James Tacklind

Antiviral Therapy for Adults With Chronic Hepatitis B: A Systematic Review for a National Institutes of Health Consensus Development Conference

Hepatitis B is highly prevalent, with 350 million chronic cases worldwide (1). Despite immunization efforts, 4713 incident cases of hepatitis B were diagnosed in the United States in 2006 (2). An estimated 2000 to 4000 deaths per year in the United States are related to chronic hepatitis B liver diseases (3), including liver cirrhosis and hepatocellular carcinoma (4). Because most patients are asymptomatic, treatment goals of antiviral therapy include long-term prevention of progression, development of cirrhosis and liver failure, and hepatocellular carcinoma. Short-term intermediate laboratory responses have been proposed as potential surrogate measures of treatment effects on clinical outcomes (1). Normalization of liver enzyme levels, viral suppression and clearance, reduction in histologic scores of liver inflammation or fibrosis, and combinations of these outcomes have been used to measure response to antiviral drugs or development of antiviral resistance (1, 5). Seven antiviral agents are approved to treat hepatitis B in the United States, including oral medications (lamivudine, telbuvidine, adefovir, tenofovir, and entecavir) and injected interferons (standard interferon-2b and pegylated interferon-2a). Other agents are under investigation. The U.S. Food and Drug Administration approved tenofovir for adults in August 2008 on the basis of ongoing, unpublished trials that compared tenofovir with adefovir on intermediate outcomes, the results of which were not available for our review (6). This review was commissioned as background material for the National Institutes of Health Consensus Development Conference on Management of Chronic Hepatitis B in Adults to synthesize the published evidence about the effectiveness of interferon therapy, oral therapy, and various combinations with defined or continuous courses of treatment. The full report, including a detailed description of our methods, is available at www.ahrq.gov/downloads/pub/evidence/pdf/hepb/hepb.pdf (7). Methods Data Sources and Study Selection We searched MEDLINE, PubMed, the Cochrane Library (8), and other databases (911). We included randomized, controlled clinical trials (RCTs) of adults with chronic hepatitis B published in English after 1989 that reported death; incidence of hepatocellular carcinoma or liver failure; prevalence and incidence of cirrhosis; presence or seroconversion of hepatitis B e antigen (HBeAg) or surface antigen (HBsAg); viral load of hepatitis B virus (HBV) DNA; aspartate aminotransferase and alanine aminotransferase (ALT) levels; and histologic necroinflammatory or fibrosis scores after therapy with interferon-2b, pegylated interferon-2a, lamivudine, adefovir, entecavir, and telbivudine (12). Studies that enrolled at least 50 adults and provided treatment for 24 weeks or more were eligible for this review. Interferon studies of any size were eligible if participants were given treatment for at least 12 weeks. We excluded studies evaluating pregnant women, patients with hepatocellular carcinoma or HIV infection at baseline, patients undergoing chemotherapy or liver transplantation, or patients with several causes of hepatitis, unless outcomes for participants meeting our eligibility criteria were reported separately. The full report describes the search strategies (7). We included publications from the multinational HBV 99-01 Study Group assessing pegylated interferon-2b, a treatment that has been intensively examined in patients with chronic hepatitis B but is not yet approved in the United States (13). Three investigators independently measured study eligibility (14). Data Extraction and Quality Assessment Three researchers independently evaluated the studies and extracted data to detect errors and discrepancies (14). We abstracted the number of events among treatment groups to calculate rates, relative risks (RRs), and absolute risk differences (15). We abstracted the number of patients randomly assigned to each treatment group as the denominator to calculate estimates, applying the intention-to-treat principle. We recorded intervals for outcome assessments in weeks from randomization for the active-treatment period and from the end of treatment for follow-up assessments. We prioritized clinical outcomes in the assessment of treatment benefits and harms. Sustained HBsAg loss or seroconversion was considered the criterion for resolution of hepatitis B viral infection and a major goal of antiviral therapy (1). Liver histologic outcomes included improved necroinflammatory and fibrosis scores. Sustained ALT normalization as diagnostic criteria of hepatocyte injury and sustained clearance of HBV DNA were assigned as secondary outcomes. Although positive associations with better clinical outcomes exist in observational studies, both outcomes may reverse after treatment. Because low levels of evidence from observational studies suggested that