Newly licensed drugs

Association of SGLT2 inhibitors with cardiovascular, kidney, and safety outcomes among patients with diabetic kidney disease: a meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis of the cardiovascular, kidney, and safety outcomes of sodium-glucose cotransporter 2 inhibitors (SGLT2i) among patients with diabetic kidney disease (DKD).

METHODS

We searched electronic databases for major randomized placebo-controlled clinical trials published up to September 30, 2021 and reporting on cardiovascular and kidney outcomes of SGLT2i in patients with DKD. DKD was defined as chronic kidney disease in individuals with type 2 diabetes. Random-effects meta-analysis models were used to estimate pooled hazard ratios (HR) and 95% confidence intervals (CI) for clinical outcomes including major adverse cardiovascular events (MACE: myocardial infarction [MI], stroke, and cardiovascular death), kidney composite outcomes (a combination of worsening kidney function, end-stage kidney disease, or death from renal or cardiovascular causes), hospitalizations for heart failure (HHF), deaths and safety events (mycotic infections, diabetic ketoacidosis [DKA], volume depletion, amputations, fractures, urinary tract infections [UTI], acute kidney injury [AKI], and hyperkalemia).

RESULTS

A total of 26,106 participants with DKD from 8 large-scale trials were included (median age: 65.2 years, 29.7-41.8% women, 53.2-93.2% White, median follow-up: 2.5 years). SGLT2i were associated with reduced risks of MACE (HR 0.83, 95% CI 0.75-0.93), kidney composite outcomes (HR 0.66, 95% CI 0.58-0.75), HHF (HR 0.62, 95% CI 0.55-0.71), cardiovascular death (HR 0.84, 95% CI 0.74-0.96), MI (HR 0.78, 95% CI 0.67-0.92), stroke (HR 0.76, 95% CI 0.59-0.97), and all-cause death (HR 0.86, 95% CI 0.77-0.96), with no significant heterogeneity detected. Similar results were observed among participants with reduced estimated glomerular filtration rate (eGFR: < 60 mL/min/1.73m2). The relative risks (95% CI) for adverse events were 3.89 (1.42-10.62) and 2.50 (1.32-4.72) for mycotic infections in men and women respectively, 3.54 (0.82-15.39) for DKA, and 1.29 (1.13-1.48) for volume depletion.

CONCLUSIONS

Among adults with DKD, SGLT2i were associated with reduced risks of MACE, kidney outcomes, HHF, and death. With a few exceptions of more clear safety signals, we found overall limited data on the associations between SGLT2i and safety outcomes. More research is needed on the safety profile of SGLT2i in this population.

Liver-related safety assessment of green tea extracts in humans: a systematic review of randomized controlled trials

There remain liver-related safety concerns, regarding potential hepatotoxicity in humans, induced by green tea intake, despite being supposedly beneficial. Although many randomized controlled trials (RCTs) of green tea extracts have been reported in the literature, the systematic reviews published to date were only based on subjective assessment of case reports. To more objectively examine the liver-related safety of green tea intake, we conducted a systematic review of published RCTs. A systematic literature search was conducted using three databases (PubMed, EMBASE and Cochrane Central Register of Controlled Trials) in December 2013 to identify RCTs of green tea extracts. Data on liver-related adverse events, including laboratory test abnormalities, were abstracted from the identified articles. Methodological quality of RCTs was assessed. After excluding duplicates, 561 titles and abstracts and 119 full-text articles were screened, and finally 34 trials were identified. Of these, liver-related adverse events were reported in four trials; these adverse events involved seven subjects (eight events) in the green tea intervention group and one subject (one event) in the control group. The summary odds ratio, estimated using a meta-analysis method for sparse event data, for intervention compared with placebo was 2.1 (95% confidence interval: 0.5-9.8). The few events reported in both groups were elevations of liver enzymes. Most were mild, and no serious liver-related adverse events were reported. Results of this review, although not conclusive, suggest that liver-related adverse events after intake of green tea extracts are expected to be rare.

