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Lunny C, Veroniki AA, Higgins JPT, Dias S, Hutton B, Wright JM, White IR, Whiting P, Tricco AC. Methodological review of NMA bias concepts provides groundwork for the development of a list of concepts for potential inclusion in a new risk of bias tool for network meta-analysis (RoB NMA Tool). Syst Rev 2024; 13:25. [PMID: 38217041 PMCID: PMC10785511 DOI: 10.1186/s13643-023-02388-x] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 11/10/2023] [Indexed: 01/14/2024] Open
Abstract
INTRODUCTION Network meta-analyses (NMAs) have gained popularity and grown in number due to their ability to provide estimates of the comparative effectiveness of multiple treatments for the same condition. The aim of this study is to conduct a methodological review to compile a preliminary list of concepts related to bias in NMAs. METHODS AND ANALYSIS We included papers that present items related to bias, reporting or methodological quality, papers assessing the quality of NMAs, or method papers. We searched MEDLINE, the Cochrane Library and unpublished literature (up to July 2020). We extracted items related to bias in NMAs. An item was excluded if it related to general systematic review quality or bias and was included in currently available tools such as ROBIS or AMSTAR 2. We reworded items, typically structured as questions, into concepts (i.e. general notions). RESULTS One hundred eighty-one articles were assessed in full text and 58 were included. Of these articles, 12 were tools, checklists or journal standards; 13 were guidance documents for NMAs; 27 were studies related to bias or NMA methods; and 6 were papers assessing the quality of NMAs. These studies yielded 99 items of which the majority related to general systematic review quality and biases and were therefore excluded. The 22 items we included were reworded into concepts specific to bias in NMAs. CONCLUSIONS A list of 22 concepts was included. This list is not intended to be used to assess biases in NMAs, but to inform the development of items to be included in our tool.
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Affiliation(s)
- Carole Lunny
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON, M5B 1T8, Canada.
- Cochrane Hypertension Review Group, the Therapeutics Initiative, University of British Columbia, Vancouver, Canada.
| | - Areti-Angeliki Veroniki
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON, M5B 1T8, Canada
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
- NIHR Applied Research Collaboration West (ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Canada
- Ottawa University, School of Epidemiology and Public Health, Ottawa, Canada
| | - James M Wright
- Cochrane Hypertension Review Group, the Therapeutics Initiative, University of British Columbia, Vancouver, Canada
| | | | - Penny Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 209 Victoria Street, East Building, Toronto, ON, M5B 1T8, Canada
- Dalla Lana School of Public Health & Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Queen's Collaboration for Health Care Quality Joanna Briggs Institute Centre of Excellence, Queen's University, Kingston, Canada
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Heinecke A, Tallarita M, De Iorio M. Bayesian splines versus fractional polynomials in network meta-analysis. BMC Med Res Methodol 2020; 20:261. [PMID: 33081698 DOI: 10.1186/s12874-020-01113-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 09/02/2020] [Indexed: 01/05/2023] Open
Abstract
Background Network meta-analysis (NMA) provides a powerful tool for the simultaneous evaluation of multiple treatments by combining evidence from different studies, allowing for direct and indirect comparisons between treatments. In recent years, NMA is becoming increasingly popular in the medical literature and underlying statistical methodologies are evolving both in the frequentist and Bayesian framework. Traditional NMA models are often based on the comparison of two treatment arms per study. These individual studies may measure outcomes at multiple time points that are not necessarily homogeneous across studies. Methods In this article we present a Bayesian model based on B-splines for the simultaneous analysis of outcomes across time points, that allows for indirect comparison of treatments across different longitudinal studies. Results We illustrate the proposed approach in simulations as well as on real data examples available in the literature and compare it with a model based on P-splines and one based on fractional polynomials, showing that our approach is flexible and overcomes the limitations of the latter. Conclusions The proposed approach is computationally efficient and able to accommodate a large class of temporal treatment effect patterns, allowing for direct and indirect comparisons of widely varying shapes of longitudinal profiles.
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Giovannoni G, Lang S, Wolff R, Duffy S, Hyde R, Kinter E, Wakeford C, Sormani MP, Kleijnen J. A Systematic Review and Mixed Treatment Comparison of Pharmaceutical Interventions for Multiple Sclerosis. Neurol Ther 2020; 9:359-374. [PMID: 32989721 PMCID: PMC7606402 DOI: 10.1007/s40120-020-00212-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/04/2020] [Indexed: 01/10/2023] Open
Abstract
Background Since 2010, 27 mixed-treatment comparisons (MTCs) of disease-modifying therapies (DMTs) for multiple sclerosis have been published. However, there has been continued evolution in the field of MTCs. Additionally, limitations in methodological approach and reporting transparency, even in the most recent publications, makes interpretation and comparison of existing studies difficult. Objectives The objectives of this study are twofold: (1) to estimate the efficacy and safety of DMTs at European Commission-approved doses compared with placebo in adults with relapsing–remitting multiple sclerosis (RRMS) using MTC, and (2) to identify and address methodological challenges when performing MTC in RRMS, thereby creating a baseline for comparisons with future treatments. Methods Searches were completed in 14 databases, including MEDLINE, Embase, CENTRAL, CDSR and DARE, from inception to June 2018 to identify published or unpublished prospective, randomised controlled trials of all European Union-approved DMTs or DMTs expected to be approved in the near future in RRMS or rapidly-evolving severe RRMS. No language or date restrictions were applied. Studies were included in the MTC if they were judged to have sufficiently similar characteristics, based on the following: patient age; proportion of male participants; Expanded Disability Status Scale (EDSS) score; duration of disease; number of relapses prior to enrolment and proportion of previously treated patients. Background information from the included studies, as well as effect size and confidence intervals (where relevant) of defined outcomes were extracted. Reporting of the MTC was consistent with the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) network meta-analysis guidelines. Results In total, 33 studies were included in the MTC. Annualised relapse rate (ARR 28 trials) was significantly reduced in all treatments compared with placebo. Alemtuzumab had the highest probability (63%) of being the most effective treatment in terms of ARR compared with placebo (rate ratio [RR] 0.28, 95% credible interval [CrI] 0.21–0.38), followed by natalizumab (30% probability; RR 0.32, 95% CrI 0.23–0.43). The risk of 3- and 6-month confirmed disability progression (CDP3M, 13 trials; CDP6M, 14 trials) were similar; CDP6M was significantly reduced for alemtuzumab (hazard ratio [HR] 0.365; 95% CrI 0.165–0.725), ocrelizumab (HR 0.405, 95% CrI 0.188–0.853) and natalizumab (HR 0.459, 95% CrI 0.252–0.840) relative to placebo. There were no significant differences in the odds of serious adverse events (SAEs, 6 trials) between any treatment and placebo. The results of the MTC were limited by the lack of studies reporting direct comparisons between the included treatments and by heterogeneous reporting of key outcome data. Conclusions Meta-analyses confirmed the benefit of all DMTs in terms of relapse rate compared with placebo with a comparable rate of SAEs for the DMTs that could be included in the network. The rigor and transparency of reporting in this study provide a benchmark for comparisons with future new agents. Electronic Supplementary Material The online version of this article (10.1007/s40120-020-00212-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gavin Giovannoni
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Shona Lang
- Kleijnen Systematic Reviews Ltd, Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | - Robert Wolff
- Kleijnen Systematic Reviews Ltd, Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK.