HBeAg-negative status was associated with worse clinical outcomes, we defined sustained HBeAg seroconversion as a desirable intermediate outcome. We analyzed RCTs for participant selection, duration of and loss to follow-up, intention-to-treat principle, masking of treatment status, randomization scheme and its adequacy, allocation concealment, and justification of sample sizes (16). We assessed the level of evidence on the basis of the Grading of Recommendations Assessment, Development and Evaluation Working Group criteria (17, 18). We assigned a low level of evidence when data were from small RCTs or RCTs with flaws in design or analysis or were from post hoc subgroup analysis. We assigned a moderate level of evidence when a single, large multinational study or several small RCTs reported consistent associations between antiviral agents and outcomes and a high level of evidence when several high-quality studies in applicable patients reported consistent sustained effects at least 6 months after therapy. Data Synthesis and Analysis The full report includes evidence tables that summarize results of individual studies (7). We compared baseline data across the studies to test for differences in the target sample and to detect unusual patterns in the data (1921). Analyses were conducted separately for clinical, biochemical, virologic, and histologic outcomes and for RRs and absolute risk differences. The protocol for meta-analyses was created according to recommendations (22, 23) to assess the consistency of the association between treatments and outcomes with random-effects models (24). Pooling criteria included the same operational definitions of outcomes and drug interventions (23). We used chi-square tests to assess heterogeneity (25, 26). Calculations used Stata statistical software, version 9.2 (StataCorp, College Station, Texas) (27). We assumed the presence of publication bias and did not use statistical tests for bias caused by sparse and heterogeneous data (14, 2830). Role of the Funding Source The Agency for Healthcare Research and Quality suggested the initial questions and provided copyright release for this manuscript. The funding source had no role in the literature search, data analysis, conduct of the study, preparation of the review, or interpretation of the results. The funding source reviewed and approved the submitted manuscript without revisions. Results Ninety-three articles represented 60 unique RCTs (31102). The full report contains the study flow diagram and the appendix with excluded studies (7). Studies enrolled 20 to 1367 patients who were predominately HBeAg-positive. Men constituted 78% of enrollees. Most enrollees were Asian (64%) or white (30%). The estimated duration of infection, reported in 8 studies, ranged from approximately 2 to 6 years. However, individual patient duration of infection ranged from 6 months to 20 years (3140). Clinical Outcomes Studies that reported death, liver-related death, hepatocellular carcinoma, hepatic decompensation, or cirrhosis (Table) were not designed and did not have sufficient power to reliably assess drug effects on these clinical outcomes. Table. Effects of Drug Therapies for Chronic Hepatitis B on Clinical Outcomes Death was assessed in 13 studies, with very few deaths reported (36, 3950). Low-level evidence suggested that lamivudine (41), entecavir (4347), interferon-2b (36, 39, 48), pegylated interferon-2a (49), pegylated interferon-2b (50), and adefovir (42) did not decrease mortality. Two studies assessed cirrhosis with small sample size and relatively short-term treatment with interferon-2b. Reduction in cirrhosis incidence (40) or prevalence (51) was not observed. Few events occurred, and the studies were not sufficiently powered to detect differences in cirrhosis (52). Three studies reported hepatic decompensation with very few events (44, 47, 53). There was no significant difference in hepatic decompensation after administration of lamivudine versus placebo (55) or entecavir versus lamivudine (44, 47). A multicenter study involving 651 Asian patients (58% were HBeAg-positive) with confirmed cirrhosis (61%) or advanced fibrosis (41) reported a decrease in disease progression (7.8% vs. 17.7% [hazard ratio, 0.45; P= 0.001]) for lamivudine versus placebo. Disease progression was the first occurrence of an increase of at least 2 points in the ChildPugh score, hepatic decompensation, bleeding varices, renal insufficiency, bleeding gastric or esophageal varices, spontaneous bacterial peritonitis with proven sepsis, hepatocellular carcinoma, or death related to liver disease. Four studies reported hepatocellular carcinoma. None demonstrated a statistically significant difference compared with no treatment after lamivudine (41), interferon-2b (54), prolonged adefovir therapy (42), or interferon monotherapy with and without corticosteroids (51). Incidence of hepatocellular carcinoma did not differ between lamivudine and placebo in the multicenter study of patients with confirmed cirrhosis or advanced fibrosis mention

