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Pokharel G, Deardon R, Johnson SR, Tomlinson G, Hull PM, Hazlewood GS. Effectiveness of initial methotrexate-based treatment approaches in early rheumatoid arthritis: an elicitation of rheumatologists' beliefs. Rheumatology (Oxford) 2021; 60:3570-3578. [PMID: 33367919 DOI: 10.1093/rheumatology/keaa803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/12/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To quantify rheumatologists' beliefs about the effectiveness of triple therapy (MTX + HCQ + SSZ) and other commonly used initial treatments for RA. METHODS In a Bayesian belief elicitation exercise, 40 rheumatologists distributed 20 chips, each representing 5% of their total weight of belief on the probability that a typical patient with moderate-severe early RA would have an ACR50 response within 6 months with MTX (oral and s.c.), MTX + HCQ (dual therapy) and triple therapy. Parametric distributions were fit, and used to calculate pairwise median relative risks (RR), with 95% credible intervals, and estimate sample sizes for new trials to shift these beliefs. RESULTS In the pooled analysis, triple therapy was perceived to be superior to MTX (RR 1.97; 1.35, 2.89) and dual therapy (RR 1.32; 1.03, 1.73). A pessimistic subgroup (n = 10) perceived all treatments to be similar, whereas an optimistic subgroup (n = 10) believed triple therapy to be most effective of all (RR 4.03; 2.22, 10.12). Similar variability was seen for the comparison between oral and s.c. MTX. Assuming triple therapy is truly more effective than MTX, a trial of 100 patients would be required to convince the pessimists; if triple therapy truly has no-modest effect (RR <1.5), a non-inferiority trial of 475 patients would be required to convince the optimists. CONCLUSION Rheumatologists' beliefs regarding the effectiveness of triple therapy vary, which may partially explain the variability in its use. Owing to the strength of beliefs, some may be reluctant to shift, even with new evidence.
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Affiliation(s)
- Gyanendra Pokharel
- Department of Mathematics and Statistics, Faculty of Science, University of Winnipeg, Winnipeg, Canada
| | - Rob Deardon
- Departments of Mathematics and Statistics and Production Animal Health, Faculties of Science and Veterinary Medicine, University of Calgary, Calgary, Canada
| | - Sindhu R Johnson
- Division of Rheumatology, Toronto Western Hospital, Mount Sinai Hospital, Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Pauline M Hull
- Department of Community Health Sciences, Calgary, Canada
| | - Glen S Hazlewood
- Department of Community Health Sciences, Calgary, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Lin J, Lin J. Incorporating propensity scores for evidence synthesis under bayesian framework: review and recommendations for clinical studies. J Biopharm Stat 2021; 32:53-74. [PMID: 33998364 DOI: 10.1080/10543406.2021.1882481] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The amount of real-world data (RWD) available from sources other than randomized-controlled trials (RCTs) has grown ultra-rapidly in recent years. It provides the impetus for generating substantial evidence of effectiveness and safety from both RCTs and RWD to accelerate medical product development. Especially in the areas of unmet needs, the conduct of fully powered RCTs is generally infeasible because of their sizes, duration, cost, or ethical constraints. The unique challenges in such areas include a small patient population, heterogeneity in disease presentation, and a lack of established endpoints. However, merging information from disparate sources is an intricate task. The value of the Bayesian framework has gained more recognition due to its flexibility in calibrating uncertainty and handling data heterogeneity, and its inherent updating process ideal for synthesizing information. Meanwhile, propensity score, as a powerful tool in causal inference, can be used in various ways to adjust for confounders. As a newly emerging data borrowing strategy in a regulatory setting, integrating propensity scores in a Bayesian setting not only utilizes the strengths from Bayesian models but also minimizes bias from external data borrowing. These methods potentially allow information sharing among data sources, provide more reliable estimates when the sample size is small, and improve the efficiency of treatment effect estimation. In this paper, we will review the recent development of methods incorporating propensity score for evidence synthesis under the Bayesian framework, and discuss different examples of incorporating external data with or without RCTs, as well as the recommendations for reporting in clinical studies.
