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Berthelsen DB, Nielsen SM, Rasmussen MU, Voshaar M, Richards P, Bartlett SJ, Hazlewood GS, Shea BJ, Tugwell P, Ellingsen T, Jørgensen TS, Kristensen S, Simon LS, Christensen R, Flurey CA. "I couldn't carry on taking a drug like that": A qualitative study of patient perspectives on side effects from rheumatology drugs. Rheumatology (Oxford) 2024:keae223. [PMID: 38613847 DOI: 10.1093/rheumatology/keae223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/25/2024] [Accepted: 04/10/2024] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVES There is growing interest in collecting outcome information directly from patients in clinical trials. This study evaluates what patients with rheumatic and musculoskeletal diseases (RMDs) consider important to know about symptomatic side effects they may experience from a new prescription drug. METHODS Patients with inflammatory arthritis, who had one or more prescribed drugs for their disease for at least 12 months, participated in focus groups and individual interviews. Discussions were analysed using reflexive thematic analysis. RESULTS We conducted seven focus groups with 34 participants across three continents. We found four overarching and two underpinning themes. The 'impact on life' was connected to participants 'daily life', 'family life', 'work life', and 'social life'. In 'psychological and physical aspects' participants described 'limitation to physical function', 'emotional dysregulation' and 'an overall mental state'. Extra tests, hospital visits and payment for medication were considered a 'time, energy and financial burden' of side effects. Participants explained important measurement issues to be 'severity', 'frequency', and 'duration'. Underpinning these issues, participants evaluated the 'benefit-harm-balance' which includes 'the cumulative burden' of having several side effects and the persistence of side effects over time. CONCLUSIONS In treatment for RMDs, there seems to be an urgent need for feasible measures of patient-reported bother (impact on life and cumulative burden) from side effects and the benefit-harm-balance. These findings contribute new evidence in support of a target domain-an outcome that represents the patient voice evaluating the symptomatic treatment-related side effects for people with RMDs enrolled in clinical trials.
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Affiliation(s)
- Dorthe B Berthelsen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
- Department of Rehabilitation, Municipality of Guldborgsund, Nykoebing F, Denmark
| | - Sabrina M Nielsen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Marianne U Rasmussen
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Marieke Voshaar
- Department of Pharmacy, Sint Maartenskliniek, Department of Pharmacy, Radboud UMC, Nijmegen, The Netherlands
| | - Pamela Richards
- Department of Rheumatology, University of Bristol, Bristol, United Kingdom
| | - Susan J Bartlett
- Department of Medicine, McGill University, Montreal, Canada
- Research Institute, McGill University Health Centre, Montreal, Canada
- Arthritis Research, Canada
| | - Glen S Hazlewood
- Department of Medicine, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary; Arthritis Research Canada
| | - Beverly J Shea
- School of Epidemiology and Public Health, University of Ottawa, Ottawa ON, Canada
| | - Peter Tugwell
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Torkell Ellingsen
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Tanja S Jørgensen
- Value-Based Outcomes Unit, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Salome Kristensen
- Department of Rheumatology, Aalborg University Hospital, and Aalborg University, Department of Clinical Medicine, Aalborg, Denmark
| | | | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
- Cochrane Denmark & Centre for Evidence-Based Medicine Odense (CEBMO), Department of Clinical Research, University of Southern Denmark, Denmark
| | - Caroline A Flurey
- School of Social Sciences, University of the West of England, Bristol, United Kingdom
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Berthelsen DB, Simon LS, Ioannidis JPA, Voshaar M, Richards P, Goel N, Strand V, Nielsen SM, Shea BJ, Tugwell P, Bartlett SJ, Hazlewood GS, March L, Singh JA, Suarez-Almazor ME, Boers M, Stevens RM, Furst DE, Woodworth T, Leong A, Brooks PM, Flurey C, Christensen R. Stakeholder endorsement advancing the implementation of a patient-reported domain for harms in rheumatology clinical trials: Outcome of the OMERACT Safety Working Group. Semin Arthritis Rheum 2023; 63:152288. [PMID: 37918049 DOI: 10.1016/j.semarthrit.2023.152288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/16/2023] [Accepted: 10/24/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVES To develop an understanding of the concept of safety/harms experienced by patients involved in clinical trials for their rheumatic and musculoskeletal diseases (RMDs) and to seek input from the OMERACT community before moving forward to developing or selecting an outcome measurement instrument. METHODS OMERACT 2023 presented and discussed interview results from 34 patients indicating that up to 171 items might be important for patients' harm-reporting. RESULTS Domain was defined in detail and supported by qualitative work. Participants in the Special-Interest-Group endorsed (96 %) that enough qualitative data are available to start Delphi survey(s). CONCLUSION We present a definition of safety/harms that represents the patient voice (i.e., patients' perception of safety) evaluating the symptomatic treatment-related adverse events for people with RMDs enrolled in clinical trials.