| | - Steven Duffy
- Kleijnen Systematic Reviews Ltd, Unit 6, Escrick Business Park, Riccall Road, Escrick, York, YO19 6FD, UK
| | | | | | | | | | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Pia Sormani M, Wolff R, Lang S, Duffy S, Hyde R, Kinter E, Wakeford C, Giovannoni G, Kleijnen J. Overview of Differences and Similarities of Published Mixed Treatment Comparisons on Pharmaceutical Interventions for Multiple Sclerosis. Neurol Ther 2020; 9:335-358. [PMID: 32978726 PMCID: PMC7606374 DOI: 10.1007/s40120-020-00213-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022] Open
Abstract
Introduction Mixed treatment comparisons (MTCs) are increasingly important in the assessment of the benefit–risk profile of pharmaceutical treatments for relapsing–remitting multiple sclerosis (RRMS). Interpretation of MTCs requires a clear understanding of the methods of analysis and population studied. The objectives of this work were to compare MTCs of pharmaceutical treatments for RRMS, including a detailed description of differences in populations, treatments assessed, methods used and findings; and to discuss key considerations when conducting an MTC. Methods Fourteen databases were searched until July 2019 to identify MTCs (published during or after 2010) in adults (at least 18 years of age) with RRMS or rapidly evolving severe RRMS treated with any form of pharmaceutical treatment. No language restriction was imposed. Results Twenty-seven MTCs assessing 21 treatments were identified. Comparison highlighted many differences in conduct and reporting between MTCs relating to the patient populations or treatments included, duration of follow-up and outcomes of interest measured. The lack of similarity between the MTCs leads to questions about variability in the robustness of analyses and makes comparisons between studies challenging. Conclusion Given the importance of MTCs for healthcare decision-making, it is imperative that reporting of methods, results and assumptions is clear and transparent to allow accurate interpretation of findings. For MTCs to be relevant, the choice of outcome measures should reflect clinical practice. Combination of treatments or of outcomes measured at different points of time should be avoided, as should imputation without justification. Furthermore, all approved treatment options should be included and updates of MTCs should be conducted when data for new treatments are published. Electronic Supplementary Material The online version of this article (10.1007/s40120-020-00213-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Shona Lang
- Kleijnen Systematic Reviews Ltd, York, UK
| | | | | | | | | | - Gavin Giovannoni
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jos Kleijnen
- School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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Kiefer C, Sturtz S, Bender R. A simulation study to compare different estimation approaches for network meta-analysis and corresponding methods to evaluate the consistency assumption. BMC Med Res Methodol 2020; 20:36. [PMID: 32093605 PMCID: PMC7041240 DOI: 10.1186/s12874-020-0917-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 08/13/2019] [Accepted: 01/30/2020] [Indexed: 11/10/2022] Open
Abstract
Background Network meta-analysis (NMA) is becoming increasingly popular in systematic reviews and health technology assessments. However, there is still ambiguity concerning the properties of the estimation approaches as well as for the methods to evaluate the consistency assumption. Methods We conducted a simulation study for networks with up to 5 interventions. We investigated the properties of different methods and give recommendations for practical application. We evaluated the performance of 3 different models for complex networks as well as corresponding global methods to evaluate the consistency assumption. The models are the frequentist graph-theoretical approach netmeta, the Bayesian mixed treatment comparisons (MTC) consistency model, and the MTC consistency model with stepwise removal of studies contributing to inconsistency identified in a leverage plot. Results We found that with a high degree of inconsistency none of the evaluated effect estimators produced reliable results, whereas with moderate or no inconsistency the estimator from the MTC consistency model and the netmeta estimator showed acceptable properties. We also saw a dependency on the amount of heterogeneity. Concerning the evaluated methods to evaluate the consistency assumption, none was shown to be suitable. Conclusions Based on our results we recommend a pragmatic approach for practical application in NMA. The estimator from the netmeta approach or the estimator from the Bayesian MTC consistency model should be preferred. Since none of the methods to evaluate the consistency assumption showed satisfactory results, users should have a strong focus on the similarity as well as the homogeneity assumption.
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Affiliation(s)
- Corinna Kiefer
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, Cologne, D-50670, Germany
| | - Sibylle Sturtz
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, Cologne, D-50670, Germany
| | - Ralf Bender
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, Cologne, D-50670, Germany. .,Faculty of Medicine, University of Cologne, Joseph-Stelzmann-Str. 20, Cologne, D-50931, Germany.
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Abstract
The objective of this study is to describe the general approaches to network meta-analysis that are available for quantitative data synthesis using R software. We conducted a network meta-analysis using two approaches: Bayesian and frequentist methods. The corresponding R packages were “gemtc” for the Bayesian approach and “netmeta” for the frequentist approach. In estimating a network meta-analysis model using a Bayesian framework, the “rjags” package is a common tool. “rjags” implements Markov chain Monte Carlo simulation with a graphical output. The estimated overall effect sizes, test for heterogeneity, moderator effects, and publication bias were reported using R software. The authors focus on two flexible models, Bayesian and frequentist, to determine overall effect sizes in network meta-analysis. This study focused on the practical methods of network meta-analysis rather than theoretical concepts, making the material easy to understand for Korean researchers who did not major in statistics. The authors hope that this study will help many Korean researchers to perform network meta-analyses and conduct related research more easily with R software.
