The bladder should be re- flected to allow for at least 2cm of anterior vaginal Figure 11 Diagrammatic representation of cervical cuff to be removed discount sildalis 120 mg online erectile dysfunction medication contraindications. The uterine artery should be cancer spread according to FIGO stages42 separately identified and ligated either at the site where the ureter runs beneath it (type 2 modified radical hysterectomy) or at its origin from the disease and even in those countries with radiation internal iliac (hypogastric) or superior vesical artery facilities buy cheap sildalis 120 mg line erectile dysfunction ed drugs, survival is poor. The peri- Treatment of early stage disease (stage 1 or stage toneum between the utero-sacral ligaments is then 2A) is generally surgical unless there are contra- opened and the rectum reflected to allow 2cm of indications to surgery, in which case primary radi- posterior vaginal cuff. The utero-sacral ligaments cal radiation is the treatment of choice. Surgery should be ligated as close to the sacrum as possible. A radical hysterectomy with pelvic mandatory and in younger women is not recom- lymph node dissection should only be performed mended; however, lifting the ovaries out of the by a well-trained gynecologist/gynecological on- potential radiation field may be useful in some cologist or surgeon with expertise in this kind of patients. Lymph nodes should be removed from the obtura- Performing radical hysterectomy tor fossa, the external and internal and common iliac nodes. Routine postoperative drainage is not The most important first steps to take prior to per- mandatory nor is closure of the peritoneum. How- forming radical hysterectomy include: ever, suprapubic drainage of the bladder for 6–7 • Correct staging and ensuring the indication for days postoperatively is recommended to prevent the procedure is correct. More Radiation is an effective treatment for cervical complex approaches to radical hysterectomy are cancer and randomized trials have shown a signifi- described, particularly nerve-sparing procedures in cantly improved survival with the addition of con- reference 45. A meta-analysis of 15 trials involving 3452 women reported on survival when women were treated for cervical cancer with Other surgical options concomitant chemotherapy: the majority of trials Increasingly, fertility-sparing surgery has been used used cisplatin as the chemotherapeutic drug, and in the surgical treatment of early-stage disease, such the minority used 5-fluorouracil, mitomycin C or a as trachelectomy or radical trachelectomy for selec- combination of both52. The review found that ted cases and with good results46 but this type of there was convincing evidence that adding chemo- surgery is generally not available in most African therapy to radiotherapy improves both overall sur- countries, nor is laparoscopic surgery. Implementing this development is neoadjuvant chemotherapy in type of protocol in most African countries is un- high-stage cervical cancer; reduction of tumor size likely to be feasible, even in South Africa, most may facilitate surgery and reduce the request for units cannot afford to co-administer chemotherapy radiotherapy in low-resource countries47. We have to women being treated with radiation for cervical to wait for results from currently ongoing studies. For infor- mation on radiotherapy and chemoradiation for cervical cancer see http://www. Most women with cervical cancer in Africa will be In terms of survival, data from a gynecology treated with primary radiation therapy, either with oncology unit are shown in Figure 12 (personal curative or more commonly, palliative intent. This graph Based on GLOBOCAN data from 2002 Barton shows that early-stage disease has a good prognosis, et al. Radiation facilities are not available at all in 15 African countries49. In those Palliative care countries where radiation facilities do exist, there is Palliation for women with advanced disease is also usually one machine per several million people – extremely limited in most low-resource countries, for example in Nigeria in 2007 there were only five where for instance, oral morphine is only available radiation facilities for a population of over 150 mil- 53 50 in 11 countries. In most cases radiation is delivered its own but the options for management range using cobalt machines which are a lot cheaper and 49 from providing emotional/psychological and spirit- easier to maintain than linear accelerators. The ual support to women, to good quality pain control median costs of radiotherapy using linear accelera- and to the judicious use of anti-cancer therapies, tors has been estimated at $11 compared to $4. A survey of 72 low and mid- dle income countries found that 24 countries with populations >1 million people did not have any radiotherapy service and the majority of these countries were in Africa52. Radiotherapy is still considered to be high-technology medicine in Africa and where facilities do exist, e. South Africa, Ethiopia (one machine for a population of >60 million), Madagascar, Nigeria, Tanzania, Uganda, Sudan, Kenya, Ghana, Senegal, Zimbabwe and Cameroon, they are located in tertiary institu- tions or in the private sector and are often non- Figure 12 Five-year survival of women treated at functional or poorly maintained. Groote Schuur Hospital, 1984–2006 by stage 333 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS including diversion surgery for women with urin- the establishment of control programs which you ary and rectal fistulae. However, there are very few can download at: http://www. ACKNOWLEDGEMENTS However, there are possible synergies with national The author has received honoraria for appearing in HIV care and treatment programs as they empha- various educational and speaker roles for both size the continuum of care and include home-based GlaxoSmithKline (GSK) and Merck/MSD. It is stated that HBC author is the principal investigator for a randomized is not only for people living with HIV/AIDS trial of the safety and efficacy of the bivalent HPV (PLWHA) but with all chronic diseases. Including vaccine in HIV-positive women sponsored by HBC for cancer patients into those programs would GSK. The author acknowledges Dr Leon Van Wijk make a better use of resources and would take away for providing data on cervical cancer treated at the the stigmatizing effect of being a client of such a author’s institution. Cervical cancer is a preventable disease yet remains the commonest cause of cancer death among REFERENCES women in poor countries. Recent research into alternative approaches for the secondary preven- 1. Worldwide particularly ‘screen and treat’ programs that have burden of cervical cancer in 2008. Ann Oncol 2011;22: been tested in randomized trials in South Africa and 2675–86 India and shown that HPV-based screening coupled 3. Geneva: WHO, 2010 with immediate treatment using cryotherapy 4. Burden and trends of significantly reduces both cervical cancer precursors type-specific human papillomavirus infections and re- and cervical cancer. In addition to new approaches lated diseases in the Asia Pacific region. Vaccine 2008;26 to secondary prevention of cervical cancer, the re- (Suppl. Human papillomavirus infection and cervical cancer prevention against HPV infection has major implications for in India, Bangladesh, Sri Lanka and Nepal. Vaccine future prevention: the bivalent vaccine targets HPV 2008;26 (Suppl. A screening programme for gets types 6 and 11 (responsible for genital warts) cervical cancer that worked. Human research is towards molecular detection of cervical papillomavirus is a necessary cause of invasive cervical cancer precursors which should overcome many of cancer worldwide. J Pathol 1999;189:12–19 the deficiencies associated with cervical cytology- 8. Human (NCCPs) is a critical next step for cancer control in papillomavirus types in invasive cervical cancer world- developing countries. Br J Cancer 2003;88:63–73 countries must adopt policies at national level. Human NCCPs have four pillars: prevention, early detec- papillomavirus genotype attribution in invasive cervical tion through diagnosis, treatment and palliation. Lancet Oncol 2010;11:1048–56 Political will is an important element in putting dis- 11. Precancerous eases such as cervical cancer on the health agenda. Blaustein’s WHO has established a cancer control program Pathology of the Female Genital Tract. NY: Springer- which has published some interesting materials on Verlag, 2002 334 Cervical Cancer Prevention and Treatment 12. N Engl J Med 2007;356: absolute risk of cervical intraepithelial neoplasia grade 3 1928–43 or worse following human papillomavirus infec- 29.
Schiller1 1Hematological Malignancy/Stem Cell Transplant Program best order sildalis erectile dysfunction obesity, David Geffen School of Medicine sildalis 120mg low price food that causes erectile dysfunction, University of California, Los Angeles, Los Angeles, CA High-risk acute myelogenous leukemia (AML) constitutes a distinct subset of disease based on clinical and biological characteristics and comprises a signiﬁcant percentage of all cases of adult AML. Biologic features such as distinct clonal cytogenetic and molecular abnormalities identify a subgroup of AML patients characterized by poor response to induction chemotherapy and poor long-term survival after treatment with consolidation chemotherapy. Clinical variables that predict for poor response include AML relapsed after less than 1 year of remission and AML characterized by resistance to conventional agents. We review here our understanding of the deﬁning biologic subtypes of AML and discuss how adequate initial evaluation can be used to inform the choice of treatment. By deﬁning high-risk biologic and clinical variables, a strong case can be made for treating patients with investigational agents, with treatment directed at distinct cytogenetic or molecular abnormalities. Allogeneic transplantation is the only form of therapy available outside of the setting of a