Medicare Policy Changes Will Make It More Difficult For Nevada Beneficiaries To Obtain Power Wheelchairs

Main Category: Medicare / Medicaid / SCHIP
Article Date: 09 Nov 2010 – 6:00 PST

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Will power wheelchairs continue to be available to Nevada’s
Medicare patients following a series of federal regulatory and policy changes?

There are grave concerns among consumer groups, Medicare beneficiaries and homecare equipment
providers in Nevada that the changes in Medicare policies may severely hamper the ability of
providers to supply quality products and services to beneficiaries.

One of the biggest threats is a new law establishing that the Medicare program will pay rental
payments over a 13 month period to homecare equipment providers after they supply power
wheelchairs to Medicare beneficiaries. The change will create significant cash flow problems for
providers, who will be forced to purchase the equipment from manufacturers, and then receive
reimbursement payments stretching over 13 months. Previously, Medicare beneficiaries could
request that the government purchase the equipment for them in the first month of use.

In addition, the Medicare program is expanding the flawed “competitive” bidding system. The
program restricts the number of providers who can supply home medical equipment in selected
geographical areas around the country, severely jeopardizing access to power wheelchairs for
seniors and those living with physical disabilities.

“We fear that the Medicare mobility benefit won’t be available for the people who need it because
there won’t be providers around to fill the power wheelchair prescriptions once doctors order them
for their patients,” said Corrie Herrera, rural director for the Northern Nevada Center for
Independent Living in Elko, Nevada. “Our organization, as well as others across the state who
represent people living with disabilities, feel that the Washington policymakers don’t understand
how much a power wheelchair means to the people who need them. We must ensure that Medicare
patients continue to have access to this equipment.”

Herrera said physicians prescribe power wheelchairs to patients needing assistance with critical
daily activities, such as grooming, getting to the bathroom and preparing food. By continuing to
perform these tasks in their homes with power wheelchairs, Herrera said it often delays the
necessity of placing beneficiaries in expensive nursing homes. Mobility assistance also reduces
emergency room visits for Medicare patients, who are less likely to suffer injuries from falls.

Jason Turner, 43, of Las Vegas, said his power wheelchair has made a dramatic difference in his
life. Turner, who has multiple sclerosis, said he has used a power chair for a dozen years. “It is like
getting my legs back,” said Turner. “I can help my daughters with their homework; and I have the
freedom and independence to go wherever I need to go.”

Moreover, Turner said that he is relieved not to be a “burden” on anyone because he can do so
many things for himself. “I hope that power wheelchairs remain available for other Medicare
beneficiaries,” he said. “Being mobile changes your life.”


Madonna Long, formerly of Reno and Battle Mountain, recalled that her mother, Ruth Crosthwaite,
began using a power wheelchair before she passed away. “My mother had severe arthritis and
could not push a manual wheelchair,” said Long, who has been in a wheelchair herself since
suffering injuries in a school bus accident as a teenager. “My wheelchair, and my mother’s
wheelchair, allowed us to live our lives, and continue to do the things that we love. It’s important
that other Medicare beneficiaries can also enjoy freedom and independence.”

But in recent years, changes in Medicare policies have significantly impacted providers, hampering
their ability to supply quality home medical equipment and services to Medicare beneficiaries. Over
the last five years, the Medicare program has cut reimbursements for power wheelchairs by more
than 35 percent. At the same time, the providers are experiencing excessive government audits and
extended delays in reimbursement payments.

The new rental reimbursement policy will slash providers’ cash-on-hand by 40 percent in the first
year. Because of the struggling economy, providers are unable to obtain loans or credit lines that
would allow them to purchase power wheelchairs from manufacturers and do the necessary
servicing so that Medicare beneficiaries have properly-adjusted equipment. Many Medicare
patients would receive chairs stored in warehouses that haven’t been specially fitted to address the
individual needs of the patients.

Consumer groups, providers, and Medicare patients are asking Congress to delay implementation of
the new policy from January 1, 2011 to January 1, 2012. The extra year would allow providers time
to adjust their business models. The delay wouldn’t increase Medicare spending because providers
would agree to a one-percent reduction in reimbursement rates for standard power wheelchairs.

Meanwhile, the bidding program for home medical equipment and services is scheduled to take
effect in nine metropolitan areas in January 2011. An additional 91 areas will start preparing for the
bidding program later in 2011, including locations in Nevada.

