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Felipe CQ, Biancardi AL, Civile VT, Carvas Junior N, Serracarbassa PD, Koike MK. Mineralocorticoid receptor antagonists for chronic central serous chorioretinopathy: systematic review and meta-analyses. Int J Retina Vitreous 2022; 8:34. [PMID: 35672807 PMCID: PMC9172176 DOI: 10.1186/s40942-022-00385-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRAs) are widely used for chronic central serous chorioretinopathy (cCSCR), but their effectiveness remains unclear. This research was conducted to evaluate the efficacy of this drugs for cCSCR. METHODS This is a review of randomized clinical trials (RCT) comparing MRAs to placebo in adults with cCSCR, using the effects of MRAs on best-corrected visual acuity (BCVA) and adverse events as primary outcomes and the effects of MRAs on anatomical parameters as secondary outcomes: central subfield thickness (CST), subretinal fluid height (SFH) and central choroidal thickness (CCT). Our all-language online search included Medline (via PubMed), Central, Embase, Lilacs, Ibecs, and RCT registers platforms, as late as May 2021. We used the Cochrane risk-of-bias tool (version 2) to assess the methodological quality of each study and synthesized the results in meta-analyses using a random-effects model. RESULTS The search identified 302 records, five of which were eligible, totaling 225 cCSCR patients (aged 45-62 years; M/F ratio 3.1:1) treated for 1 to 12 months with spironolactone (50 mg/day) or eplerenone (50 mg/day) vs. placebo. Moderate-certainty evidence suggests MRAs result in little to no improvement in BCVA compared to placebo (SMD 0.22; 95% CI - 0.04 to 0.48; studies = 5; comparisons = 6; participants = 218; I2 = 0%). Very low-certainty evidence suggests that, when compared to placebo, MRAs have a very uncertain impact on adverse effects (no meta-analysis was performed), and CST (MD 18.1; 95% CI - 113.04 to 76.84; participants = 145; studies = 2; I2 = 68%). MRAs also result in little to no difference in SFH (SMD - 0.35; 95% CI - 0.95 to 0.26; studies = 5; comparisons = 6; participants = 221; I2 = 76%; moderate certainty) and CCT (MD - 21.23; 95% CI - 64.69 to 22.24; participants = 206; studies = 4; comparisons = 5; I2 = 85%; low certainty). CONCLUSION MRAs have little to no effect on BCVA. Evidence for adverse events and CST is very uncertain. MRAs also have little to no effect on SFH and CCT. These findings should be considered when prescribing MRAs for cCSCR. This research was previous registration in the PROSPERO platform (CRD42020182601).
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Affiliation(s)
- Camila Q. Felipe
- Postgraduate Program in Health Sciences, Institute of Medical Care for Civil Servants in the State of São Paulo (IAMSPE), São Paulo, Brazil
| | - Ana Luiza Biancardi
- Laboratory of Infectious Diseases in Ophthalmology, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, Brazil
| | - Vinicius T. Civile
- Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Nelson Carvas Junior
- Cochrane Brazil and Department of Physiotherapy, Paulista University, São Paulo, Brazil
| | | | - Marcia K. Koike
- Postgraduate Program in Health Sciences, IAMSPE and Laboratory of Medical Investigation 51 (LIM-51), University of São Paulo, São Paulo, Brazil
- Postgraduate Program in Health Sciences of the Institute of Medical Care for Civil Servants in the State of São Paulo (IAMSPE), Avenida Ibirapuera 981, 2 andar, Vila Clementino, São Paulo, SP CEP 04029-000 Brazil
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Shaman AM, Smyth B, Arnott C, Palmer SC, Mihailidou AS, Jardine MJ, Gallagher MP, Perkovic V, Jun M. Comparative Efficacy and Safety of BP-Lowering Pharmacotherapy in Patients Undergoing Maintenance Dialysis: A Network Meta-Analysis of Randomized, Controlled Trials. Clin J Am Soc Nephrol 2020; 15:1129-1138. [PMID: 32675281 PMCID: PMC7409758 DOI: 10.2215/cjn.12201019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 10/08/2019] [Accepted: 05/07/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Elevated BP is an important risk factor for cardiovascular disease, with a prevalence of over 80% in patients undergoing maintenance dialysis. We assessed the comparative BP-lowering efficacy and the safety of BP-lowering drugs in patients undergoing maintenance dialysis. