Risk of thromboembolism with thrombopoietin receptor agonists in adult patients with thrombocytopenia: Systematic review and meta-analysis of randomized controlled trials / Riesgo de tromboembolismo con agonistas del receptor de la trombopoyetina en pacientes adultos con trombocitopenia: revisión sistemática y metaanálisis de ensayos clínicos aleatorizados y controlados

Background and objective: Romiplostim and eltrombopag are thrombopoietin receptor (TPOr) agonists that promote megakaryocyte differentiation, proliferation and platelet production. In 2012, a systematic review and meta-analysis reported a non-statistically significant increased risk of thromboembolic events for these drugs, but analyses were limited by lack of statistical power. Our objective was to update the 2012 meta-analysis examining whether TPOr agonists affect thromboembolism occurrence in adult thrombocytopenic patients. Materials and methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). Updated searches were conduced on PubMed, Cochrane Central, and publicly available registries (up to December 2014). RCTs using romiplostim or eltrombopag in at least one group were included. Relative risks (RR), absolute risk ratios (ARR) and number needed to harm (NNH) were estimated. Heterogeneity was analyzed using Cochran's Q test and I2 statistic. Results: Fifteen studies with 3026 adult thrombocytopenic patients were included. Estimated frequency of thromboembolism was 3.69% (95% CI: 2.95–4.61%) for TPOr agonists and 1.46% (95% CI: 0.89–2.40%) for controls. TPOr agonists were associated with a RR of thromboembolism of 1.81 (95% CI: 1.04–3.14) and an ARR of 2.10% (95% CI: 0.03–3.90%) meaning a NNH of 48. Overall, we did not find evidence of statistical heterogeneity (p = 0.43; I2 = 1.60%). Conclusions: Our updated meta-analysis suggested that TPOr agonists are associated with a higher risk of thromboemboembolic events compared with controls, and supports the current recommendations included in the European product information on this respect (AU)

Fundamento y objetivo: Los agonistas del receptor de la trombopoyetina (TPOr) (romiplostim y eltrombopag) promueven la diferenciación megacariocítica, la proliferación y la producción de plaquetas. En 2012, una revisión sistemática y metaanálisis informó de un aumento no estadísticamente significativo del riesgo tromboembólico para estos medicamentos, pero los análisis presentaban limitaciones por la falta de potencia estadística. El objetivo es actualizar el metaanálisis de 2012 examinando si los agonistas del TPOr afectan a la incidencia de tromboembolismos en los pacientes adultos con trombocitopenia. Material y métodos: Se llevó a cabo una revisión sistemática y metaanálisis de ensayos clínicos aleatorizados y controlados (ECA). Se actualizaron búsquedas llevadas a cabo en PubMed, Cochrane Central, y registros públicos (hasta Diciembre de 2014). Se incluyeron ECA en los que se administrara romiplostim o eltrombopag en al menos uno de los grupos de pacientes tratados. Se calcularon los riesgos relativos (RR), la diferencia absoluta de riesgo (ARR, por sus siglas en inglés) y el número necesario de pacientes para dañar (NNH). Se examinó la heterogeneidad estadística mediante la Q de Cochran y el estadístico I2. Resultados: Se incluyeron 15 estudios con 3026 pacientes adultos diagnosticados de trombocitopenia. Las frecuencias de acontecimientos tromboembólicos fueron de 3.69% ([intervalo de confianza] IC del 95%: 2,95–4,61%) para los agonistas del TPOr y de 1,46% (IC95%: 0,89–2,40%) para los controles. Los agonistas del TPOr se asociaron con un riesgo relativo de tromboembolismo de 1,81 (IC95%: 1,04–3,14) y una ARR del 2,10% (IC95%: 0,03–3,90%), que significa un NNH de 48. En general, no se encontró evidencia de heterogeneidad estadística (p = 0,43; I2 = 1,60%). Conclusiones: El metaanálisis actualizado sugiere que los agonistas del TPOr están asociados con un mayor riesgo de eventos thromboembólicos en comparación con los controles. Estos resultados apoyan las precauciones incluidas en la información del medicamento en la Unión Europea en relación con el riesgo tromboembólico (AU)

