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Totton N, Waddingham E, Owen R, Julious S, Hughes D, Cook J. A proposal for using benefit-risk methods to improve the prominence of adverse event results when reporting trials. Trials 2024; 25:409. [PMID: 38909232 PMCID: PMC11193225 DOI: 10.1186/s13063-024-08228-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 06/03/2024] [Indexed: 06/24/2024] Open
Abstract
Adverse events suffer from poor reporting within randomised controlled trials, despite them being crucial to the evaluation of a treatment. A recent update to the CONSORT harms checklist aims to improve reporting by providing structure and consistency to the information presented. We propose an extension wherein harms would be reported in conjunction with effectiveness outcome(s) rather than in silo to provide a more complete picture of the evidence acquired within a trial. Benefit-risk methods are designed to simultaneously consider both benefits and risks, and therefore, we believe these methods could be implemented to improve the prominence of adverse events when reporting trials. The aim of this article is to use case studies to demonstrate the practical utility of benefit-risk methods to present adverse events results alongside effectiveness results. Two randomised controlled trials have been selected as case studies, the Option-DM trial and the SANAD II trial. Using a previous review, a shortlist of 17 benefit-risk methods which could potentially be used for reporting RCTs was created. From this shortlist, three benefit-risk methods are applied across the two case studies. We selected these methods for their usefulness to achieve the aim of this paper and which are commonly used in the literature. The methods selected were the Benefit-Risk Action Team (BRAT) Framework, net clinical benefit (NCB), and the Outcome Measures in Rheumatology (OMERACT) 3 × 3 table. Results using the benefit-risk method added further context and detail to the clinical summaries made from the trials. In the case of the SANAD II trial, the clinicians concluded that despite the primary outcome being improved by the treatment, the increase in adverse events negated the improvement and the treatment was therefore not recommended. The benefit-risk methods applied to this case study outlined the data that this decision was based on in a clear and transparent way. Using benefit-risk methods to report the results of trials can increase the prominence of adverse event results by presenting them alongside the primary efficacy/effectiveness outcomes. This ensures that all the factors which would be used to determine whether a treatment would be recommended are transparent to the reader.
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Affiliation(s)
- Nikki Totton
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Ed Waddingham
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Ruth Owen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Steven Julious
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Jonathan Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Rodriguez-Gutierrez R, Flores-Rodríguez A, Raygoza-Cortez K, Garcia-Leal M, Mariño-Velasco S, Plata-Huerta HH, Sáenz-Flores M, Ramirez-Garcia LA, Rojo-Garza A, Maraka S, Singh-Ospina NV, Brito JP, Gonzalez-Gonzalez JG. Intensive vs. conventional blood pressure goals in older patients with type 2 diabetes: a systematic review and meta-analysis. Endocrine 2022; 78:13-23. [PMID: 35962895 DOI: 10.1007/s12020-022-03159-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/27/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE Assess the effect of intensive vs conventional blood pressure goals on patient-important outcomes in older adults with type 2 diabetes. METHODS A comprehensive search was performed using electronic databases. Randomized controlled trials comparing intensive vs conventional blood pressure goals in adults over 60 years of age with type 2 diabetes were included. Events were evaluated using a modified Mantel-Haenszel meta-analysis with Peto's method. Study selection and data extraction were performed independently and in duplicate. RESULTS Seven trials were included. A 19% risk reduction (OR 0.81; 95% CI 0.69-0.95; I2 = 8%; p = 0.35) in the occurrence of major adverse cardiovascular events (MACE) and 37% risk reduction (OR 0.63; 95% CI 0.51-0.79; I2 = 0%; p = 0.56) in the occurrence of fatal or non-fatal stroke was documented in the intensive treatment group. There were no differences in the occurrence of all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, and peripheral vascular disease. Data regarding treatment adverse effects and microvascular outcomes was scarce. CONCLUSIONS Intensive blood pressure goals in older patients with diabetes were associated with a lower risk of stroke and MACE, but not with all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, and peripheral vascular disease.