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Affiliation(s)
- Sung Ryul Shim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea.,Urological Biomedicine Research Institute, Soonchunhyang University Hospital, Seoul, Korea
| | - Seong-Jang Kim
- Department of Nuclear Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,BioMedical Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jonghoo Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
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Phillippo DM, Dias S, Ades AE, Didelez V, Welton NJ. Sensitivity of treatment recommendations to bias in network meta-analysis. J R Stat Soc Ser A Stat Soc 2018; 181:843-867. [PMID: 30449954 PMCID: PMC6221150 DOI: 10.1111/rssa.12341] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Network meta-analysis (NMA) pools evidence on multiple treatments to estimate relative treatment effects. Included studies are typically assessed for risk of bias; however, this provides no indication of the impact of potential bias on a decision based on the NMA. We propose methods to derive bias adjustment thresholds which measure the smallest changes to the data that result in a change of treatment decision. The methods use efficient matrix operations and can be applied to explore the consequences of bias in individual studies or aggregate treatment contrasts, in both fixed and random-effects NMA models. Complex models with multiple types of data input are handled by using an approximation to the hypothetical aggregate likelihood. The methods are illustrated with a simple NMA of thrombolytic treatments and a more complex example comparing social anxiety interventions. An accompanying R package is provided.
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Affiliation(s)
| | | | | | - Vanessa Didelez
- Leibniz Institute for Prevention Research and Epidemiology, and University of BremenGermany
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Abstract
This review aimed to arrange the concepts of a network meta-analysis (NMA) and to demonstrate the analytical process of NMA using Stata software under frequentist framework. The NMA tries to synthesize evidences for a decision making by evaluating the comparative effectiveness of more than two alternative interventions for the same condition. Before conducting a NMA, 3 major assumptions—similarity, transitivity, and consistency—should be checked. The statistical analysis consists of 5 steps. The first step is to draw a network geometry to provide an overview of the network relationship. The second step checks the assumption of consistency. The third step is to make the network forest plot or interval plot in order to illustrate the summary size of comparative effectiveness among various interventions. The fourth step calculates cumulative rankings for identifying superiority among interventions. The last step evaluates publication bias or effect modifiers for a valid inference from results. The synthesized evidences through five steps would be very useful to evidence-based decision-making in healthcare. Thus, NMA should be activated in order to guarantee the quality of healthcare system.
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Affiliation(s)
- Sungryul Shim
- Institute for Clinical Molecular Biology Research, Soonchunhyang University Hospital, Seoul, Korea
| | - Byung-Ho Yoon
- Department of Orthopaedic Surgery, Seoul Paik Hospital, ,Inje University College of Medicine, Seoul, Korea
| | - In-Soo Shin
- Department of Education, Jeonju University, Jeonju, Korea
| | - Jong-Myon Bae
- Department of Preventive Medicine, Jeju National University School of Medicine, Jeju, Korea
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Giordano A, Peruzzi M, Marullo AG, Frati G, Sciarretta S, Napolitano G, Biondi-Zoccai G. What We Learned with Recent Network Meta-analyses on Atherosclerosis Prevention and Treatment. Curr Atheroscler Rep 2017; 19:8. [PMID: 28161836 DOI: 10.1007/s11883-017-0645-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW The management of atherosclerosis requires a complex integration of the knowledge on its pathophysiology, patient values, and the synthesis of the global scientific evidence informing on its prevention and treatment. Novel statistical methods such as umbrella reviews and network meta-analyses (NMAs) offer a unique opportunity for integrating different sources of evidence stemming from randomized controlled trials (RCTs) or internally valid observational studies. We aimed to provide an updated perspective on the most important contributions of recent network meta-analyses on atherosclerosis prevention and treatment. RECENT FINDINGS We identified and appraised in detail 9 NMAs on atherosclerosis prevention, all published in 2016, whereas a total of 12 NMAs on atherosclerosis treatment published between 2014 and 2016 were identified. Most NMAs focused on RCTs only, with primary prevention analyses including on average more trials and patients than those focusing on secondary prevention. In most cases, conclusive findings for clinically relevant outcomes could be provided. Yet, several inconclusive findings were reported, suggesting thus that NMAs can also guide new research by emphasizing where new evidence is most needed. NMAs provide a unique opportunity for poignant synthesis of high-quality evidence. In particular, they seem particularly promising when the evidence base has reached a sufficient level of maturity, and several competing interventions require comprehensive and comparative risk-benefit appraisal.
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Choi M, Hyun MK, Choi S, Tchoe HJ, Lee SY, Son KM, Kim MJ, Jung YO, Kim HA. Comparative efficacy of biological agents in methotrexate-refractory rheumatoid arthritis patients: a Bayesian mixed treatment comparison. Korean J Intern Med 2017; 32:536-547. [PMID: 27253239 PMCID: PMC5432786 DOI: 10.3904/kjim.2015.135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/06/2015] [Accepted: 06/26/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Biological agents (biologics) targeting proinflammatory signaling have emerged as an important treatment option in rheumatoid arthritis (RA). Despite the clinical effectiveness of biologics for patients with RA who do not respond to 'traditional' disease-modifying anti-rheumatic drugs (DMARDs), there are concerns regarding their cost and long-term safety. In this study, we aimed to compare the efficacy of various biologics and traditional DMARDs in RA patients refractory to methotrexate (MTX). METHODS Four DMARDs (hydroxychloroquine, sulfasalazine, MTX, lef lunomide) and five anti-tumor necrosis factor drugs (adalimumab, etanercept, golimumab, inf liximab, and certolizumab) were selected. A systematic search of published studies was performed from inception through July 2013. Randomized trials of adults with MTX-refractory RA comparing two or more of the selected medications were included. Among 7,938 titles identified, in total, 16 head-to-head trials were selected. Two reviewers independently abstracted the study data and assessed methodological quality using the Cochrane Risk of Bias. Comparative efficacy was analyzed using a Bayesian mixed treatment comparison (MTC). RESULTS In total, 9, 4, and 11 studies were included for the outcome measures of the Health Assessment Questionnaire (HAQ), Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR) < 2.6 (remission), and American College of Rheumatology (ACR) 70 response, respectively. The treatments with the highest efficacy for each outcome measure were certolizumab combined with MTX, golimumab combined with MTX, and certolizumab combined with MTX, respectively. CONCLUSIONS Based on MTC analysis, using data from published randomized controlled trials, certolizumab and golimumab combined with MTX showed the highest efficacy in the three outcome measures (HAQ, DAS28-ESR < 2.6, and ACR 70 response) in MTX-refractory RA patients.