Yet, in September 166 bidding system experts and economists, including two Nobel laureates, sent
a letter to Congress warning about major problems with the bidding system. The experts concluded
that the system will fail, citing the fact that the bids are non-binding, the rules encourage
unsustainable low-ball bids, the design distorts bids and the program lacks transparency. H.R.
3790, the bill in the House of Representatives with broad bipartisan support, would replace the
bidding program with other types of cost savings but preserve patient access to mobility equipment.
Organizations that favor elimination of this bidding program include the ALS Association,
American Association of People with Disabilities, Muscular Dystrophy Association, National
Council on Independent Living, National Spinal Cord Injury Association, and United Spinal
Association, among others.

Source:

American Association for Homecare




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Today’s Op-Eds: The Medicare Cost-Cutting Debate; Two Perspectives On ‘Repeal And Replace’

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Primary Care / General Practice;  Public Health;  Health Insurance / Medical Insurance
Article Date: 09 Nov 2010 – 6:00 PST

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How Medicare Killed the Family Doctor The Wall Street Journal
Medicare introduced a whole new dynamic in the delivery of health care. Gone were the days when physicians were paid based on the value of their services. With payment coming directly from Medicare and the federal government, patients who used to pay the bill themselves no longer cared about the cost of services (Richard M. Hannon, 11/8).

Health Care Providers Should Initiate Cost Cuts; Waiting For The State Government Stalls Action The New York Daily News
So how can we make health care affordable without gutting the quality of our hospitals and primary care providers, or shredding the medical safety net for the poor? The answer lies in health care providers taking a lead rather than waiting for the state government to do what it usually does in budget crises: cut blindly at everything on the table, because political interests get in the way of creative solutions (James Knickman, 11/7).

Our View On Medical Reform: Don’t Try To Repeal The New Health Care Law, Improve It USA Today
As if Congress didn’t already have enough to do next year on jobs and taxes, incoming Republican leaders have made repeal of the new health reform law one of their top priorities. What a monumental waste of time and energy (11/7).

Opposing View On Medical Reform: Repeal And Replace ObamaCare USAToday
By putting an end to junk lawsuits, encouraging small businesses to band together to provide health plans, forcing insurance companies to compete by allowing Americans to shop across state lines, and giving states the flexibility to make changes that best meet the needs of their residents, we can reduce premiums and still provide important patient protections. … It doesn’t take $1 trillion in new government spending, $500 billion in new taxes and $500 billion in cuts to Medicare over the next decade (Dave Camp, 11/7).

Irrational About Healthcare Rationing The Los Angeles Times
It’s fair to debate how best to achieve healthcare reform. But it’s hard to see how healthcare costs can be brought under control if attempts to make the system more efficient and effective get waylaid by irrational fears about rationing (11/8).


Attacking The Health Law: The GOP’s Confusing And Incompatible Arguments Kaiser Health News
Allowing Medicare to continue going along as it has been for the last ten to twenty years — which is what repealing the new health law would do — would almost surely force a choice between much higher taxes or much worse access to care. If you don’t believe me, just look at the plan proposed by Republican Representative Paul Ryan, who is forthright enough to admit that the GOP alternative to the Democrats’ approach to Medicare is to reduce radically its guaranteed benefits (Jonathan Cohn, 11/8).

Andy Of Medicare Chicago Tribune
Aside from the suspicious timing, the ad is misleading. Griffith is right that basic Medicare benefits won’t be cut. But that makes it sound like seniors won’t feel the pinch of the new law. Many will (11/5).

Mental Health Is The New Antiabortion Battleground. But The Science Is All Wrong. The Washington Post
Women who think they made the right decision in having an abortion must be able to say so without fear of condemnation and without feeling that something is wrong with them. And women who feel sadness and regret should feel free to share their feelings as well. But their words should not be used to deceive women or to limit their choices (Brenda Major, 11/7).

This information was reprinted from kaiserhealthnews.org with kind permission from the Henry J. Kaiser Family Foundation. You can view the entire Kaiser Daily Health Policy Report, search the archives and sign up for email delivery at kaiserhealthnews.org.

© Henry J. Kaiser Family Foundation. All rights reserved.