Risk of thromboembolism with thrombopoietin receptor agonists in adult patients with thrombocytopenia: Systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND OBJECTIVE: Romiplostim and eltrombopag are thrombopoietin receptor (TPOr) agonists that promote megakaryocyte differentiation, proliferation and platelet production. In 2012, a systematic review and meta-analysis reported a non-statistically significant increased risk of thromboembolic events for these drugs, but analyses were limited by lack of statistical power. Our objective was to update the 2012 meta-analysis examining whether TPOr agonists affect thromboembolism occurrence in adult thrombocytopenic patients. MATERIALS AND METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). Updated searches were conduced on PubMed, Cochrane Central, and publicly available registries (up to December 2014). RCTs using romiplostim or eltrombopag in at least one group were included. Relative risks (RR), absolute risk ratios (ARR) and number needed to harm (NNH) were estimated. Heterogeneity was analyzed using Cochran's Q test and I(2) statistic. RESULTS: Fifteen studies with 3026 adult thrombocytopenic patients were included. Estimated frequency of thromboembolism was 3.69% (95% CI: 2.95-4.61%) for TPOr agonists and 1.46% (95% CI: 0.89-2.40%) for controls. TPOr agonists were associated with a RR of thromboembolism of 1.81 (95% CI: 1.04-3.14) and an ARR of 2.10% (95% CI: 0.03-3.90%) meaning a NNH of 48. Overall, we did not find evidence of statistical heterogeneity (p=0.43; I(2)=1.60%). CONCLUSIONS: Our updated meta-analysis suggested that TPOr agonists are associated with a higher risk of thromboemboembolic events compared with controls, and supports the current recommendations included in the European product information on this respect.

[Risks of dual blockade of the renin-angiotensin system compared with monotherapy: a systematic review and cumulative meta-analysis of randomized trials and observational studies]. / Bloqueo dual del sistema renina-angiotensina frente a la monoterapia: revisión sistemática y metaanálisis acumulativo de ensayos clínicos y estudios observacionales.

BACKGROUND: Previous work has suggested that dual blockade using inhibitors of the renin-angiotensin system (RAS) would be associated with an increase in side effects compared to monotherapy. We reexamined the safety of dual RAS blockade, especially in patients at risk, and explored the stability of the evidence accumulated over the years. METHOD: Systematic review with random-effects meta-analyses. We reviewed 15 previously published meta-analyses as the starting point. PubMed/Medline was searched for recent evidence from both observational and randomized controlled trials. Outcomes measures were: mortality (overall and cardiovascular), hyperkalemia, hypotension, renal failure, stroke, and treatment withdrawal due to adverse effects. We calculated relative risks (RR) and confidence intervals (95% CI) RESULTS: Dual RAS blockade was not associated with reduced relative risk (RR) overall mortality (RR:1.00, 0.96-1.05; 21 studies), cardiovascular mortality (RR:1.01, 0.94-1.09; 13 studies) or stroke (RR:1.02; 0.94-1.11; 11 studies) compared to monotherapy. Dual blockade was associated with an increased risk of hyperkalemia (RR:1.58, 1.37-1.81; 34 studies), hypotension (RR:1.66; 1.41-1.95; 25 studies), renal failure (RR:1.52;1.28-1.81; 29 studies) and treatment discontinuation due to adverse events (RR:1.26;1.22-1.30; 37 studies). These results were consistent in cohorts of patients with diabetes mellitus, kidney disease or heart failure. CONCLUSIONS: Dual RAS blockade increased (vs monotherapy) the risks of hyperkalemia, hypotension, renal failure and treatment discontinuation. Dual RAS blockade did not offer additional benefit in reducing overall mortality, cardiovascular mortality or stroke. These findings are consistent over time.

Bloqueo dual del sistema renina-angiotensina frente a la monoterapia: revisión sistemática y metaanálisis acumulativo de ensayos clínicos y estudios observacionales / Risks of dual blockade of the renin-angiotensin system compared with, mnotherapy: a systematic review and cumulative meta-analysis of randomized trials and observational studies

Fundamentos: Trabajos previos han sugerido que el bloqueo dual con inhibidores del sistema renina-angiotensina (SRA) estaría asociado a un incremento de efectos adversos comparado con la monoterapia. Se reexamina la seguridad del doble bloqueo del SRA, especialmente en pacientes de riesgo y se explora la estabilidad de la evidencia acumulada a lo largo de los años. Método: Revisión sistemática con metaanálisis de efectos aleatorios. Se revisaron 15 metaanálisis publicados anteriormente como punto de partida. Se realizó una búsqueda en PubMed/Medline de estudios observacionales y de ensayos clínicos controlados recientes. Las variables dependientes estudiadas fueron: mortalidad (general y cardiovascular), hiperpotasemia, hipotensión, insuficiencia renal, accidente cerebrovascular y la retirada del tratamiento por efectos adversos. Se calcularon los riesgos relativos (RR) y su intervalo de confianza (IC95%) Resultados: El bloqueo dual del SRA no se asoció con una reducción del RR de la mortalidad general (RR:1,00; IC95%: 0,96-1,05; 21 estudios), ni de la mortalidad cardiovascular (RR:1,01; 0,94-1,09; 13 estudios) ni del riesgo de accidente cerebrovascular (RR:1,02; 0,94-1,11; 11 estudios) en comparación con la monoterapia. El bloqueo dual se asoció a un riesgo aumentado de hiperpotasemia (RR:1,58; 1,37-1,81; 34 estudios), hipotensión (RR:1,66; 1,41-1,95; 25 estudios), daño renal (1,52; 1,28-1,81; 29 estudios) y retirada del tratamiento por efectos adversos (RR:1,26; 1,22-1,30; 37 estudios). Los resultados fueron consistentes en las cohortes de pacientes con diabetes mellitus, enfermedad renal o insuficiencia cardiaca. Conclusiones: El bloqueo dual del SRA vs monoterapia incrementa los riesgos de hiperpotasemia, hipotensión, insuficiencia renal e interrupción del tratamiento por efectos adversos. Además no ofrece beneficios adicionales por reducción de la mortalidad general, mortalidad cardiovascular o accidente cerebrovascular. Estos hallazgos son consistentes a lo largo del tiempo (AU)