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Affiliation(s)
- Dorthe B Berthelsen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark; Department of Rehabilitation, Municipality of Guldborgsund, Nykoebing F, Denmark
| | | | - John P A Ioannidis
- Departments of Medicine, Epidemiology and Population Health, Biomedical Data Science, and Statistics, and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, California, USA
| | - Marieke Voshaar
- Department of Pharmacy, Sint Maartenskliniek, Department of Pharmacy, RadboudUMC, Nijmegen, the Netherlands
| | - Pam Richards
- Department of Rheumatology, University of Bristol, Bristol, United Kingdom
| | - Niti Goel
- Division of Rheumatology, Duke University School of Medicine, Durham, NC, USA
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto CA, USA
| | - Sabrina M Nielsen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark
| | - Beverly J Shea
- Ottawa Hospital Research Institute, Clinical Epidemiology Program and School of Epidemiology and Public Health, University of Ottawa, Canada
| | - Peter Tugwell
- Department of Medicine, School of Epidemiology, Public Health and Community Medicine, University of Ottawa, Canada
| | | | - Glen S Hazlewood
- Department of Medicine, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary; Arthritis Research Canada
| | - Lyn March
- Department of Rheumatology, Royal North Shore Hospital, Kolling Institue and The University of Sydney, Sydney, Australia
| | - Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, AL, USA; Department of Medicine and the School of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; Department of Epidemiology and the UAB School of Public Health, Birmingham, AL, USA
| | - Maria E Suarez-Almazor
- Department of Health Services Research and Section of Rheumatology and Clinical Immunology, University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - Maarten Boers
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | | | - Daniel E Furst
- David Geffen School of Med. Department of Medicine, Division of Rheumatology, UCLA, Los Angeles, California, USA
| | - Thasia Woodworth
- David Geffen School of Med. Department of Medicine, Division of Rheumatology, UCLA, Los Angeles, California, USA
| | - Amye Leong
- Healthy Motivation, Santa Barbara, California USA
| | - Peter M Brooks
- Centre for Health Policy Melbourne School of Population and Global Health University of Melbourne, Australia
| | - Caroline Flurey
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark.
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Laliberté MC, Perreault S, Jouini G, Shea BJ, Lalonde L. Effectiveness of interventions to improve the detection and treatment of osteoporosis in primary care settings: a systematic review and meta-analysis. Osteoporos Int 2011; 22:2743-68. [PMID: 21336493 DOI: 10.1007/s00198-011-1557-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 01/10/2011] [Indexed: 01/06/2023]
Abstract
This study aims to evaluate the effectiveness of primary care interventions to improve the detection and treatment of osteoporosis. Eight electronic databases and six gray literature sources were searched. Randomized controlled trials, controlled clinical trials, quasi-randomized trials, controlled before-after studies, and interrupted time series written in English or French from 1985 to 2009 were considered. Eligible studies had to include patients at risk (women ≥ 65 years, men ≥ 70 years, and men/women ≥ 50 years with at least one major risk factor for osteoporosis) or at high risk (men/women using oral glucocorticoids or with previous fragility fractures) for osteoporosis and fractures. Outcomes included bone mineral density (BMD) testing, osteoporosis treatment initiation, and fractures. Data were pooled using a random effects model when applicable. Thirteen studies were included. The majority were multifaceted and involved patient educational material, physician notification, and/or physician education. Absolute differences in the incidence of BMD testing ranged from 22% to 51% for high-risk patients only and from 4% to 18% for both at-risk and high-risk patients. Absolute differences in the incidence of osteoporosis treatment initiation ranged from 18% to 29% for high-risk patients only and from 2% to 4% for at-risk and high-risk patients. Pooling the results of six trials showed an increased incidence of osteoporosis treatment initiation (risk difference (RD) = 20%; 95% CI: 7-33%) and of BMD testing and/or osteoporosis treatment initiation (RD = 40%; 95% CI: 32-48%) for high-risk patients following intervention. Multifaceted interventions targeting high-risk patients and their primary care providers may improve the management of osteoporosis, but improvements are often clinically modest.