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Affiliation(s)
- Junjing Lin
- Statistical and Quantitative Sciences, Takeda Pharmaceutical Co Ltd, Cambridge, United States
| | - Jianchang Lin
- Statistical and Quantitative Sciences, Takeda Pharmaceutical Co Ltd, Cambridge, United States
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Prior Elicitation for Use in Clinical Trial Design and Analysis: A Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041833. [PMID: 33668623 PMCID: PMC7917693 DOI: 10.3390/ijerph18041833] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/01/2021] [Accepted: 02/09/2021] [Indexed: 11/16/2022]
Abstract
Bayesian inference is increasingly popular in clinical trial design and analysis. The subjective knowledge derived from an expert elicitation procedure may be useful to define a prior probability distribution when no or limited data is available. This work aims to investigate the state-of-the-art Bayesian prior elicitation methods with a focus on clinical trial research. A literature search on the Current Index to Statistics (CIS), PubMed, and Web of Science (WOS) databases, considering “prior elicitation” as a search string, was run on 1 November 2020. Summary statistics and trend of publications over time were reported. Finally, a Latent Dirichlet Allocation (LDA) model was developed to recognise latent topics in the pertinent papers retrieved. A total of 460 documents pertinent to the Bayesian prior elicitation were identified. Of these, 213 (45.4%) were published in the “Probability and Statistics” area. A total of 42 articles pertain to clinical trial and the majority of them (81%) reports parametric techniques as elicitation method. The last decade has seen an increased interest in prior elicitation and the gap between theory and application getting narrower and narrower. Given the promising flexibility of non-parametric approaches to the experts’ elicitation, more efforts are needed to ensure their diffusion also in applied settings.
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Chrysohoou C, Magkas N, Antoniou CK, Manolakou P, Laina A, Tousoulis D. The Role of Antithrombotic Therapy in Heart Failure. Curr Pharm Des 2020; 26:2735-2761. [PMID: 32473621 DOI: 10.2174/1381612826666200531151823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022]
Abstract
Heart failure is a major contributor to global morbidity and mortality burden affecting approximately 1-2% of adults in developed countries, mounting to over 10% in individuals aged >70 years old. Heart failure is characterized by a prothrombotic state and increased rates of stroke and thromboembolism have been reported in heart failure patients compared with the general population. However, the impact of antithrombotic therapy on heart failure remains controversial. Administration of antiplatelet or anticoagulant therapy is the obvious (and well-established) choice in heart failure patients with cardiovascular comorbidity that necessitates their use, such as coronary artery disease or atrial fibrillation. In contrast, antithrombotic therapy has not demonstrated any clear benefit when administered for heart failure per se, i.e. with heart failure being the sole indication. Randomized studies have reported decreased stroke rates with warfarin use in patients with heart failure with reduced left ventricular ejection fraction, but at the expense of excessive bleeding. Non-vitamin K oral anticoagulants have shown a better safety profile in heart failure patients with atrial fibrillation compared with warfarin, however, current evidence about their role in heart failure with sinus rhythm is inconclusive and further research is needed. In the present review, we discuss the role of antithrombotic therapy in heart failure (beyond coronary artery disease), aiming to summarize evidence regarding the thrombotic risk and the role of antiplatelet and anticoagulant agents in patients with heart failure.
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Affiliation(s)
- Christina Chrysohoou
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Nikolaos Magkas
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | | | - Panagiota Manolakou
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Aggeliki Laina
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
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Gamalo-Siebers M, Hampson L, Kordy K, Weber S, Nelson RM, Portman R. Incorporating Innovative Techniques Toward Extrapolation and Efficient Pediatric Drug Development. Ther Innov Regul Sci 2019; 53:567-578. [DOI: 10.1177/2168479019842541] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Distler JHW, Feghali-Bostwick C, Soare A, Asano Y, Distler O, Abraham DJ. Review: Frontiers of Antifibrotic Therapy in Systemic Sclerosis. Arthritis Rheumatol 2019; 69:257-267. [PMID: 27636741 DOI: 10.1002/art.39865] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/30/2016] [Indexed: 12/15/2022]
Affiliation(s)
| | | | - Alina Soare
- University of Erlangen-Nuremberg, Erlangen, Germany
| | - Yoshihide Asano
- University of Tokyo Graduate School of Medicine, Tokyo, Japan
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Johnson SR, Tomlinson GA, Granton JT, Hawker GA, Feldman BM. Applied Bayesian Methods in the Rheumatic Diseases. Rheum Dis Clin North Am 2018; 44:361-370. [PMID: 29622302 DOI: 10.1016/j.rdc.2018.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The use of applied Bayesian methods is increasing in rheumatology. Using the Bayes theorem, past evidence is updated with new data. Preexisting data are expressed as a prior probability distribution or prior. New observations are expressed as a likelihood. Through explicit incorporation of preexisting data and new data, this process informs how this new information should change the way we think. In this article, the authors highlight the use of applied Bayesian methods in the study of rheumatic diseases.