Background: Previous work has suggested that dual blockade using inhibitors of the renin-angiotensin system (RAS) would be associated with an increase in side effects compared to monotherapy. We reexamined the safety of dual RAS blockade, especially in patients at risk, and explored the stability of the evidence accumulated over the years. Method: Systematic review with random-effects meta-analyses. We reviewed 15 previously published meta-analyses as the starting point. PubMed/Medline was searched for recent evidence from both observational and randomized controlled trials. Outcomes measures were: mortality (overall and cardiovascular), hyperkalemia, hypotension, renal failure, stroke, and treatment withdrawal due to adverse effects. We calculated relative risks (RR) and confidence intervals (95% CI) Results:Dual RAS blockade was not associated with reduced relative risk (RR) overall mortality (RR:1.00, 0.96-1.05; 21 studies), cardiovascular mortality (RR:1.01, 0.94-1.09; 13 studies) or stroke (RR:1.02; 0.94-1.11; 11 studies) compared to monotherapy. Dual blockade was associated with an increased risk of hyperkalemia (RR:1.58, 1.37-1.81; 34 studies), hypotension (RR:1.66; 1.41-1.95; 25 studies), renal failure (RR:1.52;1.28-1.81; 29 studies) and treatment discontinuation due to adverse events (RR:1.26;1.22-1.30; 37 studies). These results were consistent in cohorts of patients with diabetes mellitus, kidney disease or heart failure. Conclusions: Dual RAS blockade increased (vs monotherapy) the risks of hyperkalemia, hypotension, renal failure and treatment discontinuation. Dual RAS blockade did not offer additional benefit in reducing overall mortality, cardiovascular mortality or stroke. These findings are consistent over time (AU)

Riesgo tromboembólico con agonistas del receptor de la trombopoyetina en pacientes adultos con trombocitopenia: revisión sistemática y metaanálisis de ensayos clínicos aleatorizados y controlados / Risk of thromboembolism with thrombopoietin receptor agonists in adult patients with thrombocytopenia: systematic review and meta-analysis of randomized controlled trials

Fundamento y objetivo: Los agonistas del receptor de trombopoyetina (TPOr) (romiplostim y eltrombopag) son un nuevo enfoque para el tratamiento de la trombocitopenia asociada a algunas enfermedades. Los agonistas del TPOr promueven la diferenciación megacariocítica, la proliferación y la producción de plaquetas. En la Unión Europea, han sido autorizados como medicamentos huérfanos, con una indicación restringida a los pacientes esplenectomizados con púrpura trombocitopénica inmune que son refractarios a otros tratamientos. Debido al incremento de los recuentos de plaquetas, estos fármacos pueden representar un riesgo de tromboembolias. Se analiza si los agonistas del TPOr afectan a la incidencia de acontecimientos tromboembólicos en pacientes adultos con trombocitopenia. Material y métodos: Revisión sistemática y meta-análisis de ensayos clínicos aleatorizados y controlados (ECA). Se realizó una búsqueda en PubMed, SCOPUS, Cochrane Central Register, web de las agencias reguladoras y registros de acceso público (p.ej, gubernamentales y de los fabricantes). Se incluyeron ECA en los que se administrara romiplostim o eltrombopag en al menos uno de los grupos de pacientes tratados. Se calcularon la reducción absoluta de riesgo (RAR), el número necesario de pacientes a dañar (NNH) y el riesgo relativo (RR). Se examinó la heterogenidad mediante la Q de Cochrane y el estadístico I2. Resultados: De las 373 publicaciones identificadas, 8 estudios cumplieron los criterios de inclusión (n=1.180 pacientes). Se encontraron variaciones en la calidad de la información entre estudios. Las frecuencias de acontecimientos tromboembólicos fueron de 3,1% [intervalo de confianza (IC) del 95% = 1,8-4,4%] para los agonistas del TPOr y de 1,7% (IC95% = 0,3-3,1%) para el grupo control (AU)