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Affiliation(s)
- Miyoung Choi
- National Evidence-Based Healthcare Collaboration Agency (NECA), Seoul, Korea
| | - Min Kyung Hyun
- Department of Preventive Medicine, Dongguk University College of Korean Medicine, Seoul, Korea
| | - Seongmi Choi
- Korea Appraisal Board, Real Estate R&D Institute, Seoul, Korea
| | - Ha Jin Tchoe
- National Evidence-Based Healthcare Collaboration Agency (NECA), Seoul, Korea
| | - Sung Yeon Lee
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Kyeong Min Son
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - Min-Jeong Kim
- National Evidence-Based Healthcare Collaboration Agency (NECA), Seoul, Korea
| | - Young Ok Jung
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
- Correspondence to Young Ok Jung, M.D. Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, 1 Singil-ro, Yeongdeungpo-gu, Seoul 07441, Korea Tel: +82-2-845-5305 Fax: +82-2-846-4669 E-mail:
| | - Hyun Ah Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
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Abstract
Many randomized controlled trials (RCTs) report more than one primary outcome. As a result, multivariate meta-analytic methods for the assimilation of treatment effects in systematic reviews of RCTs have received increasing attention in the literature. These methods show promise with respect to bias reduction and efficiency gain compared to univariate meta-analysis. However, most methods for multivariate meta-analysis have focused on pairwise treatment comparisons (i.e., when the number of treatments is two). Current methods for mixed treatment comparisons (MTC) meta-analysis (i.e., when the number of treatments is more than two) have focused on univariate or very recently, bivariate outcomes. To broaden their application, we propose a framework for MTC meta-analysis of multivariate (≥ 2) outcomes where the correlations among multivariate outcomes within- and between-studies are accounted for through copulas, and the joint modeling of multivariate random effects, respectively. We consider a Bayesian hierarchical model using Markov Chain Monte Carlo methods for estimation. An important feature of the proposed framework is that it allows for borrowing of information across correlated outcomes. We show via simulation that our approach reduces the impact of outcome reporting bias (ORB) in a variety of missing outcome scenarios. We apply the method to a systematic review of RCTs of pharmacological treatments for alcohol dependence, which tends to report multiple outcomes potentially subject to ORB.
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Affiliation(s)
- Yulun Liu
- Department of Biostatistics, The University of Texas Health Science Center Houston, Houston, Texas 77030, U.S.A
| | - Stacia M DeSantis
- Department of Biostatistics, The University of Texas Health Science Center Houston, Houston, Texas 77030, U.S.A
| | - Yong Chen
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, U.S.A
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Chaimani A, Caldwell DM, Li T, Higgins JPT, Salanti G. Additional considerations are required when preparing a protocol for a systematic review with multiple interventions. J Clin Epidemiol 2017; 83:65-74. [PMID: 28088593 DOI: 10.1016/j.jclinepi.2016.11.015] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 11/21/2016] [Accepted: 11/30/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The number of systematic reviews that aim to compare multiple interventions using network meta-analysis is increasing. In this study, we highlight aspects of a standard systematic review protocol that may need modification when multiple interventions are to be compared. STUDY DESIGN AND SETTING We take the protocol format suggested by Cochrane for a standard systematic review as our reference and compare the considerations for a pairwise review with those required for a valid comparison of multiple interventions. We suggest new sections for protocols of systematic reviews including network meta-analyses with a focus on how to evaluate their assumptions. We provide example text from published protocols to exemplify the considerations. CONCLUSION Standard systematic review protocols for pairwise meta-analyses need extensions to accommodate the increased complexity of network meta-analysis. Our suggested modifications are widely applicable to both Cochrane and non-Cochrane systematic reviews involving network meta-analyses.
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Joseph A, Ayyagari R, Xie M, Cai S, Xie J, Huss M, Sikirica V. Comparative efficacy and safety of attention-deficit/hyperactivity disorder pharmacotherapies, including guanfacine extended release: a mixed treatment comparison. Eur Child Adolesc Psychiatry 2017; 26:875-97. [PMID: 28258319 DOI: 10.1007/s00787-017-0962-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 02/13/2017] [Indexed: 10/29/2022]
Abstract
This study compared the clinical efficacy and safety of attention-deficit/hyperactivity disorder (ADHD) pharmacotherapy in children and adolescents 6-17 years of age. A systematic literature review was conducted to identify randomized controlled trials (RCTs) of pharmacologic monotherapies among children and adolescents with ADHD. A Bayesian network meta-analysis was conducted to compare change in symptoms using the ADHD Rating Scale Version IV (ADHD-RS-IV), Clinical Global Impression-Improvement (CGI-I) response, all-cause discontinuation, and adverse event-related discontinuation. Thirty-six RCTs were included in the analysis. The mean (95% credible interval [CrI]) ADHD-RS-IV total score change from baseline (active minus placebo) was -14.98 (-17.14, -12.80) for lisdexamfetamine dimesylate (LDX), -9.33 (-11.63, -7.04) for methylphenidate (MPH) extended release, -8.68 (-10.63, -6.72) for guanfacine extended release (GXR), and -6.88 (-8.22, -5.49) for atomoxetine (ATX); data were unavailable for MPH immediate release. The relative risk (95% CrI) for CGI-I response (active versus placebo) was 2.56 (2.21, 2.91) for LDX, 2.13 (1.70, 2.54) for MPH extended release, 1.94 (1.59, 2.29) for GXR, 1.77 (1.31, 2.26) for ATX, and 1.62 (1.05, 2.17) for MPH immediate release. Among non-stimulant pharmacotherapies, GXR was more effective than ATX when comparing ADHD-RS-IV total score change (with a posterior probability of 93.91%) and CGI-I response (posterior probability 76.13%). This study found that LDX had greater efficacy than GXR, ATX, and MPH in the treatment of children and adolescents with ADHD. GXR had a high posterior probability of being more efficacious than ATX, although their CrIs overlapped.
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Caldwell DM, Ades AE, Dias S, Watkins S, Li T, Taske N, Naidoo B, Welton NJ. A threshold analysis assessed the credibility of conclusions from network meta-analysis. J Clin Epidemiol 2016; 80:68-76. [PMID: 27430731 PMCID: PMC5176010 DOI: 10.1016/j.jclinepi.2016.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 06/28/2016] [Accepted: 07/08/2016] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To assess the reliability of treatment recommendations based on network meta-analysis (NMA). STUDY DESIGN AND SETTING We consider evidence in an NMA to be potentially biased. Taking each pairwise contrast in turn, we use a structured series of threshold analyses to ask: (1) "How large would the bias in this evidence base have to be before it changed our decision?" and (2) "If the decision changed, what is the new recommendation?" We illustrate the method via two NMAs in which a Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment for NMAs has been implemented: weight loss and osteoporosis. RESULTS Four of the weight-loss NMA estimates were assessed as "low" and six as "moderate" quality by GRADE; for osteoporosis, six were "low," nine were "moderate," and 1 was "high." The threshold analysis suggests plausible bias in 3 of 10 estimates in the weight-loss network could have changed the treatment recommendation. For osteoporosis, plausible bias in 6 of 16 estimates could change the recommendation. There was no relation between plausible bias changing a treatment recommendation and the original GRADE assessments. CONCLUSIONS Reliability judgments on individual NMA contrasts do not help decision makers understand whether a treatment recommendation is reliable. Threshold analysis reveals whether the final recommendation is robust against plausible degrees of bias in the data.