clinical trial that may offer a chance for long-term survival for patients with high-risk AML. Introduction as they predict for distinct response and survival. So too are leukemias different, been no regulatory pathway to approval of novel agents based on but the implications are more ominous. Unfortunately, failure of induction is typically prolonged, although a subgroup often sustains early chemotherapy and early relapse still make allogeneic transplanta- relapse, those whose disease is also characterized by a mutation in tion an intervention feasible only for a fraction of patients with kit. We offer here a disease assessment and treatment characterized by complex (greater than 3) abnormalities, mono- algorithm for patients with adverse cytogenetics or high-risk somies of any chromosome (typically chromosome 5 and/or 7), molecular abnormalities based on approved therapies and make inv(3), t(3;3), t(6;9), the rare t(9;22), and 17p abnormalities. There recommendations regarding the off-label use of the limited thera- is some disagreement about chromosome 11 abnormalities, but it pies available for clinicians managing patients with adverse- appears that 11q23 abnormalities other than t(9;11) should be prognosis AML. Among the Hematology 2013 201 favorable-risk and adverse-risk AML subtypes, only the t(15;17) is Table 1. Routine evaluation of AML for the purpose of risk characterized by distinct clinical and morphological features. Cyto- stratiﬁcation genetics adds signiﬁcant value to the understanding of a patient’s Standard morphology disease, at least as long as there is no change in the current Flow cytometry/immunohistochemistry management. FISH for common abnormalities: t(8;21) RUNX1-RUNX1T1; inv(16) or t(16;16); CBFB-MYH11; t(15;17) PML-RAR ; t(9;11) MLLT3-MLL; Reﬁnements in risk stratiﬁcation inv(3) or t(3;3)RPN1-EVI1 The inability to ﬁnd a regulatory pathway for treatment that targets Karyotype biologically distinct AML outside of acute promyelocytic leukemia Molecular studies for mutations in FLT3, NPM-1, Kit, CEBP is the driver that has led to further reﬁnement in our concepts of Potentially useful biologically distinct AML subtypes. The World Health Organiza- Molecular studies for mutations in DNMT3a, TET2, MLL, IDH1, and/or IDH2 tion has recognized this reﬁnement in the diagnostic evaluation of AML by reﬁning the classiﬁcation of AML to include biphenotypic leukemia, therapy-related leukemia, cytogenetics, and molecular thyroid-stimulating hormone, has not, in general, been incorporated genetics. Therefore, AML characterized by t(8;21), Other molecular abnormalities may contribute to reﬁnements in inv(16), or t(16;16) with the kit mutation may respond well to prognostic variables, particularly in cytogenetically normal AML induction chemotherapy, but seems to be associated with a much that constitutes 30% to 40% of leukemias in the clinical setting. Recurrent mutations in IDH1, a Krebs cycle protein, considered AML of intermediate risk. The inﬂuence of kit in affect the active site of the enzyme and inhibit the activity of the inv(16;16) may not be the same as the adverse impact of the wild-type allele. Mutations in mutation in t(8;21), but may warrant consideration of alternative both IDH1 and IDH2 have been identiﬁed in approximately 20% of postremission therapy, especially allogeneic transplantation in ﬁrst patients with normal-karyotype AML and are associated with a poor remission. In this same category of intermediate risk are leukemias prognosis. MLL is a gene on chromosome 11q23; a partial tandem characterized by normal karyotype but often with mutation in ﬂt3, a duplication has been identiﬁed in fewer than 10% of patients with transmembrane tyrosine kinase with either a single amino acid cytogenetically normal AML and may confer an increased risk of substitution in the kinase domain or, more commonly, with internal relapse. Flt3 ITD is clearly associated with with chromosome 4q24 abnormalities, have been identiﬁed during adverse prognosis. Alternatively, isolated mutation in the nucleophos- evolution of myelodysplasia or myeloproliferative disease to AML min1 gene (the most common mutation identiﬁed in normal- and have been associated with diminished survival. In the TET2 have been associated with shorter survival, typically in older South German AML96 trial of 909 elderly patients entered prospec- patients with normal-karyotype AML or in younger patients with tively, patients received 2 courses of daunorubicin/cytarabine favorable-risk cytogenetics. TET2 mutations seem to function as induction and, according to protocol, patients in remission received epigenetic modiﬁers and may serve to alter the methylation pattern 1 cycle of consolidation with cytarabine (1000 mg/m2 twice daily of DNA; loss of TET2 function may result in impaired hematopoi- for 5 days) and amsacrine. Mutations in IDH1 or IDH2 do not coexist with patients of 5. RUNX1 dehydrogenase, and BM blasts at day 15 were all independent mutations have also been identiﬁed as independent