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Affiliation(s)
- M-C Laliberté
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
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Cranney A, Adachi JD, Guyatt G, Papaioannou A, Robinson VA, Shea BJ, Tugwell P, Waldegger LM, Weaver B, Wells G, Zytaruk N. WITHDRAWN: Risedronate for the prevention and treatment of postmenopausal osteoporosis. Cochrane Database Syst Rev 2007:CD004523. [PMID: 17636764 DOI: 10.1002/14651858.cd004523.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Postmenopausal osteoporosis results in an increased susceptibility to low-trauma fractures due to reduced bone volume and microarchitectural deterioration. Risedronate, a third generation bisphosphonate, has been shown in multiple clinical trials to reduce fracture risk and improve bone mineral density in postmenopausal women with osteoporosis. First and second generation bisphosphonates are known to have gastrointestinal side-effects and risedronate may be better tolerated. OBJECTIVES To systematically review the efficacy of risedronate on bone density, and fracture reduction in postmenopausal women. SEARCH STRATEGY The Cochrane Controlled Trials Registry Medline, and Current Contents were searched from 1990 - 2001. The electronic search was supplemented by handsearching four osteoporosis journals and their conference proceedings, as well as contacting content experts and industry sources for unpublished data. SELECTION CRITERIA We included eight trials that randomised women to risedronate or an alternative (placebo or calcium and /or vitamin D) and measured bone mineral density for at least one year. DATA COLLECTION AND ANALYSIS For each trial three independent reviewers assessed the methodological quality and abstracted data. Data was extracted for outcomes of fracture, bone mineral density and adverse events. The more conservative random effects model was used to pool data. The quality of trials was assessed according to the Jadad five-point scale. MAIN RESULTS Both vertebral and non-vertebral fractures were statistically and clinically reduced with risedronate. Eleven out of one hundred women who received risedronate had a vertebral fracture compared to 17 out of one hundred of those who received calcium and vitamin D (pooled relative risk for vertebral fractures of 0.64 (95% CI 0.52 - 0.77). Three percent of participants who received risedronate had a non-vertebral fracture compared to 4.6% of those who received calcium and vitamin D (pooled relative risk for nonvertebral fractures of 0.73 (95% CI 0.61 - 0.87). The weighted mean difference for the percent change from baseline for bone mineral density with 5 mg daily for lumbar spine, femoral neck and trochanter was 4.54% (95%CI 4.12 - 4.97), p<0.01; 2.75% (95% CI 2.32 - 3.17), p<0.01; and 4.38% (95% CI 3.51 - 5.25), p<0.01 respectively. AUTHORS' CONCLUSIONS There is good evidence for the efficacy of risedronate in the reduction of both vertebral and non-vertebral fractures. In addition, there is evidence from randomized trials that risedronate is able to achieve this without increasing risk for overall withdrawals due to adverse effects.
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Affiliation(s)
- A Cranney
- Ottawa Hospital, Division of Rheumatology, 1053 Carling Ave, Ottawa, Ontario, Canada, K1Y 4E9.
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Cranney A, Adachi JD, Griffith L, Guyatt G, Krolicki N, Robinson VA, Shea BJ, Wells G. WITHDRAWN: Etidronate for treating and preventing postmenopausal osteoporosis. Cochrane Database Syst Rev 2007:CD003376. [PMID: 17636719 DOI: 10.1002/14651858.cd003376.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Osteoporosis is a clinical syndrome of reduced bone mass and increased fracture susceptibility. There are now a number of options, including etidronate which can decrease the risk of fractures. OBJECTIVES To systematically review the efficacy of etidronate on bone density, fractures and toxicity in postmenopausal women. SEARCH STRATEGY We searched MEDLINE from 1966 to December 1998, examined citations of relevant articles, and the proceedings of international osteoporosis meetings. We contacted osteoporosis investigators to identify additional studies, primary authors, and pharmaceutical industry sources for unpublished data. SELECTION CRITERIA We included thirteen trials (with 1010 participants) that randomized women to etidronate or an alternative (placebo or calcium and/or vitamin D) and measured bone density for at least one year. DATA COLLECTION AND ANALYSIS For each trial, three independent reviewers assessed the methodological quality and abstracted data. MAIN RESULTS The data suggested a reduction in vertebral fractures with a pooled relative risk of 0.60% (95% CI 0.41 to 0.88). There was no effect on non-vertebral fractures (pooled relative risk 1.00, (95% CI 0.68 to 1.42)). Etidronate, relative to control, increased bone density after three years of treatment in the lumbar spine by 4.27% (95% CI 2.66 to 5.88), in the femoral neck by 2.19% (95% CI 0.43, 3.95) and in the total body by 0.97% (95% CI 0.39, 1.55). Effects were larger at 4 years, though the number of patients followed was much smaller. AUTHORS' CONCLUSIONS Etidronate increases bone density in the lumbar spine and femoral neck. The pooled estimates of fracture reduction with etidronate are consistent with a reduction in vertebral fractures, but no effect on non-vertebral fractures.