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Affiliation(s)
- Sindhu R Johnson
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Mount Sinai Hospital, 155 College Street, Toronto, Ontario M5T 3M6, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.
| | - George A Tomlinson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7, Canada; Department of Medicine, Division of Support Systems and Outcomes, Toronto General Hospital Research Institute, University Health Network, Mount Sinai Hospital, Eaton North, 13th Floor, Room 238, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - John T Granton
- Division of Respirology, Department of Medicine, Toronto General Hospital, University Health Network, MUNK Building, 11-1170, 200 Elizabeth Avenue, Toronto, Ontario M5G 2C4, Canada; Division of Critical Care Medicine, Department of Medicine, Toronto General Hospital, University Health Network, MUNK Building, 11-1170, 200 Elizabeth Avenue, Toronto, Ontario M5G 2C4, Canada
| | - Gillian A Hawker
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Rheumatology, Department of Medicine, Women's College Hospital, 76 Grenville Street, 8th Floor East, Room 815, Toronto, Ontario M5S 1B2, Canada
| | - Brian M Feldman
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Division of Rheumatology, Department of Paediatrics, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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8
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Propensity Score Methods for Bias Reduction in Observational Studies of Treatment Effect. Rheum Dis Clin North Am 2018; 44:203-213. [DOI: 10.1016/j.rdc.2018.01.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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9
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Hincapié CA, Cassidy JD, Côté P, Rampersaud YR, Jadad AR, Tomlinson GA. Chiropractic spinal manipulation and the risk for acute lumbar disc herniation: a belief elicitation study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1517-1525. [DOI: 10.1007/s00586-017-5295-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 09/04/2017] [Indexed: 12/29/2022]
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Calderone A, Stevens W, Prior D, Nandurkar H, Gabbay E, Proudman SM, Williams T, Celermajer D, Sahhar J, Wong PKK, Thakkar V, Dwyer N, Wrobel J, Chin W, Liew D, Staples M, Buchbinder R, Nikpour M. Multicentre randomised placebo-controlled trial of oral anticoagulation with apixaban in systemic sclerosis-related pulmonary arterial hypertension: the SPHInX study protocol. BMJ Open 2016; 6:e011028. [PMID: 27932335 PMCID: PMC5168661 DOI: 10.1136/bmjopen-2016-011028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a severe and costly multiorgan autoimmune connective tissue disease characterised by vasculopathy and fibrosis. One of the major causes of SSc-related death is pulmonary arterial hypertension (PAH), which develops in 12-15% of patients with SSc and accounts for 30-40% of deaths. In situ thrombosis in the small calibre peripheral pulmonary vessels resulting from endothelial dysfunction and an imbalance of anticoagulant and prothrombotic mediators has been implicated in the complex pathophysiology of SSc-related PAH (SSc-PAH), with international clinical guidelines recommending the use of anticoagulants for some types of PAH, such as idiopathic PAH. However, anticoagulation has not become part of standard clinical care for patients with SSc-PAH as only observational evidence exists to support its use. Therefore, we present the rationale and methodology of a phase III randomised controlled trial (RCT) to evaluate the efficacy, safety and cost-effectiveness of anticoagulation in SSc-PAH. METHODS AND ANALYSIS This Australian multicentre RCT will compare 2.5 mg apixaban with placebo, in parallel treatment groups randomised in a 1:1 ratio, both administered twice daily for 3 years as adjunct therapy to stable oral PAH therapy. The composite primary outcome measure will be the time to death or clinical worsening of PAH. Secondary outcomes will include functional capacity, health-related quality of life measures and adverse events. A cost-effectiveness analysis of anticoagulation versus placebo will also be undertaken. ETHICS AND DISSEMINATION Ethical approval for this RCT has been granted by the Human Research Ethics Committees of all participating centres. An independent data safety monitoring board will review safety and tolerability data for the duration of the trial. The findings of this RCT are to be published in open access journals. TRIAL REGISTRATION NUMBER ACTRN12614000418673, Pre-results.