Management of Hyperglycemia, Dyslipidemia, and Albuminuria in Patients With Diabetes and CKD: A Systematic Review for a KDOQI Clinical Practice Guideline

BACKGROUND In 2007, the National Kidney Foundation (NKF) published clinical practice guidelines and recommendations for treating patients with diabetes and kidney diseases. Given recent studies that may enhance our understanding of the benefits and harms of glycemic, lipid, and albuminuria management in patients with diabetes and chronic kidney disease (CKD), the NKF commissioned a systematic review to evaluate data on the management of these patients. STUDY DESIGN Systematic review and evidence synthesis. SETTING & POPULATION Patients with type 1 or 2 diabetes with or without CKD. SELECTION CRITERIA FOR STUDIES English-language publications indexed in the MEDLINE database from January 2003 to October 2010, as well as cited references in these publications and publications identified after consultation with the NKF Diabetes Work Group were screened. Randomized controlled trials providing evidence for the management of hyperglycemia, dyslipidemia, and albuminuria in individuals with diabetes were included. INTERVENTIONS (1) Intensive glycemic control; (2) lipid management; (3) interventions aimed at prevention of incident albuminuria and/or progression of albuminuria in normotensive patients. OUTCOMES For all interventions, all-cause mortality was the primary outcome and secondary clinical outcomes included death from cardiovascular causes, incident kidney failure, and nonfatal cardiovascular events. Intermediate outcomes included changes in albuminuria and measures of kidney function. For intensive glycemic control only, severe and mild hypoglycemia were secondary and intermediate outcomes, respectively. RESULTS 5 studies (n=27,159) assessed the impact of intensive versus conventional glycemic control strategies on clinical outcomes in type 2 diabetes. Intensive glycemic control reduced the development of micro- and macroalbuminuria, but did not reduce the incidence of primary or secondary clinical outcomes and was associated with a 2.5-fold increase in severe hypoglycemia. 11 studies (n=7,539) assessed lipid management. Statins did not reduce all-cause mortality or stroke compared to placebo in adults with diabetes and CKD. Fenofibrate increased regression of microalbuminuria to normoalbuminuria compared to placebo. 3 studies reported inconsistent effects of different angiotensin II receptor blockers on the incidence of microalbuminuria, and one study reported that telmisartan reduced macroalbuminuria in normotensive participants. No study demonstrated a benefit on primary or secondary clinical outcomes. LIMITATIONS Patients with CKD constituted a subgroup in most studies. Substantial heterogeneity with respect to population, interventions, outcome measures, and duration of follow-up. CONCLUSIONS Intensive glycemic control and lipid interventions did not improve clinical outcomes in patients with type 2 diabetes. Although interventions typically improved albuminuria, evidence was insufficient to determine whether treatment of albuminuria in normotensive patients provides beneficial effects on clinical outcomes. More intensive clinical management of patients with diabetes and CKD has inherent risks, including severe hypoglycemia, which should be considered when formulating treatment strategies.

Serenoa repens monotherapy for benign prostatic hyperplasia (BPH): an updated Cochrane systematic review

Whats known on the subject? and What does the study add?

5-α-Reductase inhibitors for prostate cancer chemoprevention: an updated Cochrane systematic review.