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Affiliation(s)
- Rene Rodriguez-Gutierrez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, 64460, México
- Knowledge and Evaluation Research Unit-Endocrinology (KER-Endo), Mayo Clinic, Rochester, MN, 55905, USA
- Endocrinology Division, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autonoma de Nuevo Leon, Monterrey, 64460, México
| | - Andrea Flores-Rodríguez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, 64460, México
| | - Karina Raygoza-Cortez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, 64460, México
| | - Mariana Garcia-Leal
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, 64460, México
| | - Sofía Mariño-Velasco
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, 64460, México
| | - Hiram H Plata-Huerta
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, 64460, México
| | - Melissa Sáenz-Flores
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, 64460, México
| | - Luz A Ramirez-Garcia
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, 64460, México
| | - Amanda Rojo-Garza
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, 64460, México
| | - Spyridoula Maraka
- Knowledge and Evaluation Research Unit-Endocrinology (KER-Endo), Mayo Clinic, Rochester, MN, 55905, USA
- Central Arkansas Veterans Healthcare System, Medicine Service, Little Rock, AR, USA
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Naikky V Singh-Ospina
- Knowledge and Evaluation Research Unit-Endocrinology (KER-Endo), Mayo Clinic, Rochester, MN, 55905, USA
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Juan P Brito
- Knowledge and Evaluation Research Unit-Endocrinology (KER-Endo), Mayo Clinic, Rochester, MN, 55905, USA
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jose G Gonzalez-Gonzalez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, 64460, México.
- Endocrinology Division, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autonoma de Nuevo Leon, Monterrey, 64460, México.
- Research Unit, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, 64460, México.
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Lee YS, Lee HY, Kim TH. Cost-effectiveness analysis of intensive blood pressure control in Korea. Hypertens Res 2021; 45:507-515. [PMID: 34934160 DOI: 10.1038/s41440-021-00774-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 08/10/2021] [Accepted: 09/04/2021] [Indexed: 01/09/2023]
Abstract
This study was a cost-effectiveness analysis of intensive blood pressure (BP) control among hypertensive patients in Korea. We constructed a Markov model comparing intensive versus standard BP control treatment and calculated the incremental cost-effectiveness ratio. The study population consisted of hypertensive patients over 50 years old with systolic blood pressures (SBPs) exceeding 140 mmHg and at high risk of cardiovascular disease. Treatment alternatives included lowering the SBP below 120 mmHg (intensive) and 140 mmHg (standard) for target BP. We assumed five scenarios with different medication adherence. The effectiveness variable was quality-adjusted life years (QALYs), and costs included medical costs related to hypertension (HT), complications, and nonmedical costs. In addition, we performed a sensitivity analysis to confirm the robustness of the results of this study. Scenario 5, with 100% medication adherence, showed the lowest incremental cost-effectiveness ratio (ICER) of $1,373 USD, followed by scenario 1 (first 15 years: 62.5%, 16-30 years: 65.2%, after 30 years: 59.5%), scenario 2 (first five years: 62.5% decrease by 5% every five years), and scenario 3 (first 10 years: 62.5% decrease by 10% every 10 years). The ICERs in all scenarios were lower than the willingness to pay (WTP) threshold of $9,492-$32,907 USD in Korea. Tornado analysis showed that the ICERs were changed greatly according to stroke incidence. Intensive treatment of HT prevents cardiovascular disease (CVD); therefore, intensive treatment is more cost-effective than standard treatment despite the consumption of more health resources. ICERs are considerably changed according to medication adherence, confirming the importance of patient adherence to treatment.
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Affiliation(s)
- Ye Seol Lee
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.,National Traffic Injury Rehabilitation Research Institute, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Division of Cardiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae Hyun Kim
- Department of Healthcare Management, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea.
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Abstract
BACKGROUND This is the first update of this review first published in 2009. When treating elevated blood pressure, doctors usually try to achieve a blood pressure target. That target is the blood pressure value below which the optimal clinical benefit is supposedly obtained. "The lower the better" approach that guided the treatment of elevated blood pressure for many years was challenged during the last decade due to lack of evidence from randomised trials supporting that strategy. For that reason, the standard blood pressure target in clinical practice during the last years has been less than 140/90 mm Hg for the general population of patients with elevated blood pressure. However, new trials published in recent years have reintroduced the idea of trying to achieve lower blood pressure targets. Therefore, it is important to know whether the benefits outweigh harms when attempting to achieve targets lower than the standard target. OBJECTIVES The primary objective was to determine if lower blood pressure targets (any target less than or equal to 135/85 mm Hg) are associated with reduction in mortality and morbidity as compared with standard blood pressure targets (less than or equal to 140/ 90 mm Hg) for the treatment of patients with chronic arterial hypertension. The secondary objectives were: to determine if there is a change in mean achieved systolic blood pressure (SBP) and diastolic blood pressure (DBP associated with "lower targets" as compared with "standard targets" in patients with chronic arterial hypertension; and to determine if there is a change in withdrawals due to adverse events with "lower targets" as compared with "standard targets", in patients with elevated blood pressure. SEARCH METHODS The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to May 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 4), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing patients allocated to lower or to standard blood pressure targets (see above). DATA COLLECTION AND ANALYSIS Two review authors (JAA, VL) independently assessed the included trials and extracted data. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure, end stage renal disease, and other serious adverse events. Secondary outcomes were achieved mean SBP and DBP, withdrawals due to adverse effects, and mean number of antihypertensive drugs used. We assessed the risk of bias of each trial using the Cochrane risk of bias tool and the certainty of the evidence using the GRADE approach. MAIN RESULTS: This update includes 11 RCTs involving 38,688 participants with a mean follow-up of 3.7 years. This represents 7 new RCTs compared with the original version. At baseline the mean weighted age was 63.1 years and the mean weighted blood pressure was 155/91 mm Hg. Lower targets do not reduce total mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.86 to 1.05; 11 trials, 38,688 participants; high-certainty evidence) and do not reduce total serious adverse events (RR 1.04, 95% CI 0.99 to 1.08; 6 trials, 18,165 participants; moderate-certainty evidence). This means that the benefits of lower targets do not outweigh the harms as compared to standard blood pressure targets. Lower targets may reduce myocardial infarction (RR 0.84, 95% CI 0.73 to 0.96; 6 trials, 18,938 participants, absolute risk reduction (ARR) 0.4%, number needed to treat to benefit (NNTB) 250 over 3.7 years) and congestive heart failure (RR 0.75, 95% CI 0.60 to 0.92; 5 trials, 15,859 participants, ARR 0.6%, NNTB 167 over 3.7 years) (low-certainty for both outcomes). Reduction in myocardial infarction and congestive heart failure was not reflected in total serious adverse events. This may be due to an increase in other serious adverse events (RR 1.44, 95% CI 1.32 to 1.59; 6 trials. 18,938 participants, absolute risk increase (ARI) 3%, number needed to treat to harm (NNTH) 33 over four years) (low-certainty evidence). Participants assigned to a "lower" target received one additional antihypertensive medication and achieved a significantly lower mean SBP (122.8 mm Hg versus 135.0 mm Hg, and a lower mean DBP (82.0 mm Hg versus 85.2 mm Hg, than those assigned to "standard target". AUTHORS' CONCLUSIONS For the general population of persons with elevated blood pressure, the benefits of trying to achieve a lower blood pressure target rather than a standard target (≤ 140/90 mm Hg) do not outweigh the harms associated with that intervention. Further research is needed to see if some groups of patients would benefit or be harmed by lower targets. The results of this review are primarily applicable to older people with moderate to high cardiovascular risk. They may not be applicable to other populations.
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Affiliation(s)
- Jose Agustin Arguedas
- Depto de Farmacologia Clinica, Facultad de Medicina, Universidad de Costa Rica, San Pedro de Montes de Oca, Costa Rica
| | - Viriam Leiva
- Escuela de Enfermeria, Facultad de Medicina, University of Costa Rica, San Jose, Costa Rica
| | - James M Wright
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
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Abstract
Supplemental Digital Content is available in the text On the basis of the benefits of antihypertensive treatment, progressively intensive treatment is advocated. However, it remains controversial whether intensive blood pressure control might increase the frequency of serious adverse events (SAEs) compared with moderate control. This review assessed the occurrence of SAEs in blood pressure treatment with predefined blood pressure targets. Seven original studies and eight post hoc analyses (derived from two original studies) met the inclusion criteria. Compared with moderate blood pressure treatment, intensive treatment was associated with a significant increase in treatment-related SAEs (Sign-test: P = 0.0002, Wilcoxon signed-rank test: P = 0.001). However, comparability between studies was limited, due to unclear determinations about the treatment-relatedness of adverse events, missing definitions of SAEs and variations in recording methods. Thus, a meta-analysis was not justified. The definitions of serious adverse events and methods of recording and reporting need to be improved and standardized to facilitate the comparison of results.
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Dimmitt SB, Stampfer HG, Martin JH, Ferner RE. Efficacy and toxicity of antihypertensive pharmacotherapy relative to effective dose 50. Br J Clin Pharmacol 2019; 85:2218-2227. [PMID: 31219198 DOI: 10.1111/bcp.14033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 01/09/2023] Open
Abstract
Antihypertensive drugs have usually been approved at doses near the top of their respective dose-response curves. Efficacy plateaus but adverse drug reactions (ADRs), such as falls, cerebral or renal ischaemia, increase as dose is increased, especially in older patients with comorbidities. ADRs reduce adherence and may be difficult to ascertain reliably. Higher doses have generally not been shown to reduce total mortality, which provides a summary of efficacy and safety. Weight loss and other lifestyle measures are essential and may be sufficient treatment in many young and low risk patients. Most antihypertensive drug lower systolic blood pressure by around 10 mmHg, which reduces stroke and heart failure by about a quarter. Clinical trials have not been designed to demonstrate specific blood pressure treatment thresholds and targets, which are mostly extrapolated from epidemiology. Mean population oral effective dose 50 may be the most appropriate dose at which to commence antihypertensive drugs. The dose can then be titrated up if greater efficacy is demonstrated, or lowered if ADRs develop. Lower dose combination therapy may best balance benefit and harms with fewer ADRs and additive, potentially synergistic, efficacy.