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Affiliation(s)
- Alicia Calderone
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - David Prior
- Department of Cardiology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- The University of Melbourne Department of Medicine at St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Harshal Nandurkar
- The University of Melbourne Department of Medicine at St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Eli Gabbay
- The University of Notre Dame, Fremantle, Western Australia, Australia
- Institute for Respiratory Health, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Susanna M Proudman
- Department of Rheumatology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia
- University of Adelaide Discipline of Medicine at Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia
| | - Trevor Williams
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Monash University, Prahran, Victoria, Australia
| | - David Celermajer
- Department of Cardiology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Joanne Sahhar
- Department of Rheumatology, Monash Health and Monash University, Clayton, Victoria, Australia
| | - Peter K K Wong
- Mid-North Coast Arthritis Clinic, Coffs Harbour, New South Wales, Australia
- Faculty of Medicine, Rural Clinical School, University of New South Wales, Coffs Harbour, New South Wales, Australia
| | - Vivek Thakkar
- Department of Rheumatology, Liverpool Hospital, Liverpool, New South Wales, Australia
- School of Medicine, University of Western Sydney, Penrith, New South Wales, Australia
| | - Nathan Dwyer
- Department of Cardiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Jeremy Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Weng Chin
- Institute for Respiratory Health, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
| | - Margaret Staples
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Cabrini Health, Suite 41 Cabrini Medical Centre, Malvern, Victoria, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Cabrini Health, Suite 41 Cabrini Medical Centre, Malvern, Victoria, Australia
| | - Mandana Nikpour
- Department of Rheumatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- The University of Melbourne Department of Medicine at St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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Abrahamyan L, Feldman BM, Tomlinson G, Faughnan ME, Johnson SR, Diamond IR, Gupta S. Alternative designs for clinical trials in rare diseases. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2016; 172:313-331. [PMID: 27862920 DOI: 10.1002/ajmg.c.31533] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Evidence-based medicine requires strong scientific evidence upon which to base treatment. In rare diseases, study populations are often small, and thus this evidence is difficult to accrue. Investigators, though, should be creative and develop a flexible toolkit of methods to deal with the problems inherent in the study of rare disease. This narrative review presents alternative clinical trial designs for studying treatments of rare diseases, including cross-over and n-of-1 trials, randomized placebo-phase design, enriched enrollment, randomized withdrawal design, and classes of adaptive designs. Examples of applications of these designs are presented along with their advantages and disadvantages. Additional analytical considerations such as Bayesian analysis, internal pilots, and use of biomarkers as surrogate outcomes are further discussed. A framework for selecting appropriate clinical trial design is proposed to guide investigators in the process of selecting alternative designs for rare diseases. © 2016 Wiley Periodicals, Inc.
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Spagnolo P, Cordier JF, Cottin V. Connective tissue diseases, multimorbidity and the ageing lung. Eur Respir J 2016; 47:1535-58. [PMID: 26917611 DOI: 10.1183/13993003.00829-2015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 01/23/2016] [Indexed: 12/14/2022]
Abstract
Connective tissue diseases encompass a wide range of heterogeneous disorders characterised by immune-mediated chronic inflammation often leading to tissue damage, collagen deposition and possible loss of function of the target organ. Lung involvement is a common complication of connective tissue diseases. Depending on the underlying disease, various thoracic compartments can be involved but interstitial lung disease is a major contributor to morbidity and mortality. Interstitial lung disease, pulmonary hypertension or both are found most commonly in systemic sclerosis. In the elderly, the prevalence of connective tissue diseases continues to rise due to both longer life expectancy and more effective and better-tolerated treatments. In the geriatric population, connective tissue diseases are almost invariably accompanied by age-related comorbidities, and disease- and treatment-related complications, which contribute to the significant morbidity and mortality associated with these conditions, and complicate treatment decision-making. Connective tissue diseases in the elderly represent a growing concern for healthcare providers and an increasing burden of global health resources worldwide. A better understanding of the mechanisms involved in the regulation of the immune functions in the elderly and evidence-based guidelines specifically designed for this patient population are instrumental to improving the management of connective tissue diseases in elderly patients.