Background and objective: Thrombopoietin receptor (TPOr) agonists (romiplostim and eltrombopag) are a new approach for the treatment of thrombocytopenia-associated conditions. They promote megakaryocyte differentiation, proliferation and platelet production. In the European Union, both are orphan drugs with an indication restricted to splenectomized immune thrombocytopenic purpura patients who are refractory to other treatments. Due to increasing platelet counts, these drugs may represent a risk for thromboembolic complications. We analyzed whether TPOr agonists affect thromboembolisms occurrence in adult thrombocytopenic patients. Materials and methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). Searches were carried out in PubMed, SCOPUS, Cochrane Central Register, regulatory agencies websites and publicly available registries of manufacturers. RCTs using romiplostim or eltrombopag in at least one group were included. Absolute risk ratios (ARR), number needed to harm (NNH) and relative risks (RR) were provided. Heterogeneity was analyzed using Cochran's Q test and I2 statistic. Results: Of 373 publications identified, 8 studies met the inclusion criteria (n=1180 patients). The quality of reporting amongst studies was variable. Estimated frequency of thromboembolisms was 3.1% (95% CI, 1.8-4.4%) for TPOr agonists and 1.7% (95% CI, 0.3-3.1%) for controls. Summary analyses produced overall meta-ARR for thromboembolisms of 1.8% (95% CI, −0.1-3.6%), and meta-RR of 1.5 (95% CI, 0.7-3.3), meaning a NNH of 55 (1 additional thromboembolism for each 55 patients treated with TPOr agonists). All pooled estimates were homogeneous (AU)

Uso de olmesartán en la prevención o retraso de la nefropatía diabética: algunas consideraciones / Olmesartan for the prevention or delay of diabetic nephropathy: some considerations

No disponible

Risk of thromboembolism with thrombopoietin receptor agonists in adult patients with thrombocytopenia: systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND OBJECTIVE: Thrombopoietin receptor (TPOr) agonists (romiplostim and eltrombopag) are a new approach for the treatment of thrombocytopenia-associated conditions. They promote megakaryocyte differentiation, proliferation and platelet production. In the European Union, both are orphan drugs with an indication restricted to splenectomized immune thrombocytopenic purpura patients who are refractory to other treatments. Due to increasing platelet counts, these drugs may represent a risk for thromboembolic complications. We analyzed whether TPOr agonists affect thromboembolisms occurrence in adult thrombocytopenic patients. MATERIALS AND METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). Searches were carried out in PubMed, SCOPUS, Cochrane Central Register, regulatory agencies websites and publicly available registries of manufacturers. RCTs using romiplostim or eltrombopag in at least one group were included. Absolute risk ratios (ARR), number needed to harm (NNH) and relative risks (RR) were provided. Heterogeneity was analyzed using Cochran's Q test and I(2) statistic. RESULTS: Of 373 publications identified, 8 studies met the inclusion criteria (n=1180 patients). The quality of reporting amongst studies was variable. Estimated frequency of thromboembolisms was 3.1% (95% CI, 1.8-4.4%) for TPOr agonists and 1.7% (95% CI, 0.3-3.1%) for controls. Summary analyses produced overall meta-ARR for thromboembolisms of 1.8% (95% CI, -0.1-3.6%), and meta-RR of 1.5 (95% CI, 0.7-3.3), meaning a NNH of 55 (1 additional thromboembolism for each 55 patients treated with TPOr agonists). All pooled estimates were homogeneous. CONCLUSIONS: TPOr agonists show a numerically but non-statistically significant trend to increase the occurrence of thromboembolisms compared to controls, but analyses were underpowered and in some studies information on outcomes was incomplete and of poor quality.

Estudio de la utilización de ticlopidina en oficinas de farmacia de España / Ticlopidine use in Spain: a pharmacy-based drug utilization study

Fundamento: En 1997 se puso en marcha un programa dirigido a los prescriptores a fin de mejorar la utilización de ticlopidina. Se analiza si se alcanzó dicho objetivo. Pacientes y métodos: Se realizó un estudio de corte transversal en oficinas de farmacia. Resultados: De los 346 pacientes entrevistados, el 56 por ciento presentaban una indicación de ticlopidina que no se encontraba entre las especificaciones de la ficha técnica, el 23 por ciento utilizaban dosis diferentes de las recomendadas y sólo el 28 por ciento se realizaron todos los análisis quincenales correspondientes. Conclusiones: El uso de ticlopidina en España no es coherente con la ficha técnica, y el programa diseñado para mejorarlo no ha dado resultados satisfactorios (AU)