prognostic prognostic factors for remission induction. The combination of markers for shorter survival in a retrospective study of intermediate- NPM1 and ﬂt3 mutational status was important in the multivariate risk cytogenetic AML. In their analysis of disease-free survival latter in T-cell acute lymphoblastic leukemia (ALL). ASXL1 mutations are seen in older group for survival, multivariate analysis again showed that cytoge- patients with AML. Whether these latter abnormalities will add netic risk group, NPM1/ﬂt3 mutational status, lactate dehydroge- prognostic value in prospective studies remains to be determined nase, and WBC at diagnosis were independent risk factors. In clinical practice, we recommend routine testing at diagnosis of These ﬁndings have been corroborated in other settings: among cytogenetic abnormalities by both FISH and cytogenetic analysis younger patients and among patients with AML undergoing alloge- and evaluation for a manageable set of gene-based molecular neic transplantation in ﬁrst remission. These typically include ﬂt3, NPM1, CEBPA, and The prognostic value of both pretreatment cytogenetics and molecu- kit. In a large randomized study of dose-intensive induction of lar analysis, at least for NPM1 and ﬂt3, is of sufﬁcient importance to daunorubicin and cytarabine conducted by the Eastern Cooperative recommend that these studies be done for all patients at diagnosis28; Oncology Group (ECOG), the recently identiﬁed IDH2 R140Q muta- anything below this could be considered an incomplete evaluation, tions ASXL1 and PHF6 contributed to adverse survival. Reﬂex testing, as further risk-stratiﬁcation of patients with intermediate-risk AML. Cytogenetics and mutational ﬁndings characteristic of compared different treatment strategies for a diverse group of AML newly diagnosed high-risk AML* patients comparing 5 different treatment strategies against a com- mon standard treatment of cytarabine at 100 mg/m2 daily by Cytogenetic classiﬁcation Mutation continuous infusion and daunorubicin 60 mg/m2 by IV infusion over Intermediate-risk 2 hours on days 3, 4, and 5. Standard consolidation consisted of Normal ﬂt3 ITD-positive cytarabine 3 g/m2 every 12 hours by infusion over 3 hours on days 1, 8 Mutant TET2, MLL-PTD, DNMT3A, 27 3,and 5. The studies did not enroll patients on the basis of speciﬁc ASXL1, PHF6 disease-related or clinical features, but regardless of the investiga- Unfavorable-risk 5/ 7 tional treatment, which included high-dose cytarabine induction, 11q23, 20q intermediate-dose cytarabine with daunorubicin, the addition of 3 or more etoposide to induction, or double induction with thioguanine, Favorable-risk cytarabine, and daunorubicin followed by high-dose cytarabine and t(8;21) kit mitoxantrone, no survival advantage could be detected in favor of inv(16) or t(16;16) any of the investigational regimens. Because the studies did not 4 enroll on the basis of risk proﬁles, retrospective analysis of age, *AdaptedfromPatelandLevine. The absence of IDH mutation results regardless of induction may represent the limit of current adversely affects the otherwise favorable population. Strictly speaking, however, none of the combination of potentially favorable or adverse alleles determines studies attempted to “build a better mousetrap” on the basis of relapse risk, particularly in normal-karyotype, ﬂt3-wild type AML. For randomization at diagnosis of distinct AML subtypes. This would require Mutational proﬁling may provide prognostic information to the waiting to identify biologic risk factors at diagnosis or enrolling treating physician. The question is whether this prognostic informa- based on clinical factors known to be associated with a high risk of tion can contribute to treatment decisions that might favorably induction failure, such as secondary AML or AML relapsed or affect an otherwise dismal outcome with conventional chemo- refractory after standard treatment. High-dose cytarabine is the therapy or might suggest less intense therapy for those with standard against which all other treatments must be compared for favorable disease features. The beneﬁt of features associated with a high risk of resistance to induction dose escalation was demonstrated in small studies in refractory and therapy, there are many clinical factors associated with poor relapsed AML, with a dose limit of 3 g/m2 given every 12 hours for prognosis. Ophthalmologic, skin, and central nervous system toxicity often cited as risk factors for treatment-related mortality, but limited the dose. The variation in response rates from 20% to 80% resistance to therapy is the major cause of treatment failure and is can be attributed to the signiﬁcant biological and clinical heteroge- also more common among patients over age 70, suggesting that neity of patients enrolled, but this makes comparative analysis of even in the absence of known biologic risk factors, advanced age salvage regimens difﬁcult. Few randomized studies stratiﬁed for confers resistance to leukemia treatment. Of