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Affiliation(s)
- Paolo Spagnolo
- Medical University Clinic, Canton Hospital Baselland, and University of Basel, Liestal, Switzerland
| | - Jean-François Cordier
- Hospices Civils de Lyon, Hôpital Louis Pradel, National Reference Center for Rare Pulmonary Diseases, Lyon, France Claude Bernard Lyon 1 University, University of Lyon, Lyon, France
| | - Vincent Cottin
- Hospices Civils de Lyon, Hôpital Louis Pradel, National Reference Center for Rare Pulmonary Diseases, Lyon, France Claude Bernard Lyon 1 University, University of Lyon, Lyon, France INRA, UMR754, Lyon, France
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Preston IR, Roberts KE, Miller DP, Sen GP, Selej M, Benton WW, Hill NS, Farber HW. Effect of Warfarin Treatment on Survival of Patients With Pulmonary Arterial Hypertension (PAH) in the Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL). Circulation 2015; 132:2403-11. [PMID: 26510696 PMCID: PMC4689180 DOI: 10.1161/circulationaha.115.018435] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 09/25/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Long-term anticoagulation is recommended in idiopathic pulmonary arterial hypertension (IPAH). In contrast, limited data support anticoagulation in pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SSc-PAH). We assessed the effect of warfarin anticoagulation on survival in IPAH and SSc-PAH patients enrolled in Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL), a longitudinal registry of group I PAH. METHODS AND RESULTS Patients who initiated warfarin on study (n=187) were matched 1:1 with patients never on warfarin, by enrollment site, etiology, and diagnosis status. Descriptive analyses were conducted to compare warfarin users and nonusers by etiology. Survival analyses with and without risk adjustment were performed from the time of warfarin initiation or a corresponding quarterly update in matched pairs to avoid immortal time bias. Time-varying covariate models were used as sensitivity analyses. Mean warfarin treatment was 1 year; mean international normalized ratios were 1.9 (IPAH) and 2.0 (SSc-PAH). Two-thirds of patients initiating warfarin discontinued treatment before the last study assessment. There was no survival difference with warfarin in IPAH patients (adjusted hazard ratio, 1.37; P=0.21) or in SSc-PAH patients (adjusted hazard ratio, 1.60; P=0.15) in comparison with matched controls. However, SSc-PAH patients receiving warfarin within the previous year (hazard ratio, 1.57; P=0.031) or any time postbaseline (hazard ratio, 1.49; P=0.046) had increased mortality in comparison with warfarin-naïve patients. CONCLUSIONS No significant survival advantage was observed in IPAH patients who started warfarin. In SSc-PAH patients, long-term warfarin was associated with poorer survival than in patients not receiving warfarin, even after adjusting for confounders. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00370214.
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Affiliation(s)
- Ioana R Preston
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Kari E Roberts
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Dave P Miller
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Ginny P Sen
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Mona Selej
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Wade W Benton
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Nicholas S Hill
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.)
| | - Harrison W Farber
- From Tufts University School of Medicine, Boston, MA (I.R.P., K.E.R., N.S.H.); ICON Clinical Research, San Francisco, CA (D.P.M., G.P.S.); Actelion Pharmaceuticals US Inc., South San Francisco, CA (M.S., W.W.B.); and Boston University School of Medicine, Boston, MA (H.W.F.).
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Anticoagulation in patients with pulmonary arterial hypertension: An update on current knowledge. J Heart Lung Transplant 2015; 35:151-64. [PMID: 26527532 DOI: 10.1016/j.healun.2015.10.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 09/05/2015] [Accepted: 10/01/2015] [Indexed: 11/23/2022] Open
Abstract
Pulmonary hypertension is a severe clinical condition characterized by molecular and anatomic changes in pulmonary circulation. It is associated with increased pulmonary vascular resistance, which leads to right-sided heart failure if left untreated and, ultimately, death. Treatment of patients with pulmonary arterial hypertension (PAH) involves a complex strategy that takes into consideration disease severity, general and supportive measures, and combination drug regimens. Abnormalities of blood coagulation factors, anti-thrombotic factors, and the fibrinolytic system may contribute to a prothrombotic state in patients with idiopathic PAH. These physiologic changes, in concert with the presence of non-specific risk factors for venous thromboembolism such as heart failure and immobility, are thought to be the basis for oral anticoagulation in PAH. Several observational studies provide helpful information in favor of anticoagulation use in idiopathic PAH but not in other pulmonary hypertension etiologies. Guideline recommendations are based on the lack of prospective comparative trials in this regard. For that reason, large differences exist in the use of anticoagulants in different countries and centers. More studies should be carried out to clarify the risks and the potential benefits of anticoagulant use in a heterogeneous population of patients who are already at considerable life risk.