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Ban Tobacco Ads And Restrict Alcohol And Erectile Dysfunction Ads, Urges The American Academy Of Pediatrics

Editor’s Choice
Main Category: Pediatrics / Children’s Health
Also Included In: Smoking / Quit Smoking;  Alcohol / Addiction / Illegal Drugs;  Erectile Dysfunction / Premature Ejaculation
Article Date: 27 Sep 2010 – 9:00 PDT

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The monumental task of persuading children and adolescents to say “No” to drugs, alcohol and tobacco is being constantly undermined by the $25 billions’ worth of advertising and marketing each year, which has precisely the opposite effect, says the American Academy of Pediatrics (AAP). The AAP adds that children should not be exposed to erectile dysfunction ads before ten at night.

A new AAP policy statement – “Children, Adolescents, Substance Abuse and the Media” – appears in the latest issue of the peer reviewed medical journal Pediatrics.

The policy statement calls for a total ban on all tobacco advertising, restrictions on the advertising of alcoholic drinks, and a ban on erectile dysfunction drug ads before 10pm.

Parents should be wary about letting their children watch PG-13 and R-rated movies and TV programs, the AAP adds. These shows and movies frequently feature substance abuse.

Pediatricians are advised to urge parents to restrict unsupervised media and TV channels which overexpose the viewer to substance abuse.

The White House Office on Drug Control Policy is being called on to start creating and broadcasting anti-smoking and anti-drinking public service announcements.

A study this year found that recurrent teen headaches are linked to smoking, overweight and physical inactivity. (Link)

According to a recent sub-study, part of long-term Nicotine Dependence in Teens (NDIT) study based at the University of Montreal Hospital Research Centre, University of Toronto and the University of Montreal, professionals discovered that smoking can increase depressive symptoms in teens. (Link)

Although the rate of overall illegal drug use among young people in 2009 remained below 2002 levels, youth use was higher in 2009 compared to 2008 (10.0% of youth in 2009, compared to 9.3% in 2008, versus 11.6% in 2002). The rate of marijuana use in this age group followed a similar pattern, declining from 8.2 percent of young people in 2002, to 6.7 percent in 2006, remaining level until 2008, and then increasing to 7.3 percent in 200. (Link)

“Policy Statement – Children, Adolescents, Substance Abuse, and the Media”
Published online September 27, 2010
PEDIATRICS (doi:10.1542/peds.2010-1635)

Written by Christian Nordqvist

Copyright: Medical News Today

Not to be reproduced without permission of Medical News Today




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so why not HFCS

posted by Eli on 27 Sep 2010 at 10:59 am

Look the real issue is not whether some kids will have a sip of bear. I mean any teen you tell them not to do something they do the opposite. I did, when my mom told me not to smoke every hour of every day then my freshmen year of college I started smoking. (since then I have stopped) My point is that if your going to do this also include HFCS (High Fructose Corn Syrup) That substance is in nearly 90% of our foods and studies have shown that rats eating the same amount of Corn Syrup as apposed to sugar cain gained weight much faster and suffered symptoms of depression. Obesity is the main cause of death in this country so why go after things that kids will try at some point anyway?

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Researchers Discover A Drug Combination That Shrinks Prostate Tumors In Vivo

 

Main Category: Prostate / Prostate Cancer
Also Included In: Cardiovascular / Cardiology;  Erectile Dysfunction / Premature Ejaculation
Article Date: 28 Sep 2010 – 3:00 PDT

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Virginia Commonwealth University School of Medicine and VCU Massey Cancer Center researchers have shown that the impotence drug Viagra, in combination with doxorubicin, a powerful anti-cancer drug, enhances its anti-tumor efficacy in prostate cancer while alleviating the damage to the heart at the same time.

For more than four decades the chemotherapeutic agent doxorubicin has been used to treat a number of human cancers, including that of the prostate. Despite doxorubicin’s clinical efficacy for cancer treatment, its use is associated with irreversible heart damage, often presenting several years after treatment stops. Researchers have been working over the past 15 years to find an optimal therapeutic intervention for protecting the heart against the cytotoxicity associated with doxorubicin.

In the study published online the week of Sept. 27 in the Early Edition of the journal Proceedings of the National Academy of Sciences, researchers using a variety of powerful in vitro and in vivo approaches, have shown that a combination of Viagra, generically known as sildenafil, and doxorubcin significantly enhances the generation of reactive oxygen species that trigger cell death, or apoptosis, in prostate cancer cells. They also observed that the combination did not harm the normal, healthy prostate epithelial cells.

