Comparing medications in a therapeutic area using an NNT model

Amikacin Liposome Inhalation Suspension Clinical Benefit-Risk Assessment for Refractory MAC Lung Disease

Mycobacterium avium complex (MAC) is the leading cause of nontuberculous mycobacterial lung disease, which can be associated with progressive lung damage and increased mortality [1]. Patients with MAC lung disease have substantial disease burden and limited treatment options [1]. Up to 40% of patients experience failure, with lengthy multidrug treatments, relapse or reinfection [2]. For patients with treatment-refractory MAC lung disease (persistent MAC-positive sputum despite ≥6 months of guideline-based therapy (GBT)), international guidelines recommend the addition of amikacin liposome inhalation suspension (ALIS) to GBT regimens [3]. In clinical trials, patients with treatment-refractory MAC lung disease had improved culture conversion with ALIS+GBT versus GBT [4, 5].

Marraset al. report a low number needed to treat and high number needed to harm supporting addition of amikacin liposome inhalation suspension to guideline-based treatments in patients with treatment-refractory Mycobacterium avium complex lung diseasehttps://bit.ly/3tPFW7D

Going from evidence to recommendations: Can GRADE get us there?

The evidence based medicine movement has championed the need for objective and transparent methods of clinical guideline development. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was developed for that purpose. Central to this framework is criteria for assessing the quality of evidence from clinical studies and the impact that body of evidence should have on our confidence in the clinical effectiveness of a therapy under examination. Grades of Recommendation, Assessment, Development, and Evaluation has been adopted by a number of professional medical societies and organizations as a means for orienting the development of clinical guidelines. As a result, the method of GRADE has implications on how health care is delivered and patient outcomes. In this paper, we reveal several issues with the underlying logic of GRADE that warrant further discussion. First, the definitions of the "grades of evidence" provided by GRADE, while explicit, are functionally vague. Second, the "criteria for assigning grade of evidence" is seemingly arbitrary and arguably logically incoherent. Finally, the GRADE method is unclear on how to integrate evidence grades with other important factors, such as patient preferences, and trade-offs between costs, benefits, and harms when proposing a clinical practice recommendation. Much of the GRADE method requires judgement on the part of the user, making it unclear as to how the framework reduces bias in recommendations or makes them more transparent-both goals of the programme. It is our view that the issues presented in this paper undermine GRADE's justificatory scheme, thereby limiting the usefulness of GRADE as a tool for developing clinical recommendations.

Model-observational bridging study on the effectiveness of ezetimibe on cardiovascular morbidity and mortality in France: A population-based study

BACKGROUND

To evaluate the real-life impact of ezetimibe on cardiovascular (CV) morbidity and mortality in France.

OBJECTIVE

To estimate the number of non-fatal and fatal CV events that could be prevented and corresponding number of patients needed to treat (NNT) with ezetimibe to prevent one CV event over 5 years.

METHODS

Non-interventional 48-month follow-up cohort conducted in hypercholesterolemic patients starting on ezetimibe <3 months at study entry, either as monotherapy or combined with statins. Prediction modeling using discrete event simulation with calibrated Framingham CV risk equations was applied to data from pivotal clinical trials on ezetimibe and real-life data derived from the cohort.

RESULTS

A total of 3215 patients in the cohort accumulated 9314 person-years of follow-up for an average of 2.9 years. Mean age was 61.5 (standard deviation [SD] = 10.7), 54.6% were males, and 27.0% had a history of CV disease. Baseline LDL-cholesterol averaged 4.1 mmol/L (159 mg/dL; SD = 1.0) and HDL-C 1.6 mmol/L (62 mg/dL; SD = 0.5). LDL-C decreased in the first 12 months in ezetimibe-LLT (lipid-lowering therapy) initiators, switchers (monotherapy), and combination therapy with a statin by respectively 21.3%, 6.4%, and 29.1%. The corresponding predicted rate reductions of CV events (non-fatal and fatal) compared to no treatment or to a statin (combination therapy) were respectively 8, 2, and 12 per 1000 patients treated over 5 years, with a global NNT of 143 patients over 5 years.

CONCLUSION

These results, accounting for observed CV event rates, risk factors evolution over time and adherence to treatment in real life, were consistent with those from clinical trials.

Clinical and public health assessment of benefits and risks of statins in primary prevention of coronary events: resolved and unresolved issues

Peer-reviewed, evidence-based recommendations for statin use in primary prevention of cardiovascular events are limited. A narrative review of published randomized controlled trials and meta-analyses was conducted to critically appraise the benefits and risks of statins in primary prevention. Statins effectively reduce plasma concentrations of low-density lipoprotein cholesterol, and reduce the risk of cardiovascular events and death. The greatest benefits are observed in high-risk subjects, such as patients with diabetes or hypertension. Serious cardiovascular events should not be included among serious adverse events because they are efficacy outcomes and are dependent on the baseline risk of patients. Rates of specific serious adverse events, such as cancer and rhabdomyolysis, seem to be similar between the statin and control arms of the clinical trials examined. Thus, the benefits of statins in primary prevention outweigh the risks, particularly among high-risk patients. However, the benefit-risk ratio would likely be optimized through interventions designed to increase persistence and adherence in a real-life setting.

Evaluating the effectiveness of combination therapy to prevent COPD exacerbations: the value of NNT analysis

The effective prevention of exacerbations in patients with chronic obstructive pulmonary disease (COPD) has the potential to improve patients' health-related quality of life, reduce rates of hospitalisation and mortality and lower healthcare costs. Several pharmacological agents, including inhaled corticosteroid/long-acting beta2-agonist combination therapies, have demonstrated beneficial effects on COPD exacerbations. The number needed to treat (NNT) analysis is a simple, concise method that allows physicians to quantify directly the benefits that alternative treatment options have on disease outcomes in terms of the number of patients who need to be treated before a benefit is observed. This review evaluates the applicability and clinical relevance of NNT analysis for determining the effectiveness of combination therapies against COPD exacerbations, focusing on budesonide/ formoterol in the same inhaler. Physicians are encouraged to consider NNT data within the context of their limitations and in conjunction with other analytical methods when selecting treatments for patients with COPD.