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Affiliation(s)
- Deborah M Caldwell
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK.
| | - A E Ades
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Sofia Dias
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Sarah Watkins
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Tianjing Li
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, USA
| | - Nichole Taske
- Centre for Clinical Practice, National Institute for Health and Care Excellence, 10 Spring Gardens, London SW1A 2BU, UK
| | - Bhash Naidoo
- Centre for Clinical Practice, National Institute for Health and Care Excellence, 10 Spring Gardens, London SW1A 2BU, UK
| | - Nicky J Welton
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
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Han Y, Stevens AL, Dashtipour K, Hauser RA, Mari Z. A mixed treatment comparison to compare the efficacy and safety of botulinum toxin treatments for cervical dystonia. J Neurol 2016; 263:772-80. [PMID: 26914922 PMCID: PMC4826665 DOI: 10.1007/s00415-016-8050-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 11/05/2015] [Revised: 01/23/2016] [Accepted: 01/25/2016] [Indexed: 12/17/2022]
Abstract
A systematic pair-wise comparison of all available botulinum toxin serotype A and B treatments for cervical dystonia (CD) was conducted, as direct head-to-head clinical trial comparisons are lacking. Five botulinum toxin products: Dysport® (abobotulinumtoxinA), Botox® (onabotulinumtoxinA), Xeomin® (incobotulinumtoxinA), Prosigne® (Chinese botulinum toxin serotype A) and Myobloc® (rimabotulinumtoxinB) have demonstrated efficacy for managing CD. A pair-wise efficacy and safety comparison was performed for all toxins based on literature-reported clinical outcomes. Multi-armed randomized controlled trials (RCTs) were identified for inclusion using a systematic literature review, and assessed for comparability based on patient population and efficacy outcome measures. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) was selected as the efficacy outcome measurement for assessment. A mixed treatment comparison (MTC) was conducted using a Bayesian hierarchical model allowing indirect comparison of the interventions. Due to the limitation of available
clinical data, this study only investigated the main effect of toxin treatments without explicitly considering potential confounding factors such as gender and formulation differences. There was reasonable agreement between the number of unconstrained data points, residual deviance and pair-wise results. This research suggests that all botulinum toxin serotype A and serotype B treatments were effective compared to placebo in treating CD, with the exception of Prosigne. Based on this MTC analysis, there is no significant efficacy difference between Dysport, Botox, Xeomin and Myobloc at week four post injection. Of the adverse events measured, neither dysphagia nor injection site pain was significantly greater in the treatment or placebo groups.
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Affiliation(s)
- Yi Han
- WG Consulting, 200 Fifth Avenue, New York, NY, 10010, USA.
| | | | - Khashayar Dashtipour
- Faculty of Medical Offices, School of Medicine, Loma Linda University, 11370 Anderson, Suite B-100, Loma Linda, CA, 92354, USA
| | - Robert A Hauser
- Health Byrd Institute, University of South Florida, 4001 E. Fletcher Ave, 6th Floor, Tampa, FL, 33613, USA
| | - Zoltan Mari
- School of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Meyer 6-181B, Baltimore, MD, 21287, USA
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Svedsater H, Stynes G, Wex J, Frith L, Leather D, Castelnuovo E, Detry M, Berry S. Once-daily fluticasone furoate/vilanterol versus twice daily combination therapies in asthma- mixed treatment comparisons of clinical efficacy. Asthma Res Pract 2016; 2:4. [PMID: 27965772 PMCID: PMC5142397 DOI: 10.1186/s40733-015-0016-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 12/16/2015] [Indexed: 11/13/2022] Open
Abstract
Background Fluticasone furoate (FF)/vilanterol (VI) is a once-daily inhaled corticosteroid (ICS)/long-acting beta2 agonist (LABA) combination. FF/VI, 92/22mcg and 184/22mcg, are approved in Europe as maintenance therapy in persistent asthma. We report data from mixed treatment comparisons (MTC) of once-daily FF/VI against established twice-daily ICS/LABA combination therapies on clinical efficacy outcomes. Methods Data from 31 parallel-group randomised controlled trials (RCTs) of ICS/LABA, of ≥8 weeks’ duration in patients aged ≥12 years with asthma, identified by systematic review, were analysed using covariate-adjusted Bayesian hierarchical models for four efficacy outcomes (primary analysis). Lung function, assessed by change from baseline morning peak expiratory flow (PEF) (n = 18 studies) and forced expiratory volume in 1 s (FEV1) (n = 28), was the outcome of primary interest. Secondary objectives were assessment of relative efficacy in terms of exacerbation rates (n = 6) and health status (n = 7). Overall, 24 different treatment arms were included in the MTC; we report findings comparing FF/VI (92/22mcg and 184/22mcg) with fluticasone propionate/salmeterol (FP/SAL) (250/50mcg and 500/50mcg) and budesonide/formoterol (BUD/FORM) (320/9mcg and 640/18mcg). Results For PEF (margin = 12 l/min), FF/VI 92/22mcg demonstrated ≥94 % probability and FF/VI 184/22mcg >99 % probability of non-inferiority to corresponding doses of both FP/SAL and BUD/FORM. For FEV1 (margin = 100 ml), FF/VI demonstrated ≥98 % (92/22mcg) and >99 % (184/22mcg) probability of non-inferiority to both FP/SAL and BUD/FORM. Findings for exacerbations were inconclusive due to lack of data: FF/VI 92/22mcg demonstrated 74 % and 82 % probability of non-inferiority (margin = 10 %) to FP/SAL 250/50mcg and BUD/FORM 320/9mcg, respectively. For Asthma Quality of Life Questionnaire (AQLQ) score, FF/VI 92/22mcg demonstrated >99 % and 90 % probability of non-inferiority (margin = 0.25) to FP/SAL 250/50mcg and BUD/FORM 320/9mcg. Data were unavailable to assess non-inferiority of FF/VI 184/22mcg on exacerbations or AQLQ. Conclusions Both strengths of once-daily FF/VI in asthma were comparable with corresponding doses of twice-daily FP/SAL and BUD/FORM in terms of lung function in this MTC analysis. FF/VI 92/22mcg was comparable with FP/SAL and BUD/FORM on AQLQ, but exacerbation results were inconclusive. Model limitations include disconnected treatment networks and variability across studies. Our data support previous RCT findings suggesting that the efficacy of once-daily FF/VI in improving lung function and health status in asthma is comparable with twice-daily ICS/LABAs. Electronic supplementary material The online version of this article (doi:10.1186/s40733-015-0016-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Henrik Svedsater
- Value Evidence and Outcomes, GlaxoSmithKline, Stockley Park West, Blg 10, 1-3 Iron Bridge Road, Uxbridge, Middlesex UB11 1BT UK
| | - Gillian Stynes
- Value Evidence and Outcomes, GlaxoSmithKline, Stockley Park West, Blg 10, 1-3 Iron Bridge Road, Uxbridge, Middlesex UB11 1BT UK
| | - Jaro Wex
