incidence of death, and savings of 304 baht per catheter used. For peripheral catheter site care, the results were similar, although the differences were smaller. Conclusion: Use of chlorhexidine gluconate in place of the current standard solution for vascular catheter site care is a cost-effective method of improving patient safety in Siriraj Hospital.
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    Cost-Effectiveness Analysis of Fondaparinux vs Enoxaparin in Non-ST Elevation Acute Coronary Syndrome in Thailand
    (2015-09-01) Unchalee Permsuwan; Nathorn Chaiyakunapruk; Surakit Nathisuwan; Apichard Sukonthasarn; Chiang Mai University; Monash University Malaysia; Naresuan University; University of Queensland; University of Wisconsin Madison; Mahidol University
    © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Background: Non-ST elevation acute coronary syndrome (NSTE-ACS) imposes a significant health and economic burden on a society. Anticoagulants are recommended as standard therapy by various clinical practice guidelines. Fondaparinux was introduced and evaluated in a number of large randomised, controlled trials. This study therefore aimed to determine the cost-effectiveness of fondaparinux versus enoxaparin in the treatment of NSTE-ACS in Thailand. Methods: A two-part construct model comprising a one-year decision tree and a Markov model was developed to capture short and long-term costs and outcomes from the perspective of provider and society. Effectiveness data were derived from OASIS-5 trial while bleeding rates were derived from the Thai Acute Coronary Syndrome Registry (TACSR). Costs data were based on a Thai database and presented in the year of 2013. Both costs and outcomes were discounted by 3% annually. A series of sensitivity analyses were performed. Results: The results showed that compared with enoxaparin, fondaparinux was a cost-saving strategy (lower cost with slightly higher effectiveness). Cost of revascularisation with major bleeding had a greater impact on the amount of cost saved both from societal and provider perspectives. With a threshold of 160,000 THB ((4,857.3 USD) per QALY in Thailand, fondaparinux was about 99% more cost-effective compared with enoxaparin. Conclusion: Fondaparinux should be considered as a cost-effective alternative when compared to enoxaparin for NSTE-ACS based on Thailand's context, especially in the era of limited healthcare resources.
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    Cost-Effectiveness Analysis of Non-Statin Lipid-Modifying Agents for Secondary Cardiovascular Disease Prevention Among Statin-Treated Patients in Thailand
    (2019-10-01) Khachen Kongpakwattana; Zanfina Ademi; Thanaputt Chaiyasothi; Surakit Nathisuwan; Ella Zomer; Danny Liew; Nathorn Chaiyakunapruk; University of Utah; Monash University; Monash University Malaysia; Mahidol University; Srinakharinwirot University
    © 2019, Springer Nature Switzerland AG. Background: Using non-statin lipid-modifying agents in combination with statin therapy provides additional benefits for cardiovascular disease (CVD) risk reduction, but their value for money has only been evaluated in high-income countries (HICs). Furthermore, studies mainly derive effectiveness data from a single trial or older meta-analyses. Objectives: Our study used data from the most recent network meta-analysis (NMA) and local parameters to assess the cost effectiveness of non-statin agents in statin-treated patients with a history of CVD. Methods: A published Markov model was adopted to investigate lifetime outcomes: (1) number of recurrent CVD events prevented, (2) quality-adjusted life-years (QALYs) gained, (3) costs and (4) incremental cost-effectiveness ratios (ICERs) of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) and ezetimibe added to statin therapy. Event rates and effectiveness inputs were obtained from the NMA. Cost and utility data were gathered from published studies conducted in Thailand. A series of sensitivity analyses were performed. Results: Patients receiving PCSK9i and ezetimibe experienced fewer recurrent CVD events (number needed to treat [NNT] 17 and 30) and more QALYs (0.168 and 0.096 QALYs gained per person). However, under the societal perspective and at current acquisition costs in 2018, ICERs of both agents were $US1,223,995 and 27,361 per QALY gained, respectively. Based on threshold analyses, the costs need to be reduced by 97 and 85%, respectively, for PCSK9i and ezetimibe to be cost-effective. Conclusions: Despite the proven effectiveness of PCSK9i and ezetimibe, the costs of these agents need to reduce to a much greater extent than in HICs to be cost-effective in Thailand.