course, regardless of signiﬁcant variables that are available to guide therapy and, in the risk, relapsed leukemia, leukemia refractory to induction chemo- absence of effective postremission strategies for the majority of therapy, and leukemia characterized by the persistence of minimal patients, it is difﬁcult to demonstrate a superior survival of residual disease after induction chemotherapy deﬁne high-risk combination regimens over single-agent high-dose cytarabine. Of these, residual disease deﬁned by multiparameter ﬂow cytometry or positive PCR for disease-speciﬁc genes describes a Against this background of high-dose cytarabine salvage, a variety group of patients with signiﬁcant risk of early recurrence after of agents have been added, including anthracyclines, etoposide, and consolidation therapy, including consolidation in the form of purine analogs.
For the update the original search terms were used discount sildalis online natural erectile dysfunction pills reviews, but titles and abstracts and then full- text articles were screened to include additional active-control studies that address the updated key questions and new head-to-head and placebo-controlled studies cheap sildalis 120mg mastercard erectile dysfunction drugs class. Updated searches were conducted in November 2007 (Appendix A). Electronic searches were supplemented by hand searches of dossiers received from the makers of pioglitazone and rosiglitazone, and medical and statistical reviews available on the Food and Drug Administration website. Articles deemed potentially relevant after review of titles and abstracts were retrieved in full-text form. Two independent reviewers achieved consensus on all included and excluded articles. Excluded articles were coded in the EndNote database with the reason for exclusion. Study Selection The pharmacotherapeutic agents reviewed were the 2 thiazolidinediones currently available in the United States: pioglitazone hydrochloride (Actos ) and rosiglitazone maleate (Avandia™). Muraglitazar (Pargluva™) was not reviewed as it was not available in the United States as of January 1, 2008. Participants in included studies were adults with type 2 diabetes, prediabetes, or the metabolic syndrome. As noted above, various definitions exist for the metabolic syndrome. Any study examining persons with the metabolic syndrome was included if the authors used 1 of the widely accepted definitions mentioned above (see Table 1). Included studies examining type 2 diabetes had to present 1 or more of the primary outcomes of interest to this review: glycemic control (A1c), time to initiation of insulin for glycemic control, progression or occurrence of microvascular disease (nephropathy, retinopathy, and neuropathy), progression or occurrence of macrovascular disease (cardiovascular disease, cerebral vascular disease, amputation), other complications of diabetes, mortality, and quality of life. Included studies examined either effectiveness or efficacy of the 2 included drugs. The purpose of this report was primarily to examine effectiveness; however, since there were very few data available on effectiveness, efficacy studies were included and reviewed in detail. For efficacy, effectiveness, and safety, published and unpublished English-language reports in any geographic setting were included if they had a total sample size of ten or more participants. We included letters if primary data were presented and there was sufficient detail to evaluate quality. We excluded abstracts and conference proceedings, as these publications Thiazolidinediones Page 12 of 193 Final Report Update 1 Drug Effectiveness Review Project generally do not have sufficient detail to assess internal or external validity. Theses were not included as the full text is frequently difficult to retrieve. Selection criteria for the original report For the assessment of efficacy and effectiveness in the original report, we included reports of randomized controlled trials and controlled clinical trials. We included trials comparing rosiglitazone and pioglitazone (head-to-head trials), as well as trials comparing either one of these drugs to placebo. We also included trials comparing these drugs to another pharmacotherapeutic agent (active-control trials) only if they examined effectiveness outcomes or population subgroups. For examination of efficacy and effectiveness among subgroups, we expanded our inclusion criteria to encompass all study designs (that is, observational, before-after, case-control studies, and time series) where data were available. We used this approach because few controlled trials were available that examined subgroups; therefore, we expanded our inclusion criteria in order to examine the best available evidence, recognizing that study designs that do not involve randomization are weaker designs and are more likely to be biased or confounded by known or unknown factors affecting the outcomes of interest. For the assessment of tolerability and adverse effects, we included observational studies, including