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Affiliation(s)
- A Cranney
- Ottawa Hospital, Division of Rheumatology, 1053 Carling Ave, Ottawa, Ontario, Canada, K1Y 4E9.
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Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) have been widely used as a pharmacologic treatment to relieve pain for patients with OA of the hip. However, these agents are associated with significant toxicity, particularly in the elderly population (age > 65 years). OBJECTIVES To review all randomized trials of analgesics and anti-inflammatory therapy in osteoarthritis (OA) of the hip. To determine which non-steroidal, anti-inflammatory drug (NSAID) is the most effective, and which NSAID is the most toxic. SEARCH STRATEGY We searched the Cochrane Musculoskeletal Group's trials register, the Cochrane Controlled Trials Register and MEDLINE up to August 1994. Reference lists of all trials were also manually searched. SELECTION CRITERIA All randomized controlled trials comparing non-steroidal anti-inflammatory drugs (NSAIDs) and/or analgesics in patients with Osteoarthritis. The trials selected for inclusion were identified by one reviewer (TT) and rechecked by a second (MH). DATA COLLECTION AND ANALYSIS Qualitative assessments were performed using a quality scoring system designed for NSAID trials in rheumatoid arthritis. Both the design and analysis aspects of the trials were evaluated, each aspect being rated on a scale of 0 to 8. A quantitative method, which calculates the ratio of improvement produced by one NSAID to that produced by another, was used to rate the relative efficacy of different NSAIDs with respect to pain relief. Toxicity comparisons were made according to the reviewer findings. All quality assessments were carried out independently by two reviewers (TT, BS). All data abstraction was carried out by one reviewer (TT) and rechecked by two other reviewers (BS, GW). A consensus was reached on discrepancies. MAIN RESULTS Forty-three trials were identified, and of these, 39 evaluated NSAIDs, while four evaluated only analgesics. The median design and analysis scores were two and four respectively. Six NSAIDs were included in at least five trials. Of these, indomethacin was rated more effective in five of its seven comparisons, but more toxic in seven of 12 comparisons. Only five of the 29 (17%) NSAID comparisons found statistically significant differences in efficacy. Of the 43 RCTs identified only 17 had statistical data available for future pooling for this meta-analysis. In the case where data was missing, authors of the trials will be contacted for inclusion of data in future reviews. AUTHORS' CONCLUSIONS NSAID trials in patients with OA of the hip appear to be weakened by the lack of standardization of case definition of OA, and also by the lack of standardization of outcome assessments. No clear recommendations for the choice of specific NSAID therapy in hip OA can be offered at this time based on this analysis.
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Affiliation(s)
- T E Towheed
- Queen's University, Medicine and of Community Health and Epidemiology, Etherington Hall-Room 2066, Kingston, Ontario, Canada, K7L 3N6.
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Kristjansson EA, Robinson V, Petticrew M, MacDonald B, Krasevec J, Janzen L, Greenhalgh T, Wells G, MacGowan J, Farmer A, Shea BJ, Mayhew A, Tugwell P. School feeding for improving the physical and psychosocial health of disadvantaged elementary school children. Cochrane Database Syst Rev 2007:CD004676. [PMID: 17253518 DOI: 10.1002/14651858.cd004676.pub2] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Early malnutrition and/or micronutrient deficiencies can adversely affect physical, mental, and social aspects of child health. School feeding programs are designed to improve attendance, achievement, growth, and other health outcomes. OBJECTIVES The main objective was to determine the effectiveness of school feeding programs in improving physical and psychosocial health for disadvantaged school children. SEARCH STRATEGY We searched a number of databases including CENTRAL (2006 Issue 2), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), PsycINFO (1980 to May 2006) and CINAHL (1982 to May 2006). Grey literature sources were also searched. Reference lists of included studies and key journals were handsearched and we also contacted selected experts in the field. SELECTION CRITERIA Data from randomized controlled trials (RCTs), non-randomised controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series studies (ITSs) were included. Feeding had to be done in school; the majority of participants had to be socio-economically disadvantaged. DATA COLLECTION AND ANALYSIS Two reviewers assessed all searches and retrieved studies. Data extraction was done by one of four reviewers and reviewed by a second. Two reviewers independently rated quality. If sufficient data were available, they were synthesized using random effects meta-analysis, adjusting for clustering if needed. Analyses were performed separately for RCTs and CBAs and for higher and lower income countries. MAIN RESULTS We included 18 studies. For weight, in the RCTs and CBAs from Lower Income Countries, experimental group children gained an average of 0.39 kg (95% C.I: 0.11 to 0.67) over an average of 19 months and 0.71 kg (95% C.I.: 0.48 to 0.95) over 11.3 months respectively. Results for weight were mixed in higher income countries. For height, results were mixed; height gain was greater for younger children. Attendance in lower income countries was higher in experimental groups than in controls; our results show an average increase of 4 to 6 days a year. Math gains were consistently higher for experimental groups in lower income countries; in CBAs, the Standardized Mean Difference was 0.66 (95% C.I. = 0.13 to 1.18). In short-term studies, small improvements in some cognitive tasks were found. AUTHORS' CONCLUSIONS School meals may have some small benefits for disadvantaged children. We recommend further well-designed studies on the effectiveness of school meals be undertaken, that results should be reported according to socio-economic status, and that researchers gather robust data on both processes and carefully chosen outcomes.