•  To estimate the benefits and harms of 5‐α‐reductase inhibitors (5‐α‐RIs) in preventing prostate cancer.

Management of Chronic Hepatitis B

OBJECTIVES Synthesize evidence of the natural history of chronic hepatitis B (CHB) and effects and harms of antiviral drugs on clinical, virological, histological, and biochemical outcomes. DATA SOURCES MEDLINE, electronic databases, and manual searches of systematic reviews. REVIEW METHODS We included original observational studies to assess natural history and randomized controlled trials (RCTs) of adults with CHB published in English to assess treatment effects and harms if they reported mortality, incidence of hepato-cellular carcinoma (HCC), cirrhosis or failure, HBeAg or HBsAg, viral load (HBV DNA), alanine aminotransferase (ALT) levels, histological necroinflammatory and fibrosis scores, and adverse events after interferon alfa-2b, pegylated interferon alfa 2-a, lamivudine, adefovir, entecavir, tenovir or telbivudine. We excluded pregnant women, transplant patients, and individuals undergoing cancer chemotherapy. We calculated relative risk or absolute risk differences at end of treatment and post-treatment. RESULTS Observational studies (41 publications) suggested that male gender, coinfection with hepatitis C, D, or HIV, increased HBV DNA, and cirrhosis were associated with increased risk of HCC and death. Drugs did not reduce death, liver failure, or HCC in 16 RCTs not designed to test long-term clinical outcomes. Evidence from 93 publications of 60 RCTs suggested drug effects on viral load or replication, liver enzymes, and histology at end of treatment and lasting from 3 to 6 months off treatment. No one treatment improved all outcomes and there was limited evidence on comparative effects. Two RCTs suggested interferon alfa-2b increased CHB solution versus placebo. Interferon alfa-2b or lamivudine improved off treatment HBV DNA and HBeAg clearance and seroconversion and ALT normalization. Adefovir improved off treatment ALT normalization and HBV DNA clearance. Pegylated interferon alfa 2-a versus lamivudine improved off-treatment HBV DNA and HBeAg clearance and seroconversion, ALT normalization and liver histology. Lamivudine combined with interferon alfa-2b versus lamivudine improved off treatment HBV DNA clearance and HBeAg seroconversion and reduced HBV DNA mutations. Pegylated interferon alfa 2-a plus lamivudine improved off treatment HBV DNA and HBeAg clearance and seroconversion and ALT normalization compared to lamivudine but not pegylated interferon alfa 2-a monotherapy. Adverse events were common but generally mild and did not result in increased treatment discontinuation. Longer hepatitis duration, male gender, baseline viral load and genotype, HBeAg, and histological status may modify treatment effect on intermediate outcomes. Adefovir and pegylated interferon alfa 2-a with lamivudine improved off treatment viral clearance in HBeAg negative patients. There was insufficient evidence to determine if biochemical, viral, or histological measures are valid surrogates of treatment effect on mortality, liver failure, or cancer. CONCLUSION Adults with CHB have an increased risk of death, hepatic decompensation, and HCC. Mono or combined drug therapy improves selected virological, biochemical, and histological markers with no consistent effects on all examined outcomes. Patient and disease characteristics may modify treatment-induced intermediate outcomes. Evidence was insufficient to assess treatment effect on clinical outcomes, predict individualized patient response, or determine if intermediate measures are reliable surrogates. Future research should assess long-term drug effects on clinical outcomes and among patient subpopulations.

Review: Serenoa repens does not improve symptom scale scores in benign prostatic hyperplasia

Source Citation Tacklind J, MacDonald R, Rutks I, Stanke JU, Wilt TJ. Serenoa repens for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2012;(12):CD001423. 23235581

Serenoa repens monotherapy for benign prostatic hyperplasia (BPH): an updated Cochrane systematic review: SERENOA REPENS MONOTHERAPY FOR BPH

Whats known on the subject? and What does the study add?

Serenoa repens monotherapy for benign prostatic hyperplasia (BPH)

Whats known on the subject? and What does the study add?