case series with a sample size greater than ten, before-after studies, randomized controlled trials, and controlled clinical trials. Clinical trials are often not designed to assess adverse events, may select low-risk patients (in order to minimize drop-out rates), or may have too short a follow-up period in which to adequately assess safety. Observational studies designed to assess adverse event rates may include broader populations, carry out observations over a longer time period, use higher quality methodological techniques for assessing adverse events, or examine larger sample sizes. Safety and tolerability were examined using data provided on overall and serious adverse events, withdrawals due to adverse effects, and other relevant specific adverse events including hypoglycemia, liver toxicity, heart failure, pulmonary edema, weight gain, and edema. Selection criteria for the updated report For the updated report we expanded our inclusion criteria with respect to study designs for effectiveness outcomes in order to be consistent with criteria used in the Agency for Healthcare Research and Quality report. Most notably, we expanded our examination of active-control comparisons, which was previously restricted by sample size, follow-up interval, or outcomes. These criteria are listed in Table 3, where they are contrasted with those of the prior report and of the Agency for Healthcare Research and Quality report. Thiazolidinediones Page 13 of 193 Final Report Update 1 Drug Effectiveness Review Project Table 3. Inclusion criteria for the original and updated reports Criteria domain and key question Original DERP report Updated DERP report AHRQ report Type 2 diabetes: adults ≥ Type 2 diabetes: adults ≥ Type 2 diabetes: adults ≥ Population 18 years 18 years 18 years Prediabetes: adults ≥ 18 Prediabetes: adults ≥ 18 years years Metabolic syndrome as Metabolic syndrome as defined by ATPIII criteria: defined by ATPIII criteria: adults ≥ 18 years adults ≥ 18 years Interventions Rosiglitazone, pioglitazone Rosiglitazone, pioglitazone Oral hypoglycemic drugs Drugs not on US market if members of their class were in use (voglibose, gliclazide, glibenclamide) Combination of 2 included oral agents st Excluded: 1 -generation SU, insulin, troglitazone Comparisons Rosiglitazone compared Rosiglitazone compared Rosiglitazone compared Within class with pioglitazone with pioglitazone with pioglitazone Rosiglitazone or Rosiglitazone or Rosiglitazone or pioglitazone compared pioglitazone compared with pioglitazone compared with with placebo placebo placebo Rosiglitazone or Rosiglitazone or Rosiglitazone or pioglitazone compared pioglitazone compared with pioglitazone compared with with other active other oral hypoglycemic other oral hypoglycemic Between classes hypoglycemic drug when agents agents st study examined st Exclude: insulin and 1 - Excluded: insulin and 1 - effectiveness outcomes or generation SU generation SU or population subgroups Study designs Study duration and size: ≥3 Excluded: non-English Excluded: non-English months, ≥ 40 subjects General features studies, letters, editorials, studies, letters, editorials, Excluded: non-English abstracts, and theses abstracts, and theses studies, letters, editorials, abstracts, and theses Efficacy RCTs or CCTs RCTs or SRs RCTs RCTs, CCTs or cohort studies with or without a RCTs, CCTs, cohort with Effectiveness RCTs or CCTs comparison group comparison group or SRs Excluded: case reports or case series RCTs, CCTs, cohort RCTs, CCTs, cohort RCTs, CCTs, cohort studies with or without a studies with or without a studies with or without a Adverse events comparison group, case- comparison group, case- comparison group, or case- control studies, case control studies, and SRs control studies series (N>10), or SRs Excluded: case reports Excluded: case reports and Thiazolidinediones Page 14 of 193 Final Report Update 1 Drug Effectiveness Review Project Criteria domain and key question Original DERP report Updated DERP report AHRQ report Excluded: case reports case series As above for efficacy, As above for efficacy, As above for efficacy, Population effectiveness, or effectiveness, or effectiveness, or subgroups adverse events adverse events adverse events Outcomes A1c, postprandial glucose, Efficacy A1c A1c blood pressure, and lipids For prediabetes: incidence For prediabetes: Incidence of type 2 diabetes of type 2 diabetes For type 2 diabetes: CVD events, death, stroke, For type 2 diabetes: durability of control, nephropathy, neuropathy, Effectiveness durability of control, progression or occurrence PVD, amputations, QoL, progression or occurrence of micro- or macrovascular and functional status of micro- or macrovascular disease, mortality, and disease, mortality, and QoL QoL Hypoglycemia, liver failure, Hypoglycemia, liver failure, heart failure, lactic heart failure, lactic acidosis, Hypoglycemia, liver failure, acidosis, anemia, liver anemia, liver function, heart failure, lactic acidosis, Adverse events function, edema, edema, gastrointestinal