Drug safety assessment in clinical trials: methodological challenges and opportunities

Randomized controlled trials are the principal means of establishing the efficacy of drugs. However pre-marketing trials are limited in size and duration and exclude high-risk populations. They have limited statistical power to detect rare but potentially serious adverse events in real-world patients. We summarize the principal methodological challenges in the reporting, analysis and interpretation of safety data in clinical trials using recent examples from systematic reviews. These challenges include the lack of an evidentiary gold standard, the limited statistical power of randomized controlled trials and resulting type 2 error, the lack of adequate ascertainment of adverse events and limited generalizability of trials that exclude high risk patients. We discuss potential solutions to these challenges. Evaluation of drug safety requires careful examination of data from heterogeneous sources. Meta-analyses of drug safety should include appropriate statistical methods and assess the optimal information size to avoid type 2 errors. They should evaluate outcome reporting biases and missing data to ensure reliable and accurate interpretation of findings. Regulatory and academic partnerships should be fostered to provide an independent and transparent evaluation of drug safety.

Antibiotics and allergic disorders in childhood

AIM

This paper explores the possible association between antibiotics prescribed in infancy and allergic disorders, mainly eczema and asthma, in childhood.

BACKGROUND

No-one fully understands why childhood asthma and eczema have become so common. Some authorities suggest that there may be an association between eczema and asthma and antibiotics prescribed in childhood; however, others disagree. METHOD/EVALUATION: The available literature was reviewed to examine the links between prescribed antibiotics and childhood eczema and asthma. FINDINGS/KEY ISSUE: Some, but not all, research indicates that antibiotic administration in pregnancy, childbirth or infancy may be linked to childhood asthma and eczema, but much uncertainty remains. None of the papers identified stated the doses of antibiotics prescribed. In addition, we were unable to locate studies reporting the interactions between antibiotics and the developing immune system.

CONCLUSION

Health care professionals should be selective when prescribing antibiotics. Further prospective work is needed to guide the prescribing of antibiotics in childbirth and infancy.

Did knowledge, opinions, background, and health authority advice influence early prescribing of the novel Alzheimer's disease drug donepezil in general practice?--national postal survey

BACKGROUND

Donepezil was licensed in the UK in February 1997 for the treatment of Alzheimer's disease.

AIMS

To determine the advice from health authorities about prescribing Alzheimer's disease drugs. To determine whether the first general practitioners who prescribed donepezil in England differed from non-prescribers in terms of knowledge, opinions, background, and the prescribing-advice issued by their health authority.

METHODS

National postal survey of pharmaceutical advisors. Structured postal survey of all general practitioners in England who prescribed donepezil to two or more patients within the first 6 months of launch, compared with a random sample of non-prescribers.

RESULTS

Pharmaceutical advisors' survey: 75/100 pharmaceutical advisors responded, of whom 83% indicated that general practitioners should not initiate prescribing of Alzheimer's disease drugs and 63% said that they should not prescribe, even under shared care arrangements. General practitioner survey: 311/473 (66%) prescribers and 484/947 (51%) non-prescribers responded after two mailings. Prescribers were similar to non-prescribers in terms of demographic and practice characteristics, knowledge about Alzheimer's disease, diagnostic and initial management strategies, and the prescribing advice from health authorities. Prescribers were significantly more likely than non-prescribers to strongly agree/agree that new drugs should be prescribed for mild (p=0.0008) and moderate (p=0.003) Alzheimer's disease, that they should normally be initiated (p=0.003) and monitored by a general practitioner (p<0.0001), and that financial constraints should not be a consideration (p=0.0001).

CONCLUSION

Early prescribers differed from non-prescribers in their opinions about using Alzheimer's disease drugs. Future research should examine methods to promote nationally equitable and rational prescribing of new drugs.

Prescribing new drugs: qualitative study of influences on consultants and general practitioners

OBJECTIVE

To explore consultants' and general practitioners' perceptions of the factors that influence their decisions to introduce new drugs into their clinical practice.

DESIGN

Qualitative study using semistructured interviews. Monitoring of hospital and general practice prescribing data for eight new drugs.

SETTING

Teaching hospital and nearby general hospital plus general practices in Birmingham.