“We believe sildenafil could be an excellent candidate for incorporation into cancer treatment protocols – with the potential of enhancing the anti-tumor efficacy, while protecting the heart against both short term and long term damage from doxorubicin,” said principal investigator Rakesh C. Kukreja, Ph.D., scientific director of the VCU Pauley Heart Center and the Eric Lipman professor in cardiology in the VCU School of Medicine, and Anindita Das, Ph.D., assistant professor in the Department of Internal Medicine the VCU School of Medicine.

Kukreja is excited about the potential translational impact of this work. “My team and I are hoping to move the research Root Explorer Apk is an ultimate file manager especially for the rooted Android phone users.  forward to a clinical trial and plans are under way to do so,” he said. The clinical trial would evaluate the effectiveness of the drug combination in cancer patients.

Kukreja’s laboratory is one of the first to explore the area of preconditioning. This preconditioning effect was modeled in his lab by “pretreating” mice with doses of sildenafil which also increases therapeutic levels of nitric oxide in the heart.

A preconditioned or pretreated heart has an improved ability to produce nitric oxide and directly improves a patient’s outcome following a heart attack. Generally, damage following a heart attack is related to an inability to recover from lack of oxygen.

Notes:
The work was supported in part by a MERIT Award to Kukreja from the National, Heart, Lung and Blood Institute of the National Institutes of Health.

Kukreja and Das collaborated with Paul Dent, Ph.D., a research member with the VCU Massey Cancer Center. Also contributing to this work were VCU researchers David Durrant, Clint Mitchell, a postdoctoral fellow in Dent’s lab, Eric Mayton, a research assistant in Kukreja’s lab, Nicholas N. Hoke, a graduate student in Kukreja’s lab, Fadi N. Salloum, assistant professor of Internal Medicine and researcher with the VCU Pauley Heart Center, Margaret A. Park, a postdoctoral fellow with Dent’s lab, Ian Quershi, a graduate student in Kurkeja’s lab, and Ray Lee, former assistant professor of internal medicine.

Source:
Sathya Achia Abraham
Virginia Commonwealth University

 





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Sexual Issues A Major Concern For Cancer Patients Taking New Targeted Drugs

Main Category: Cancer / Oncology
Also Included In: Sexual Health / STDs;  Erectile Dysfunction / Premature Ejaculation
Article Date: 13 Oct 2010 – 0:00 PDT

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New drugs that target specific molecular mechanisms of cancer have improved the treatment of cancer patients in recent years, but those benefits may come with a cost to the patient’s sex life, researchers have found.

At the 35th Congress of the European Society for Medical Oncology (ESMO) in Milan, Italy, French researchers reported on one of the few studies to investigate the impact of cancer therapy on the sexual functioning of patients.

Dr Yohann Loriot and Dr Thomas Bessede from Institut Gustave Roussy in Villejuif, France and colleagues found that patients taking targeted therapies had significantly decreased levels of sexual function and satisfaction.

“The new molecular targeted therapies have been available for 6 or 7 years and researchers and physicians have observed some new side-effects not often reported with chemotherapy such as cutaneous side-effects and gastro-intestinal toxicity. But very few studies have been conducted in the field of sexuality, mainly because patients are not willing to talk with their physicians on this topic,” Dr Loriot said.

The researchers surveyed 51 patients (40 men and 11 women) who had been taking molecular targeted therapies for more than three months without progressive disease about changes in their sexual life.

The drugs involved were sunitinib, sorafenib, temsirolimus, everolimus, bevacizumab, tarceva and cetuximab. Men completed the International Index of Erectile Function (IEEF) questionnaire –which includes questions on erectile function, intercourse satisfaction, orgasmic function, sexual desire and overall satisfaction.

Women in the study completed the Female Sexual Function Index (FSFI) questionnaire, which includes questions on desire, arousal, lubrication, orgasm, satisfaction and pain.

The median overall IIEF score for men was 40, just 53% of the maximum score. For women, the median FSFI score was 8.4, just 24% of the maximum.