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS We performed a frequentist random effects network meta-analysis of randomized, controlled trials evaluating BP-lowering agents in adult patients undergoing maintenance dialysis. Electronic databases (CENTRAL, MEDLINE, and Embase) were systematically searched (up to August 2018) for relevant trials. The main outcome was systolic BP reduction. RESULTS Forty trials (4283 participants) met our inclusion criteria. Angiotensin-converting enzyme inhibitors, β-blockers, calcium-channel blockers, and aldosterone antagonists lowered systolic BP to a greater extent than placebo, with effect sizes ranging from -10.8 mm Hg (95% confidence interval, -14.8 to -6.7 mm Hg) for the aldosterone antagonists to -4.3 mm Hg (95% confidence interval, -7.2 to -1.5 mm Hg) for angiotensin-converting enzyme inhibitors. Aldosterone antagonists and β-blockers were superior to angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium-channel blockers, and renin inhibitors at lowering systolic BP. Compared with angiotensin-converting enzyme inhibitors, aldosterone antagonists and β-blockers lowered systolic BP by 6.4 mm Hg (95% confidence interval, -11.4 to -1.4 mm Hg) and 4.4 mm Hg (95% confidence interval, -7.4 to -1.3 mm Hg), respectively. Systolic BP reduction was not different with angiotensin receptor blockers, α-blockers, and calcium-channel blockers compared with angiotensin-converting enzyme inhibitors. Renin inhibitors were less effective. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone antagonists incurred risks of drug discontinuation due to adverse events and hypotension. CONCLUSIONS BP-lowering agents significantly reduced systolic BP in patients undergoing maintenance dialysis. β-Blockers and aldosterone antagonists may confer larger reductions, although treatment with aldosterone antagonists may be limited by adverse events.
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Affiliation(s)
- Ahmed M Shaman
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Medication Safety Research Chair, Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Brendan Smyth
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Cardiology, The Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Anastasia S Mihailidou
- Department of Cardiology and Kolling Institute, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia.,Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Meg J Jardine
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Martin P Gallagher
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Concord Clinical School, Sydney Medical School, Faculty of Health and Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Min Jun
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
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George JC, Zafar W, Bucaloiu ID, Chang AR. Risk Factors and Outcomes of Rapid Correction of Severe Hyponatremia. Clin J Am Soc Nephrol 2018; 13:984-992. [PMID: 29871886 PMCID: PMC6032596 DOI: 10.2215/cjn.13061117] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Rapid correction of severe hyponatremia can result in serious neurologic complications, including osmotic demyelination. Few data exist on incidence and risk factors of rapid correction or osmotic demyelination. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a retrospective cohort of 1490 patients admitted with serum sodium <120 mEq/L to seven hospitals in the Geisinger Health System from 2001 to 2017, we examined the incidence and risk factors of rapid correction and osmotic demyelination. Rapid correction was defined as serum sodium increase of >8 mEq/L at 24 hours. Osmotic demyelination was determined by manual chart review of all available brain magnetic resonance imaging reports. RESULTS Mean age was 66 years old (SD=15), 55% were women, and 67% had prior hyponatremia (last outpatient sodium <135 mEq/L). Median change in serum sodium at 24 hours was 6.8 mEq/L (interquartile range, 3.4-10.2), and 606 patients (41%) had rapid correction at 24 hours. Younger age, being a woman, schizophrenia, lower Charlson comorbidity index, lower presentation serum sodium, and urine sodium <30 mEq/L were associated with greater risk of rapid correction. Prior hyponatremia, outpatient aldosterone antagonist use, and treatment at an academic center were associated with lower risk of rapid correction. A total of 295 (20%) patients underwent brain magnetic resonance imaging on or after admission, with nine (0.6%) patients showing radiologic evidence of osmotic demyelination. Eight (0.5%) patients had incident osmotic demyelination, of whom five (63%) had beer potomania, five (63%) had hypokalemia, and seven (88%) had sodium increase >8 mEq/L over a 24-hour period before magnetic resonance imaging. Five patients with osmotic demyelination had apparent neurologic recovery. CONCLUSIONS Among patients presenting with severe hyponatremia, rapid correction occurred in 41%; nearly all patients with incident osmotic demyelination had a documented episode of rapid correction. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_06_05_CJASNPodcast_18_7_G.mp3.