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Elicitation of expert prior opinion: application to the MYPAN trial in childhood polyarteritis nodosa. PLoS One 2015; 10:e0120981. [PMID: 25822991 PMCID: PMC4378846 DOI: 10.1371/journal.pone.0120981] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 02/09/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Definitive sample sizes for clinical trials in rare diseases are usually infeasible. Bayesian methodology can be used to maximise what is learnt from clinical trials in these circumstances. We elicited expert prior opinion for a future Bayesian randomised controlled trial for a rare inflammatory paediatric disease, polyarteritis nodosa (MYPAN, Mycophenolate mofetil for polyarteritis nodosa). METHODS A Bayesian prior elicitation meeting was convened. Opinion was sought on the probability that a patient in the MYPAN trial treated with cyclophosphamide would achieve disease remission within 6-months, and on the relative efficacies of mycophenolate mofetil and cyclophosphamide. Expert opinion was combined with previously unseen data from a recently completed randomised controlled trial in ANCA associated vasculitis. RESULTS A pan-European group of fifteen experts participated in the elicitation meeting. Consensus expert prior opinion was that the most likely rates of disease remission within 6 months on cyclophosphamide or mycophenolate mofetil were 74% and 71%, respectively. This prior opinion will now be taken forward and will be modified to formulate a Bayesian posterior opinion once the MYPAN trial data from 40 patients randomised 1:1 to either CYC or MMF become available. CONCLUSIONS We suggest that the methodological template we propose could be applied to trial design for other rare diseases.
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Hampson LV, Whitehead J, Eleftheriou D, Brogan P. Bayesian methods for the design and interpretation of clinical trials in very rare diseases. Stat Med 2014; 33:4186-201. [PMID: 24957522 PMCID: PMC4260127 DOI: 10.1002/sim.6225] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 04/07/2014] [Accepted: 05/17/2014] [Indexed: 11/29/2022]
Abstract
This paper considers the design and interpretation of clinical trials comparing treatments for conditions so rare that worldwide recruitment efforts are likely to yield total sample sizes of 50 or fewer, even when patients are recruited over several years. For such studies, the sample size needed to meet a conventional frequentist power requirement is clearly infeasible. Rather, the expectation of any such trial has to be limited to the generation of an improved understanding of treatment options. We propose a Bayesian approach for the conduct of rare-disease trials comparing an experimental treatment with a control where patient responses are classified as a success or failure. A systematic elicitation from clinicians of their beliefs concerning treatment efficacy is used to establish Bayesian priors for unknown model parameters. The process of determining the prior is described, including the possibility of formally considering results from related trials. As sample sizes are small, it is possible to compute all possible posterior distributions of the two success rates. A number of allocation ratios between the two treatment groups can be considered with a view to maximising the prior probability that the trial concludes recommending the new treatment when in fact it is non-inferior to control. Consideration of the extent to which opinion can be changed, even by data from the best feasible design, can help to determine whether such a trial is worthwhile.
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Affiliation(s)
- Lisa V Hampson
- Medical and Pharmaceutical Statistics Research Unit, Department of Mathematics and Statistics, Lancaster UniversityLancaster, LA1 4YF, U.K.
| | - John Whitehead
- Medical and Pharmaceutical Statistics Research Unit, Department of Mathematics and Statistics, Lancaster UniversityLancaster, LA1 4YF, U.K.
| | - Despina Eleftheriou
- Department of Paediatric Rheumatology, UCL Institute of Child Health30 Guilford Street, London WC1N 1EH, U.K.
| | - Paul Brogan
- Department of Paediatric Rheumatology, UCL Institute of Child Health30 Guilford Street, London WC1N 1EH, U.K.
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Abstract
Adverse drug events (ADEs) are an important public health concern, accounting for 5% of all hospital admissions and two-thirds of all complications occurring shortly after hospital discharge. There are often long delays between when a drug is approved and when serious ADEs are identified. Recent and ongoing advances in drug safety surveillance include the establishment of government-sponsored networks of population databases, the use of data mining approaches, and the formal integration of diverse sources of drug safety information. These advances promise to reduce delays in identifying drug-related risks and in providing reassurance about the absence of such risks.