anemia, liver function, gastrointestinal effects, effects, weight, macular edema, gastrointestinal weight, macular edema, edema, fractures, and effects, and others fractures, and others others Abbreviations: A1c, hemoglobin A1c; AHRQ, Agency for Healthcare Research and Quality; ATP III, Adult Treatment Panel III of the National Cholesterol Education Program; CCTs, controlled clinical trials; CVD, cardiovascular disease; DERP, Drug Effectiveness Review Project; N, sample size; PVD, peripheral vascular disease; QoL, quality of life; RCTs, randomized controlled trials; SRs, good-quality systematic reviews; SU, sulfonylureas. Data Abstraction The following data were abstracted from included trials into a relational database developed for this review: study design; setting; population characteristics (including sex, age, race/ethnicity, diagnosis, duration of type 2 diabetes, A1c, weight, and body mass index); eligibility and exclusion criteria; drug dosage and frequency; treatment duration; comparison group care; numbers screened, eligible, enrolled, and lost to follow-up; and results for each prespecified outcome. Similar data were abstracted for studies that were not controlled trials and which examined adverse events. We recorded results achieved with an intention-to-treat analytic approach, when reported. If only per protocol results were reported, we specified the nature of these results and reported them. In trials with crossover, outcomes for the first intervention were recorded if available. This was because of the potential for bias due to differential withdrawal prior to crossover, the possibility of a “carryover effect” (from the first treatment) in studies without a washout period, and a “rebound” effect from withdrawal of the first intervention. Thiazolidinediones Page 15 of 193 Final Report Update 1 Drug Effectiveness Review Project Quality Assessment We assessed the internal validity (quality) of controlled clinical trials using the predefined criteria listed in the quality assessment tool found in Appendix C. These criteria are based on 29 those used by the US Preventive Services Task Force and the National Health Service Centre 30 for Reviews and Dissemination. For each included trial we assessed methods for the following charateristics: randomization; allocation concealment; blinding of participants, investigators, and assessors of outcomes; the similarity of comparison groups at baseline; adequate reporting of attrition, crossover, adherence, and contamination; post-allocation exclusions; and use of intention-to-treat analysis. We based assessment of observational and other study designs with adverse event data on unbiased selection of patients, loss to follow-up, unbiased and accurate ascertainment of events, and control for potential confounders (Appendix C). These criteria were then used to categorize studies as good-, fair-, and poor-quality studies. Studies that had a significant flaw in design or implementation such that the results were potentially not valid were categorized as “poor”. Studies that met all quality criteria were rated good quality. As the “fair quality” category is broad, studies with this rating vary in their strengths and weaknesses. Studies were not excluded on the basis of poor quality as there is a lack of empirical evidence for a relationship between criteria thought to measure validity and actual study 31 outcomes. Studies rated as poor-quality were carefully examined and the potential sources of bias and its potential impact are presented in the evidence tables. If data were sufficient, a sensitivity analysis was performed to compare results between studies with high and low risk of bias. External validity of studies was assessed by examining the following: adequacy of population description; inclusion and exclusion criteria; and whether the treatment received by the comparison group was reasonably representative of standard practice. Systematic reviews that fulfilled inclusion criteria were rated for quality using pre- defined criteria (see Appendix C) to ensure the following: clear statement of the questions and inclusion criteria; adequate search strategy; adequate assessment of individual trials; adequate provision of information; and appropriate methods of synthesis.