- Value Evidence and Outcomes, GlaxoSmithKline, Stockley Park West, Blg 10, 1-3 Iron Bridge Road, Uxbridge, Middlesex UB11 1BT UK
| | - Lucy Frith
- Respiratory Medicines Development Centre, GlaxoSmithKline, Stockley Park, UK
| | - David Leather
- Respiratory Medicines Development Centre, GlaxoSmithKline, Stockley Park, UK
| | - Emanuela Castelnuovo
- Health Investment Evidence (Formerly), Global Health Outcomes, GlaxoSmithKline, Stockley Park, UK
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Stevens JW, Khunti K, Harvey R, Johnson M, Preston L, Woods HB, Davies M, Goyder E. Preventing the progression to type 2 diabetes mellitus in adults at high risk: a systematic review and network meta-analysis of lifestyle, pharmacological and surgical interventions. Diabetes Res Clin Pract 2015; 107:320-31. [PMID: 25638454 DOI: 10.1016/j.diabres.2015.01.027] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 10/31/2014] [Accepted: 01/02/2015] [Indexed: 11/29/2022]
Abstract
AIMS Individuals with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) have an increased risk of progression to Type 2 diabetes mellitus. The objective of this review was to quantify the effectiveness of lifestyle, pharmacological and surgical interventions in reducing the progression to Type 2 diabetes mellitus in people with IFG or IGT. METHODS A systematic review was carried out. A network meta-analysis (NMA) of log-hazard ratios was performed. Results are presented as hazard ratios and the probabilities of treatment rankings. RESULTS 30 studies were included in the NMA. There was a reduced hazard of progression to Type 2 diabetes mellitus associated with all interventions versus standard lifestyle advice; glipizide, diet plus pioglitazone, diet plus exercise plus metformin plus rosiglitazone, diet plus exercise plus orlistat, diet plus exercise plus pedometer, rosiglitazone, orlistat and diet plus exercise plus voglibose produced the greatest effects. CONCLUSIONS Lifestyle and some pharmacological interventions are beneficial in reducing the risk of progression to Type 2 diabetes mellitus. Lifestyle interventions require significant behaviour changes that may be achieved through incentives such as the use of pedometers. Adverse events and cost of pharmacological interventions should be taken into account when considering potential risks and benefits.
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Biondi-Zoccai G, Abbate A, Benedetto U, Palmerini T, D'Ascenzo F, Frati G. Network meta-analysis for evidence synthesis: what is it and why is it posed to dominate cardiovascular decision making? Int J Cardiol 2015; 182:309-14. [PMID: 25585376 DOI: 10.1016/j.ijcard.2015.01.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/22/2014] [Accepted: 01/04/2015] [Indexed: 02/08/2023]
Abstract
Clinical decision-making requires synthesis of an often complex evidence base. Novel tools have been developed building upon the historical approach of reviewing the literature focusing on a specific topic. Stemming from qualitative reviews, systematic reviews of randomized clinical trials, typically encompassing statistical pooling with pairwise meta-analysis, have been devised and are now considered one of the uppermost ladders in the hierarchy of clinical evidence. In the last decade, the exponential growth in randomized trials and the introduction of original computational methods have created the novel opportunity to compare indirectly competing treatments, as well as combining effect estimates stemming from head-to-head trials with those obtained by indirect comparisons. These methods include adjusted indirect comparison meta-analysis, network meta-analysis, and mixed treatment comparison. While still the focus of intense research and debate, they represent a powerful tool for evidence synthesis and comparative effectiveness in cardiovascular research, and thus are likely to become increasingly popular and impactful in shaping research agenda and clinical practice. This is clearly highlighted by a number of recent landmark network meta-analyses on smoking cessation therapies, coronary stents, and management of patent foramen ovale in patients with history of cryptogenic stroke.
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Affiliation(s)
- Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Eleonora Lorillard Spencer Cenci Foundation, Rome, Italy; VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA.
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Umberto Benedetto
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
| | - Tullio Palmerini
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy
| | | | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy
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Sun Y, van Valkenhoef G, Morel T. A mixed treatment comparison of gabapentin enacarbil, pramipexole, ropinirole and rotigotine in moderate-to-severe restless legs syndrome. Curr Med Res Opin 2014; 30:2267-78. [PMID: 25050588 DOI: 10.1185/03007995.2014.946124] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE A mixed treatment comparison (MTC) was performed to investigate the relative efficacy and safety of licensed pharmaceuticals for moderate-to-severe restless legs syndrome (RLS). METHODS RLS trials published over the past 10 years were identified via systematic literature searches of MEDLINE, Embase, Cochrane CENTRAL, and manufacturers' websites. MTC was performed with WinBUGS software using a Bayesian approach. Identified primary outcomes: change in International RLS Study Group Rating Scale (IRLS) at week 12 and end of maintenance (EoM). SECONDARY OUTCOMES IRLS and Clinical Global Impression - Improvement Scale (CGI-I) responders, RLS-6 items and adverse events (AEs). RESULTS Twenty-eight clinical trials were identified. Fifteen were included in the primary analysis. Indirect comparisons were established among gabapentin enacarbil, pramipexole, ropinirole, rotigotine and placebo. Overall, the four active treatments showed similar efficacies as assessed by changes in IRLS scores, IRLS responders, CGI-I responders, and RLS-6 scores. The sole exception was change in IRLS at week 12, for which rotigotine was likely more efficacious than ropinirole (mean difference: -2.52 [95% CrI: -4.74, -0.40]). Indirect comparisons on safety endpoints indicated ropinirole was associated with a higher risk of nausea than the other agents, and was more likely to result in discontinuations due to lack of efficacy than pramipexole. Nausea was likely more frequent with pramipexole than gabapentin enacarbil, and rotigotine was more likely to result in discontinuation due to AEs than ropinirole and pramipexole. CONCLUSIONS This MTC confirmed the superiority of gabapentin enacarbil, pramipexole, ropinirole, and rotigotine above placebo in alleviating RLS symptoms. Compared to ropinirole, rotigotine showed some additional benefit in terms of change in IRLS at Week 12. Choice of RLS drugs requires careful evaluation of effectiveness and safety profiles in clinical practice. Due to lack of head-to-head trials, inconsistency could not be assessed in our analysis. Head-to-head trials on a more homogeneous population are needed to validate the MTC results.