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Affiliation(s)
- Sean Hennessy
- Center for Pharmacoepidemiology Research and Training; Center for Clinical Epidemiology and Biostatistics; Department of Biostatistics and Epidemiology; and Department of Pharmacology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104;
| | - Brian L. Strom
- Rutgers the State University of New Jersey, Newark, New Jersey 07103, and Center for Pharmacoepidemiology Research and Training; Center for Clinical Epidemiology and Biostatistics; and Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104;
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Oral Anticoagulation for Pulmonary Arterial Hypertension: Systematic Review and Meta-analysis. Can J Cardiol 2014; 30:879-87. [DOI: 10.1016/j.cjca.2014.04.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 03/30/2014] [Accepted: 04/02/2014] [Indexed: 11/30/2022] Open
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Ezedunukwe IR, Enuh H, Nfonoyim J, Enuh CU. Anticoagulation therapy versus placebo for pulmonary hypertension. Cochrane Database Syst Rev 2014; 2014:CD010695. [PMID: 24887213 PMCID: PMC6885066 DOI: 10.1002/14651858.cd010695.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Elevation of pulmonary pressure is no longer a rare disease, given its multifactorial etiology. However data on the actual incidence of this condition are still limited, and controversies regarding its management are ongoing. Use of anticoagulation in the management of pulmonary hypertension is based on the presence of in situ thrombosis in the patient with pulmonary arterial hypertension (PAH) and on retrospective evidence of clinical benefit. Current practice is dependent mostly on expert opinion and individualised experience. The real benefit of its use in different types of pulmonary hypertension is still debatable, and the therapeutic target of the international normalised ratio (INR) among treated patients remains inconclusive. Adverse outcomes associated with anticoagulants are significant and can include fatal haemorrhage. Justification for the use of this intervention requires critical evaluation of randomised controlled trials. OBJECTIVES 1. To evaluate the effectiveness of, and potential adverse events associated with, anticoagulation in the management of pulmonary hypertension (PH).2. To evaluate the effective therapeutic INR in pulmonary hypertensive patients receiving anticoagulants (North American centres 1.5 to 2.5, European centres 2.0 to 3.0). SEARCH METHODS We identified trials through searches of the following databases.Cochrane Airways Group Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library; MEDLINE (Ovid); EMBASE (Ovid); CINAHL (EBSCOhost); Clinical trials.gov and the World Health Organization (WHO) trials portal. The trial search date was 28 March 2014. SELECTION CRITERIA We planned to include only randomised controlled trials. Participants with PH with co-morbidities including medical conditions requiring long-term anticoagulation were to be included. We also planned to include trials comparing any anticoagulant with placebo. DATA COLLECTION AND ANALYSIS Review authors (IE and HE) independently appraised all identified citations to establish their relevance for inclusion in the review. IE and HE independently screened the titles and abstracts of all identified potential studies for inclusion. MAIN RESULTS No eligible trials were identified for inclusion in this review. AUTHORS' CONCLUSIONS No eligible studies were identified for inclusion in this review. Although our review of available non-randomised studies shows beneficial effect, this finding should be interpreted with caution since there are likely to be biases associated with their design and our methods were not designed to identify, appraise and summarise evidence from them. So that better decisions can be made regarding the effectiveness of this intervention, well-designed randomised controlled trials are needed.
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Affiliation(s)
| | - Hilary Enuh
- Richmond University Medical CenterDepartment of Internal MedicineStaten IslandUSA
| | - Jay Nfonoyim
- Richmond University Medical CenterDepartment of Pulmonary Critical Care355 Bard AvenueStaten IslandUSA1030
| | - Collins U Enuh
- University of Abuja Teaching HospitalDepartment of AnaesthesiologyGwagwalda FCTAbujaNigeria234
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Nikpour M, Stevens W, Proudman SM, Buchbinder R, Prior D, Zochling J, Williams T, Gabbay E, Nandurkar H. Should patients with systemic sclerosis-related pulmonary arterial hypertension be anticoagulated? Intern Med J 2014; 43:599-603. [PMID: 23668273 DOI: 10.1111/imj.12111] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 03/03/2013] [Indexed: 11/29/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a major cause of mortality in scleroderma and despite 'advanced' therapies confers a median survival of less than 5 years. Anticoagulation in systemic sclerosis-related PAH (SSc-PAH) is currently one of the most contentious issues in the management of patients with connective tissue disease. While some studies have shown a survival benefit with warfarin therapy in this disease, others have not. Accordingly, a state of clinical equipoise exists in relation to anticoagulation in SSc-PAH. With an over fivefold reduction in mortality demonstrated in some observational studies, the issue of anticoagulation in SSc-PAH demands resolution through a well-designed randomised controlled trial.
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Affiliation(s)
- M Nikpour
- Department of Medicine, St Vincent's Academic Centre, The University of Melbourne, Melbourne, Victoria, Australia.