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Affiliation(s)
- Jason C George
- Department of Nephrology, Geisinger Medical Center, Danville, Pennsylvania; and
| | - Waleed Zafar
- Kidney Health Research Institute, Geisinger, Danville, Pennsylvania
| | - Ion Dan Bucaloiu
- Department of Nephrology, Geisinger Medical Center, Danville, Pennsylvania; and
| | - Alex R Chang
- Department of Nephrology, Geisinger Medical Center, Danville, Pennsylvania; and
- Kidney Health Research Institute, Geisinger, Danville, Pennsylvania
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Mayyas F, Ibrahim K, Alzoubi KH. Awareness of physicians and pharmacists of aldosterone antagonists in heart failure and myocardial infarction in Jordan. Pharm Pract (Granada) 2017; 15:994. [PMID: 28943982 PMCID: PMC5597810 DOI: 10.18549/pharmpract.2017.03.994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 08/22/2017] [Indexed: 01/14/2023] Open
Abstract
Objective: to evaluate physicians and clinical pharmacists’ awareness and
practices regarding use of aldosterone antagonists in heart failure (HF) and
post-myocardial infarction (MI). Methods: First, we reviewed the prescription of aldosterone antagonists among 408
patients presenting to the cardiology clinic at a major hospital in Jordan.
Second, physicians and pharmacists working in cardiovascular departments
completed a questionnaire related to use of aldosterone antagonists in HF
and post-MI. Results: Thirty patients (7.59%) were eligible for aldosterone antagonist; only
4 received them at discharge (13.3%). The survey was completed by 153
professionals (response rate 76.12%). About 72.1% of
participants were aware of studies regarding use of aldosterone antagonists
post-MI and in HF. Moreover, 10.45%/53.6% of participants
strongly agreed/agreed that these agents are useful in normotensive post-MI
and HF patients. Spironolactone was the most prescribed drug by 92.1%
of participants. About 41.8% of participants reported use of
spironolactone in post-MI and HF. With respect to guidelines, only
39.2% of participants agreed that adding spironolactone to standard
therapy in HF is recommended, and 48.3% agreed on adding it directly
post-MI. Clinical pharmacists and cardiologists were generally more aware of
guidelines than pharmacists, cardiac surgeons and residents/fellows. Conclusions: there is an under-use of aldosterone antagonists in HF and post-MI patients,
and a lack of detailed awareness of current guidelines among health care
providers. Dissemination of evidence-based guidelines and usage protocols
may improve management of post-MI and HF.
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Affiliation(s)
- Fadia Mayyas
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. Irbid (Jordan).
| | - Khalid Ibrahim
- Division of Cardiac Surgery, Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology. Irbid (Jordan).
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid (Jordan).
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Abstract
Among patients on dialysis, hypertension is highly prevalent and contributes to the high burden of cardiovascular morbidity and mortality. Strict volume control via sodium restriction and probing of dry weight are first-line approaches for the treatment of hypertension in this population; however, antihypertensive drug therapy is often needed to control BP. Few trials compare head-to-head the superiority of one antihypertensive drug class over another with respect to improving BP control or altering cardiovascular outcomes; accordingly, selection of the appropriate antihypertensive regimen should be individualized. To individualize therapy, consideration should be given to intra- and interdialytic pharmacokinetics, effect on cardiovascular reflexes, ability to treat comorbid illnesses, and adverse effect profile. β-Blockers followed by dihydropyridine calcium-channel blockers are our first- and second-line choices for antihypertensive drug use. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers seem to be reasonable third-line choices, because the evidence base to support their use in patients on dialysis is sparse. Add-on therapy with mineralocorticoid receptor antagonists in specific subgroups of patients on dialysis (i.e., those with severe congestive heart failure) seems to be another promising option in anticipation of the ongoing trials evaluating their efficacy and safety. Adequately powered, multicenter, randomized trials evaluating hard cardiovascular end points are urgently warranted to elucidate the comparative effectiveness of antihypertensive drug classes in patients on dialysis. In this review, we provide an overview of the randomized evidence on pharmacotherapy of hypertension in patients on dialysis, and we conclude with suggestions for future research to address critical gaps in this important area.
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Affiliation(s)
- Panagiotis I. Georgianos
- Division of Nephrology and Hypertension, First Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indianapolis; and
- Division of Nephrology, Department of Medicine, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indianapolis
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