“The sex lives of the patients in our study had reduced quality and intensity,” Dr Loriot said. “We also found that more than half of the patients expressed a wish for a satisfying sexuality, but many of them found it difficult to initiate a discussion on the topic with their doctors.”

The impact of treatment on the sexuality of cancer patients is poorly understood, and is generally not considered in clinical trials of treatments, Dr Loriot said.

“Oncologists can address this issue first by assessing this concern more often in clinical trials, and by talking with their patients about it,” he said.

He suggested that oncologists could offer patients an assessment for sexual disorders during their treatment course, establish an outpatient clinic to deal with sexual disorders, or, if needed, refer patients to a specialist.

Sexuality is a major concern for cancer patients, as it is for everyone, noted Professor Raphael Catane, Chair of the department of oncology at Sheba Medical Center in Tel Hashomer, Israel. “The disease itself, and frequently its therapy, may have a major detrimental effect on the patient’s sex life. It is hoped that the new biological/targeted treatments would be less injurious to the sexual life of cancer patients. ”

“The study by this French group has taken an important step toward understanding the effect of biological/targeted treatments on sexuality,” Prof Catane said. “They meticulously reviewed the sexual function of their patients receiving biological agents. The results show a diminished sexual drive and pleasure, but the degree and the duration, and how it compares to the standard/conventional therapy, is not yet known. This study can be a basis for further investigation of this very important aspect of cancer therapy.”

Source:
Vanessa Pavinato

European Society for Medical Oncology





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NovaDel Pharma Inc. Announces Positive Data From Pilot Pharmacokinetic Study Comparing Duromist™ (Sildenafil Citrate Oral Spray) To Viagra(R)

 

Main Category: Erectile Dysfunction / Premature Ejaculation
Article Date: 20 Oct 2010 – 1:00 PDT

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NovaDel Pharma Inc. (OTCBB: NVDL), a specialty pharmaceutical company developing oral spray formulations for a broad range of marketed pharmaceutical products, announced pharmacokinetic (PK) and safety results from its pilot PK study comparing Duromist™ to Viagra®. Duromist™ is NovaDel’s oral spray formulation of sildenafil citrate. Viagra® is the tablet formulation of sildenafil citrate developed and marketed by Pfizer. Sildenafil citrate is a leading drug indicated for the management of pulmonary hypertension and erectile dysfunction. NovaDel now plans to review the results from this study with the FDA to obtain guidance on defining definitive clinical trial requirements as a pathway to NDA approval.

Objectives of the Study

This pilot PK study was designed primarily to assess the relative bioavailability of one, two and three doses of 10 mg/0.12ml of Duromist™, compared to that of the 25 mg Viagra® tablet in healthy adult male subjects.

The secondary objective was to assess the relative safety of Duromist™ following single oral dose administration compared to that of 25 mg Viagra® tablets. Safety assessments included evaluation of changes in orthostatic hypotension, oral irritation, vital sign and electrocardiogram assessments.

Results of the Study

The preliminary study data demonstrated that 20 mg or two sprays of Duromist™ is bioequivalent to the 25 mg Viagra® tablet with respect to systemic exposure (AUC0-inf). The mean AUC0-inf for the 10 mg or one spray dose was approximately 40% of the 25 mg Viagra® tablet, as expected. The mean AUC0-inf for the 30 mg (or three spray) dose was approximately 40 % higher than the 25 mg Viagra® tablet which is about 20% higher than expected. The increased systemic exposure (AUC) observed with the 20 and 30 mg oral spray doses compared to the Viagra® tablet is suggestive of absorption of sildenafil via the oral transmucosal route.

A slightly lower Cmax than that of the 25 mg Viagra® tablet was observed with the 20 mg oral spray dose. The Tmax for the 20 mg oral spray dose was essentially the same as the 25 mg Viagra® tablet (1.10 and 1.04 hour, respectively).

N-desmethylsildenafil is an active metabolite of sildenafil formed as a result of first-pass liver metabolism. TheDownload the best Android apps and games on Aptoide apk  Discover, download and share Android APK rate of metabolite formation with the oral spray is different than that observed with the reference tablet and is consistent with transmucosal absorption.


Duromist™ demonstrated an excellent safety profile and was well tolerated in this pilot PK study. There was no evidence of oral irritation and no adverse events were reported after administration of up to three doses of Duromist™. Vital signs were within normal range and there were no episodes of orthostatic hypotension observed in any of the four treatment periods. No changes were observed in the subjects’ electrocardiograms in any of the four treatment periods.