PARTICIPANTS

38 consultants and 56 general practitioners who regularly referred to the teaching hospital.

MAIN OUTCOME MEASURES

Reasons for prescribing a new drug; sources of information used for new drugs; extent of contact between consultants and general practitioners; and amount of study drugs used in hospitals and by general practitioners.

RESULTS

Consultants usually prescribed new drugs only in their specialty, used few new drugs, and used scientific evidence to inform their decisions. General practitioners generally prescribed more new drugs and for a wider range of conditions, but their approach varied considerably both between general practitioners and between drugs for the same general practitioner. Drug company representatives were an important source of information for general practitioners. Prescribing data were consistent with statements made by respondents.

CONCLUSIONS

The factors influencing the introduction of new drugs, particularly in primary care, are more multiple and complex than suggested by early theories of drug innovation. Early experience of using a new drug seems to strongly influence future use.

The quantity and quality of clinical practice guidelines for the management of depression in primary care in the UK

BACKGROUND

Despite research evidence that guidelines can improve patient care, concerns remain over their cost-effectiveness. This is particularly so when there is a proliferation of guidelines for the same condition. Faced with differing recommendations, users will wish to make informed decisions on which guideline to follow. In creating a guideline appraisal instrument we have assessed guidelines developed in the United Kingdom (UK) for the management of a range of disorders including depression in primary care.

AIM

To identify the number of UK clinical guidelines for the management of depression in primary care and to describe their quality and clinical content.

METHOD

A survey was undertaken to identify all depression guidelines developed in the UK between January 1991 and January 1996. All guidelines produced by national organizations and a random sample of local guidelines were appraised using a validated instrument by six assessors: a national expert in the disease area, a general practitioner, a public health physician, a hospital consultant, a nurse specializing in the disease area, and a researcher on guideline methodology. The clinical content of each guideline was then assessed by one of the researchers (RB) according to a defined framework.

RESULTS

Forty-five depression guidelines were identified. While there was a considerable range in the quality of the six national and three local guidelines appraised, at a group level their performance was similar to guidelines for other diseases. Clinical recommendations tended to reflect the joint consensus statement produced by the Royal College of General Practitioners and Royal College of Psychiatrists in 1992. The most obvious difference was in the style in which the guidelines were written and presented.

CONCLUSION

A 'national template' was the starting place for most guidelines. Steps need to be taken to ensure that these templates are based on the best possible research evidence and professional opinion. Local clinicians should concentrate on effective dissemination and implementation strategies, rather than creating new guidelines.

Fairness, public expenditure and the cost of new treatments in the UK

Current differences in standards for allocating resources in the UK for, on the one hand, drugs and surgery, and on the other, chronic community and social care and social security lead to significant inequality. Using a case study of hypothetical patients, it can be shown that adoption of new treatments, at high cost, to make marginal improvements in well-being would lead to much greater spending on some patients than on others with similar problems from different causes. Inequality occurs because society tolerates tighter constraints on community and social care and social security than on acute care and drug budgets for new treatments. Resolution of the inequality would involve establishing fairly the resources to increase the welfare of patients with different chronic diseases to some target level of welfare. However, this would make overt the current rationing of community and social services and demonstrate the low levels of welfare of many with chronic diseases. Governments concerned with lower taxation might prefer to avoid exposing such issues.

The need for pharmacoeconomic evaluations in the NHS

New medicines can be cost effective, and the under use of many therapeutic advances has been a cause for concern. Equally, the introduction of certain expensive products onto the market prematurely where adequate clinical studies have not been conducted equally represents an unsatisfactory situation. Many of these products that have reached the market 'too soon' have been for serious conditions where current treatments are inadequate and the new product represents a new hope which may or may not be realised. For some products, studies may have to take place after marketing and a condition for patients receiving treatment is that they are enrolled into a postmarketing study. Ultimately, decisions on the use of such treatments should be made after adequate clinical efficacy studies are available and independent pharmacoeconomic assessment has taken place. Decisions on the use of expensive treatments should be made nationally and not left to local health authorities desperate to balance their budgets.