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Nikolakopoulou A, Mavridis D, Salanti G. Using conditional power of network meta-analysis (NMA) to inform the design of future clinical trials. Biom J 2014; 56:973-90. [PMID: 25225031 DOI: 10.1002/bimj.201300216] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [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: 10/01/2013] [Revised: 05/09/2014] [Accepted: 05/31/2014] [Indexed: 01/19/2023]
Abstract
Clinical trials are typically designed with an aim to reach sufficient power to test a hypothesis about relative effectiveness of two or more interventions. Their role in informing evidence-based decision-making demands, however, that they are considered in the context of the existing evidence. Consequently, their planning can be informed by characteristics of relevant systematic reviews and meta-analyses. In the presence of multiple competing interventions the evidence base has the form of a network of trials, which provides information not only about the required sample size but also about the interventions that should be compared in a future trial. In this paper we present a methodology to evaluate the impact of new studies, their information size, the comparisons involved, and the anticipated heterogeneity on the conditional power (CP) of the updated network meta-analysis. The methods presented are an extension of the idea of CP initially suggested for a pairwise meta-analysis and we show how to estimate the required sample size using various combinations of direct and indirect evidence in future trials. We apply the methods to two previously published networks and we show that CP for a treatment comparison is dependent on the magnitude of heterogeneity and the ratio of direct to indirect information in existing and future trials for that comparison. Our methodology can help investigators calculate the required sample size under different assumptions about heterogeneity and make decisions about the number and design of future studies (set of treatments compared).
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Affiliation(s)
- Adriani Nikolakopoulou
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, University Campus, Ioannina, 45110, Greece
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Orme M, Fenici P, Lomon ID, Wygant G, Townsend R, Roudaut M. A systematic review and mixed-treatment comparison of dapagliflozin with existing anti-diabetes treatments for those with type 2 diabetes mellitus inadequately controlled by sulfonylurea monotherapy. Diabetol Metab Syndr 2014; 6:73. [PMID: 25006351 PMCID: PMC4085736 DOI: 10.1186/1758-5996-6-73] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 05/15/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND To compare the first-in-class sodium glucose co-transporter 2 (SGLT2) inhibitor, dapagliflozin, with existing type 2 diabetes mellitus (T2DM) treatment options available within the European Union (EU) for add-on therapy to sulfonylureas (SUs). METHODS A systematic review was conducted to identify randomised controlled trials (RCTs) in T2DM patients inadequately controlled by SU monotherapy. Direct meta-analysis, Bucher indirect comparisons and Bayesian network meta-analysis (NMA) were conducted on studies meeting predefined inclusion criteria. Sufficient data were available to assess three clinical endpoints at 24 (+/- 6) weeks follow-up: mean change in HbA1c from baseline, mean change in weight from baseline, and the proportion of patients experiencing at least one episode of hypoglycaemia. The effect of confounding baseline factors was explored through covariate analyses. RESULTS The search identified 1,901 unique citations, with 1,870 excluded based on title/abstract. From reviewing full-texts of the remaining 31 articles, 5 studies were considered eligible for analysis. All studies were comparable in terms of baseline characteristics, including: HbA1c, age and body mass index (BMI). In addition to dapagliflozin, sufficient data for meta-analysis was available for three dipeptidyl peptidase-4 (DPP-4) inhibitors and one glucagon-like peptide-1 (GLP-1) analogue. Based on fixed-effect NMA, all treatment classes resulted in statistically significant decreases in HbA1c at follow-up compared to placebo. Dapagliflozin treatment resulted in significantly decreased weight at follow-up compared to placebo (-1.54 kg; 95% CrI -2.16, -0.92), in contrast to treatment with GLP-1 analogues (-0.65 kg; 95% CrI -1.37, 0.07) and DPP-4 inhibitors (0.57 kg; 95% CrI 0.09, 1.06). The odds of hypoglycaemia were similar to placebo for dapagliflozin and DPP-4 inhibitor add-on treatment, but significantly greater than placebo for GLP-1 analogue add-on treatment (10.89; 95% CrI 4.24, 38.28). Assessment of NMA model heterogeneity was hindered by the small size of the network. CONCLUSIONS Dapagliflozin, DPP-4 inhibitors and GLP-1 analogues, in combination with SU, all provided better short-term glycaemic control compared to SU monotherapy. Dapagliflozin was the only add-on therapy that had both a favourable weight and hypoglycaemia profile compared to the other classes of treatment evaluated.