“These results are encouraging and demonstrate that greater bioavailability can be achieved with sildenafil administered as an oral spray form with the potential for a differentiated, patented Duromist™ product,” commented Mr. Steven B. Ratoff, NovaDel’s Chairman of the Board, President Chief Executive Officer. “This initial clinical study provides NovaDel with a solid foundation for our future clinical development efforts.”

About the Study

This was a single-center, open-label, single-dose, randomized, four-period, four-treatment crossover study under fasting conditions. The total number of healthy adult male subjects enrolled in the study was 24. All subjects were required to stay at the clinical site for at least 24 hours after each treatment period.

The Duromist™ oral spray test article used in this study was supplied as 10 mg/120 µl sildenafil per spray actuation. The 25 mg sildenafil citrate tablet was supplied from commercial sources as Viagra® from Pfizer Inc.

Measurements:

Pharmacokinetic: The following parameters were used in the data analysis for plasma sildenafil and N-desmethylsildenafil concentrations: AUC0-t, The area under the plasma concentration versus time curve, from time 0 to the last measurable concentration; AUC0-inf, Calculated as the sum of the AUC0-t plus the ratio of the last measurable plasma concentration to the elimination rate constant; AUC0-t/AUC0-inf, The ration of the AUC0-t to AUC0-inf; Cmax, The maximum measured plasma concentration observed; Tmax, defined as the time point of Cmax; Kel, The apparent first-order terminal elimination rate constant; T1/2, The apparent first-order terminal elimination half-life; Ratio Metabolite/Parent, The ratio of the metabolite/parent assessed at each concentration, Cmax, AUC0-t, AUC0-inf.

Safety: Vital signs (supine and standing); Electrocardiogram at screening and post-dose; Changes in physical examinations, including oral soft tissue examinations at and after each oral spray dosing, laboratory parameters and adverse events.

About Erectile Dysfunction

Erectile dysfunction (ED) is a condition in which men are unable to achieve penile erection or are unable to sustain an erection sufficient for successful sexual intercourse. In the United States alone, it is estimated that 18 million individuals suffer from ED with the disorder being most prevalent in men age 40 years and above. Since the risk of developing ED increases with age, the increasingly aged population and other risk factors such as physical inactivity, smoking and high cholesterol are expected to lead to an increase in the number of men with this condition over the next few years.

Source:

NovaDel Pharma Inc.

 





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Apricus Bio Announces First Patent Grant For Femprox(R) In Japan

Main Category: Erectile Dysfunction / Premature Ejaculation
Article Date: 20 Oct 2010 – 2:00 PDT

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Apricus Biosciences, Inc., (“Apricus Bio”) (Nasdaq: APRI) backed by a revenue generating CRO business and seeking to leverage its multi-route NexACT® drug delivery technology and internal pipeline through out-licensing partnerships, today announced that the Japanese Patent Office has issued a Decision to Grant a Patent for the Company’s application on Femprox entitled, “Compositions and Methods for Amelioration of Human Female Sexual Dysfunction.” This patent, when issued, will provide Japanese patent protection to December 2019, and is one in a series of patents and pending applications that Apricus Bio owns on Femprox and the underlying NexACT technology.

“Compositions and Methods for Amelioration of Human Female Sexual Dysfunction.”

Commenting on today’s news, Dr. Bassam Damaj, President and Chief Executive Officer of Apricus Bio, stated, “We are very pleased with our first patent allowance for Femprox in Japan. We continue to aggressively pursue intellectual property (“IP”) coverage for our technology and product candidates under development and this allowance adds to the strength of our overall IP position. In addition to the newly allowed claims in Japan, we have corresponding coverage and protection for Femprox in many other major international markets. The advancement of our patent portfolio comes at an optimal time, as we are in active discussions with potential partners to out-license Femprox.”

Femprox is an alprostadil-based cream intended for the treatment of female sexual arousal disorder. Apricus has completed nine clinical studies to date, including one, 98-patient Phase 2 study in the U.S. and a 400-patient proof-of-concept Phase 2/3 study in China, where the cost for conducting clinical studies was significantly lower than in the U.S.

Source:

Apricus Biosciences




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