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Affiliation(s)
- E A Kristjansson
- Institute of Population Health, School of Psychology and Centre for Global Health, 1 Stewart Street, Ottawa, Ontario, Canada, K1N 6N5.
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Abstract
BACKGROUND Glucocorticoid use in rheumatoid arthritis (RA) is widespread. Two Cochrane Reviews have been published examining the short term clinical benefit of low dose glucocorticoids compared to non-steroidal anti-inflammatory drugs and demonstrate good short term and medium term clinical benefits. The possibility that glucocorticoids may have a fundamental 'disease modifying' effect in RA, which would be seen by a reduction in the rate of radiological progression, has been raised by several authors. OBJECTIVES To perform a systematic review of studies evaluating glucocorticoid efficacy in inhibiting the progression of radiological damage in rheumatoid arthritis. SEARCH STRATEGY A search of MEDLINE (from 1966 to 22 February 2005) and the Cochrane Controlled Trials Register was undertaken, using the terms 'corticosteroids' and 'rheumatoid arthritis' expanded according to the Cochrane Collaboration recommendations. Identified abstracts were reviewed and appropriate reports obtained in full. Additional reports were identified from the reference lists and from expert knowledge. SELECTION CRITERIA Randomized controlled or cross-over trials in adults with a diagnosis of rheumatoid arthritis in which prednisone or a similar glucocorticoid preparation was compared to either placebo controls or active controls (i.e. comparative studies) and where there was evaluation of radiographs of hands, or hands and feet, or feet by any standardised technique. Eligible studies had at least one treatment arm with glucocorticoids and one without glucocorticoids. DATA COLLECTION AND ANALYSIS Standardised data extraction obtain the mean and standard deviation (SD) of change in erosion scores over 1 year or 2 years. (Where SD for change was not given a conservative estimate was taken from baseline data.) At least two authors selected the studies and extracted the data. Radiographic erosion scores were expressed as a percentage of the maximum possible score for the method used. The results were pooled after weighting in a random effects model to provide a standardised mean difference (SMD). MAIN RESULTS The initial search produced 217 citations, and 15 were added from experts, abstracts and review of reference lists. Authors of 4 trials being prepared for publication (and subsequently published) kindly shared their data. After application of eligibility criteria 15 studies and 1,414 patients were included. The majority of trials studied early RA (disease duration up to 2 yrs), and the mean cumulative dose of glucocorticoid was 2,300 mg prednisone equivalent (range 270 mg - 5,800 mg) over the first year. Glucocorticoids were mostly added to other disease modifying anti-rheumatoid drug (DMARD) treatment. The standardised mean difference in progression was 0.40 in favour of glucocorticoids (95% CI 0.27, 0.54). In studies lasting 2 years (806 patients included), the standardised mean difference in progression in favour of glucocorticoids at 1 year was 0.45 (0.24, 0.66) and at 2 years was 0.42 (0.30, 0.55). All studies except one showed a numerical treatment effect in favour of glucocorticoids. The beneficial effects of glucocorticoids were generally achieved when used in conjunction with other DMARD treatment. AUTHORS' CONCLUSIONS Even in the most conservative estimate, the evidence that glucocorticoids given in addition to standard therapy can substantially reduce the rate of erosion progression in rheumatoid arthritis is convincing. There remains concern about potential long-term adverse reactions to glucocorticoid therapy, such as increased cardiovascular risk, and this issue requires further research.
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Affiliation(s)
- J R Kirwan
- Liverpool Women's Hospital, Crown Street, Liverpool, UK, L8 7SS.
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