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Affiliation(s)
- Michelle Orme
- ICERA Consulting Ltd, 17 Redbridge Close, Swindon SN5 8ZL, UK
| | - Peter Fenici
- Bristol-Myers Squibb, 3 rue Joseph Monier, Rueil-Malmaison 92500, France
| | | | - Gail Wygant
- Bristol-Myers Squibb, 100 Nassau Park Blvd, Princeton, NJ 08543, USA
| | - Rebecca Townsend
- Affiliation at time of study: AstraZeneca, Rue Egide van Ophemstraat 110, Brussels B-1180, Belgium
| | - Marina Roudaut
- Bristol-Myers Squibb, 3 rue Joseph Monier, Rueil-Malmaison 92500, France
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Biondi-Zoccai G, Lotrionte M, Thomsen HS, Romagnoli E, D'Ascenzo F, Giordano A, Frati G. Nephropathy after administration of iso-osmolar and low-osmolar contrast media: evidence from a network meta-analysis. Int J Cardiol 2014; 172:375-80. [PMID: 24502883 DOI: 10.1016/j.ijcard.2014.01.075] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/18/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVES Contrast-induced nephropathy (CIN) may be a severe complication to the administration of iodine-based contrast media for diagnostic or interventional procedure using radiation exposure. Whether there is a difference in nephrotoxic potential between the various agents is uncertain. We aimed to perform a systematic review and network meta-analysis of randomized trials on iodine-based contrast agents. METHODS Randomized trials of low-osmolar or iso-osmolar contrast media were searched in CENTRAL, Google Scholar, MEDLINE/PubMed, and Scopus. Risk of CIN was appraised within a hierarchical Bayesian model computing absolute rates (AR) and odds ratios (OR) with 95% credibility intervals, and probability of being best (Pbest) for each agent. RESULTS A total of 42 trials (10048 patients) were included focusing on 7 different iodine-based contrast media. Risk of CIN was similarly low with iodixanol (AR=5.7% [2.2%-13.9%], Pbest=18.8%), iomeprol (AR=6.0% [2.2%-15.4%], Pbest=24.8%), iopamidol (AR=6.1% [2.2%-15.5%], Pbest=21.5%), and ioversol (AR=6.0% [2.1%-16.4%], Pbest=31.3%). Conversely, CIN was twice as common with iohexol (AR=11.2% [4.1%-29.5%], Pbest=0.1%) and ioxaglate (AR=11.0% [4.0%-26.9%], Pbest<0.1%), with both proving less safe than iodixanol (respectively OR=2.18 [1.22-3.92] and 2.05 [1.26-3.29]), iomeprol (OR=2.08 [1.04-4.17] and 1.96 [1.06-3.48]) and iopamidol (OR=2.04 [1.15-3.85] and 1.92 [1.06-3.45]). Data on iopromide were less conclusive (AR=6.9% [2.6%-17.1%], Pbest=3.6%). CONCLUSIONS Iodixanol, iomeprol, iopamidol and ioversol are iodine-based contrast media with a similar renal safety profile. Iohexol and ioxaglate have a poorer renal safety profile, whereas further data may be required on iopromide.
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Affiliation(s)
- Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.
| | - Marzia Lotrionte
- Heart Failure and Cardiac Rehabilitation Unit, Columbus Integrated Complex, Rome, Italy
| | | | | | | | - Arturo Giordano
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy; Unità Operativa di Emodinamica, Casa di Salute Santa Lucia, San Giuseppe Vesuviano, Italy
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
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Maman K, Aballea S, Nazir J, Desroziers K, Neine ME, Siddiqui E, Odeyemi I, Hakimi Z. Comparative efficacy and safety of medical treatments for the management of overactive bladder: a systematic literature review and mixed treatment comparison. Eur Urol 2013; 65:755-65. [PMID: 24275310 DOI: 10.1016/j.eururo.2013.11.010] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [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: 07/23/2013] [Accepted: 11/07/2013] [Indexed: 11/25/2022]
Abstract
CONTEXT Overactive bladder (OAB) treatment guidelines recommend antimuscarinics as first-line pharmacologic therapy. Mirabegron is a first-in-class β3-adrenoceptor agonist licensed for the treatment of OAB and has shown to be well tolerated and effective in the treatment of OAB symptoms. OBJECTIVE To assess the relative efficacy and tolerability of OAB medications, specifically mirabegron 50 mg versus antimuscarinics in patients with OAB. EVIDENCE ACQUISITION A systematic literature search was performed on published peer-reviewed articles from 2000 to 2013. This review included randomised controlled trials (RCTs) studying changes in symptoms (micturition frequency, incontinence, and urgency urinary incontinence [UUI] episodes) and incidence of the most frequently reported adverse events (dry mouth, constipation) associated with current OAB medications. The following drugs were considered in addition to mirabegron: darifenacin, tolterodine immediate release (IR) and extended release (ER), oxybutynin IR/ER, trospium, solifenacin, and fesoterodine. Bayesian mixed treatment comparisons (MTCs) were performed for efficacy (micturition, incontinence, UUI) and tolerability (dry mouth, constipation, blurred vision). EVIDENCE SYNTHESIS Overall, 44 RCTs involving 27,309 patients were included. The MTCs showed that mirabegron 50 mg was as efficacious as antimuscarinics in reducing the frequency of micturition incontinence and UUI episodes, with the exception of solifenacin 10 mg that was more efficacious than mirabegron 50 mg in improving micturition frequency and frequency of UUI. Mirabegron 50 mg had an incidence of dry mouth similar to placebo and significantly lower than all included antimuscarinics. CONCLUSIONS Mirabegron 50 mg had similar efficacy to most antimuscarinics and lower incidence of dry mouth, the most common adverse event reported with antimuscarinics and one of the main causes of discontinuation of treatment. Despite being a powerful tool for evidence-based health care evaluation, the Bayesian MTC method has limitations. Further head-to-head comparisons between mirabegron and antimuscarinics should be conducted to confirm our results.
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Affiliation(s)
| | | | | | | | | | - Emad Siddiqui
- Astellas Pharma Europe, Chertsey, UK; Department of Urology, Ealing Hospital, London, UK
| | | | - Zalmai Hakimi
- Astellas Pharma Global Development, Leiden, The Netherlands
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Lee AW. Review of mixed treatment comparisons in published systematic reviews shows marked increase since 2009. J Clin Epidemiol 2014; 67:138-43. [PMID: 24090930 DOI: 10.1016/j.jclinepi.2013.07.014] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 07/17/2013] [Accepted: 07/19/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To identify and summarize published systematic reviews that report results of meta-analyses that combined direct and indirect comparisons. STUDY DESIGN AND SETTING Narrative review of mixed treatment comparisons (MTCs) reported in systematic reviews of health interventions. MEDLINE, MEDLINE In-Process, Embase, CINAHL, DARE, the Cochrane Database of Systematic Reviews, and SIGLE were searched for reviews published up to June 2012 in which a meta-analysis had been conducted that combined direct and indirect comparisons among more than two interventions. RESULTS Reviews reporting MTCs are difficult to identify when searching major databases. These databases offer no way to identify MTCs, and authors use various names when reporting them. Of the 201 eligible reviews identified, more than three-quarters had been published in full. MTC methods have been used to study a wide range of clinical topics. The reported use of these methods has increased rapidly since 2009, and results from MTCs are commonly used in health policy decisions, through the evidence considered in health technology assessments. CONCLUSION In view of the increasing use of MTCs, indexing of this study type in databases and a consensus on terminology and standards for conduct and reporting would be timely.
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