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Kinnersley N, Day S. Structured approach to the elicitation of expert beliefs for a Bayesian-designed clinical trial: a case study. Pharm Stat 2013; 12:104-13. [DOI: 10.1002/pst.1552] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Simon Day
- Roche Products Ltd; Welwyn Garden City, Herts AL7 1TW UK
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Ngian GS, Stevens W, Prior D, Gabbay E, Roddy J, Tran A, Minson R, Hill C, Chow K, Sahhar J, Proudman S, Nikpour M. Predictors of mortality in connective tissue disease-associated pulmonary arterial hypertension: a cohort study. Arthritis Res Ther 2012; 14:R213. [PMID: 23039366 PMCID: PMC3580525 DOI: 10.1186/ar4051] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 10/05/2012] [Indexed: 01/14/2023] Open
Abstract
Introduction Pulmonary arterial hypertension (PAH) is a major cause of mortality in connective tissue disease (CTD). We sought to quantify survival and determine factors predictive of mortality in a cohort of patients with CTD-associated PAH (CTD-PAH) in the current era of advanced PAH therapy. Methods Patients with right heart catheter proven CTD-PAH were recruited from six specialised PAH treatment centres across Australia and followed prospectively. Using survival methods including Cox proportional hazards regression, we modelled for all-cause mortality. Independent variables included demographic, clinical and hemodynamic data. Results Among 117 patients (104 (94.9%) with systemic sclerosis), during 2.6 ± 1.8 (mean ± SD) years of follow-up from PAH diagnosis, there were 32 (27.4%) deaths. One-, two- and three-year survivals were 94%, 89% and 73%, respectively. In multiple regression analysis, higher mean right atrial pressure (mRAP) at diagnosis (hazard ratio (HR) = 1.13, 95% CI: 1.04 to 1.24, P = 0.007), lower baseline six-minute walk distance (HR = 0.64, 95% CI: 0.43 to 0.97, P = 0.04), higher baseline World Health Organization functional class (HR = 3.42, 95% CI: 1.25 to 9.36, P = 0.04) and presence of a pericardial effusion (HR = 3.39, 95% CI: 1.07 to 10.68, P = 0.04) were predictive of mortality. Warfarin (HR = 0.20, 95% CI: 0.05 to 0.78, P = 0.02) and combination PAH therapy (HR = 0.20, 95% CI: 0.05 to 0.83, P = 0.03) were protective. Conclusions In this cohort of CTD-PAH patients, three-year survival was 73%. Independent therapeutic predictors of survival included warfarin and combination PAH therapy. Our findings suggest that anticoagulation and combination PAH therapy may improve survival in CTD-PAH. This observation merits further evaluation in randomised controlled trials.
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Johnson SR, Granton JT, Tomlinson GA, Grosbein HA, Le T, Lee P, Seary ME, Hawker GA, Feldman BM. Warfarin in systemic sclerosis-associated and idiopathic pulmonary arterial hypertension. A Bayesian approach to evaluating treatment for uncommon disease. J Rheumatol 2012; 39:276-85. [PMID: 22247353 DOI: 10.3899/jrheum.110765] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Warfarin is recommended in systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) and idiopathic PAH (IPAH) to improve survival. There is no evidence to support this in SSc-PAH and the evidence in IPAH is conflicting. We evaluated the ability of warfarin to improve survival using 2 large SSc-PAH and IPAH cohorts. METHODS The effect of warfarin on all-cause mortality was evaluated. Bayesian propensity scores (PS) were used to adjust for baseline differences between patients exposed and not exposed to warfarin, and to assemble a matched cohort. Bayesian Cox proportional hazards models were constructed using informative priors based on international PAH expert elicitation. RESULTS Review of 1138 charts identified 275 patients with SSc-PAH (n = 78; 28% treated with warfarin) and 155 patients with IPAH (n = 91; 59% treated with warfarin). Baseline differences in PAH severity and medications were resolved using PS matching. In the matched cohort of 98 patients with SSc-PAH (49 treated with warfarin), the posterior median hazard ratio (HR) was 1.06 [95% credible interval (CrI) 0.70, 1.63]. In the matched cohort of 66 patients with IPAH (33 treated with warfarin), the posterior median HR was 1.07 (95% CrI 0.57, 1.98). The probability that warfarin improves median survival by 6 months or more is 23.5% in SSc-PAH and 27.7% in IPAH. Conversely, there is a > 70% probability that warfarin provides no significant benefit or is harmful. CONCLUSION There is a low probability that warfarin improves survival in SSc-PAH and IPAH. Given the availability of other PAH therapies with demonstrable benefits, there is little reason to use warfarin to improve survival for these patients.
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Affiliation(s)
- Sindhu R Johnson
- Division of Rheumatology, Department of Medicine, Toronto Western Hospital, Toronto, Ontario, Canada.
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Subramanian G, Mehta S. Treatment of pulmonary arterial hypertension: great expectations! J Rheumatol 2011; 38:403-405. [PMID: 21362776 DOI: 10.3899/jrheum.101250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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