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Affiliation(s)
- Simon B Dimmitt
- Division of Internal Medicine, Medical School, University of Western Australia, Crawley, Western Australia, Australia.,University of Newcastle School of Medicine and Public Health, Callaghan, New South Wales, Australia
| | - Hans G Stampfer
- Division of Psychiatry, Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Jennifer H Martin
- University of Newcastle School of Medicine and Public Health, Callaghan, New South Wales, Australia.,Department of Medicine, Hunter New England Local Health District, Newcastle, Australia
| | - Robin E Ferner
- West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, UK.,Institute of Clinical Sciences, University of Birmingham, UK
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Rueda-Ochoa OL, Rizopoulos D, Kavousi M. Letter by Rueda-Ochoa et al Regarding Article, "Potential Cardiovascular Disease Events Prevented With Adoption of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline". Circulation 2019; 139:e1019-e1020. [PMID: 31157998 DOI: 10.1161/circulationaha.118.039332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Oscar L Rueda-Ochoa
- Department of Epidemiology (O.L.R.-O., M.K.), Erasmus MC - University Medical Center Rotterdam, The Netherlands.,Electrocardiography Research Group, Department of Basic Sciences, School of Medicine, Universidad Industrial de Santander, UIS, Bucaramanga, Colombia (O.L.R.-O.)
| | - Dimitris Rizopoulos
- Department of Biostatistics (D.R.), Erasmus MC - University Medical Center Rotterdam, The Netherlands
| | - Maryam Kavousi
- Department of Epidemiology (O.L.R.-O., M.K.), Erasmus MC - University Medical Center Rotterdam, The Netherlands
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Chi G, Kerneis M, Kalayci A, Liu Y, Mehran R, Bode C, Halperin JL, Verheugt FW, Wildgoose P, van Eickels M, Lip GY, Cohen M, Peterson ED, Fox KA, Gibson CM. Safety and efficacy of non-vitamin K oral anticoagulant for atrial fibrillation patients after percutaneous coronary intervention: A bivariate analysis of the PIONEER AF-PCI and RE-DUAL PCI trial. Am Heart J 2018; 203:17-24. [PMID: 30015064 DOI: 10.1016/j.ahj.2018.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 06/05/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND The tradeoff in safety versus efficacy in substituting a non-vitamin K antagonist oral anticoagulant for a vitamin K antagonist (VKA) in the stented atrial fibrillation patient has not been quantitatively evaluated. METHODS Based on summary data from the PIONEER AF-PCI and RE-DUAL PCI trials, 4 antithrombotic regimens were compared with VKA-based triple therapy: (1) rivaroxaban (riva) 15 mg daily + P2Y12 inhibitor, (2) riva 2.5 mg twice daily + P2Y12 inhibitor + aspirin, (3) dabigatran (dabi) 110 mg twice daily + P2Y12 inhibitor, and (4) dabi 150 mg twice daily + P2Y12 inhibitor. A bivariate model with a noninferiority margin of 1.38 was used to simultaneously assess safety and efficacy. The safety end point was major or clinically relevant nonmajor bleeding by International Society on Thrombosis and Haemostasis definitions. The efficacy end point was a thromboembolic event (myocardial infarction, stroke, or systemic embolism), death, or urgent revascularization. The bivariate outcome, a measure of risk difference in the net clinical outcome, was compared between antithrombotic regimens. RESULTS All 4 non-vitamin K antagonist oral anticoagulant regimens were superior in bleeding and noninferior in efficacy compared with triple therapy with VKA. Riva 15 mg daily and 2.5 mg twice daily were associated with bivariate combined risk reductions of 5.6% (2.3%-8.8%) and 5.5% (2.1%-8.7%), respectively, and dabi 110 mg twice daily and 150 mg twice daily reduced the bivariate risk by 3.8% (0.5%-7.0%) and 6.3% (2.4%-9.8%), respectively. CONCLUSIONS A bivariate analysis that simultaneously characterizes both risk and benefit demonstrates that riva- and dabi-based regimens were both favorable over VKA plus dual antiplatelet therapy among patients with atrial fibrillation undergoing PCI.
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