Sensitivity analysis: An analysis used to determine how sensitive the results of a study or systematic review are to changes in how it was done order sildalis online now erectile dysfunction doctors in coimbatore. Sensitivity analyses are used to assess how robust the results are to uncertain decisions or assumptions about the data and the methods that were used cheap 120 mg sildalis free shipping erectile dysfunction treatment herbs. Side effect: Any unintended effect of an intervention. Side effects are most commonly associated with pharmaceutical products, in which case they are related to the pharmacological properties of the drug at doses normally used for therapeutic purposes in humans. Standard deviation (SD): A measure of the spread or dispersion of a set of observations, calculated as the average difference from the mean value in the sample. Standard error (SE): A measure of the variation in the sample statistic over all possible samples of the same size. The standard error decreases as the sample size increases. Standard treatment: The treatment or procedure that is most commonly used to treat a disease or condition. In clinical trials, new or experimental treatments sometimes are compared to standard treatments to measure whether the new treatment is better. Statistically significant: A result that is unlikely to have happened by chance. Study: A research process in which information is recorded for a group of people. The data are used to answer questions about a health care problem. Study population: The group of people participating in a clinical research study. The study population often includes people with a particular problem or disease. It may also include people who have no known diseases. Subgroup analysis: An analysis in which an intervention is evaluated in a defined subset of the participants in a trial, such as all females or adults older than 65 years. Superiority trial: A trial designed to test whether one intervention is superior to another. Surrogate outcome: Outcome measures that are not of direct practical importance but are believed to reflect outcomes that are important; for example, blood pressure is not directly important to patients but it is often used as an outcome in clinical trials because it is a risk factor for stroke and heart attacks. Surrogate endpoints are often physiological or biochemical markers that can be relatively quickly and easily measured, and that are taken as being predictive of important clinical outcomes. They are often used when observation of clinical outcomes requires long follow-up. Second-generation antidepressants 189 of 190 Final Update 5 Report Drug Effectiveness Review Project Survival analysis: Analysis of data that correspond to the time from a well-defined time origin until the occurrence of some particular event or end-point; same as time-to-event analysis. Systematic review: A review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research and to collect and analyze data from the studies that are included in the review. The extent to which a drug’s adverse effects impact the patient’s ability or willingness to continue taking the drug as prescribed. These adverse effects are often referred to as nuisance side effects, because they are generally considered to not have long-term effects but can seriously impact compliance and adherence to a medication regimen. Treatment regimen: The magnitude of effect of a treatment versus no treatment or placebo; similar to “effect size”. Can be calculated in terms of relative risk (or risk ratio), odds ratio, or risk difference. Two-tailed test (two-sided test): A hypothesis test in which the values that reject the null hypothesis are located in both tails of the probability distribution. For example, testing whether one treatment is different than another (rather than testing whether one treatment is either better than another). Type I error: A conclusion that there is evidence that a treatment works, when it actually does not work (false-positive). Type II error: A conclusion that there is no evidence that a treatment works, when it actually does work (false-negative). Validity: The degree to which a result (of a measurement or study) is likely to be true and free of bias (systematic errors). Variable: A measurable attribute that varies over time or between individuals. Variables can be • Discrete: taking values from a finite set of possible values (e. Washout period: [In a cross-over trial] The stage after the first treatment is withdrawn, but before the second treatment is started. The washout period aims to allow time for any active effects of the first treatment to wear off before the new one gets started. The purpose of this report is to make available information regarding the comparative effectiveness and safety profiles of different drugs within pharmaceutical classes. Reports are not usage guidelines, nor should they be read as an endorsement of, or recommendation for, any particular drug, use or approach. Oregon Health & Science University does not recommend or endorse any guideline or recommendation developed by users of these reports. Sheps Center for Health Services Research University of North Carolina at Chapel Hill 725 Martin Luther King Jr. Blvd, CB# 7590 Chapel Hill, NC 27599-7590 Tim Carey, M. Final Update 1 Report Drug Effectiveness Review Project The medical literature relating to this topic is scanned periodically. Prior versions of this report can be accessed at the DERP website. Controller medications for asthma 2 of 369 Final Update 1 Report Drug Effectiveness Review Project STRUCTURED ABSTRACT Purpose To compare the efficacy and safety of inhaled corticosteroids (ICSs), long-acting beta-2 agonists (LABAs), leukotriene modifiers (LMs), anti-IgE therapy, combination products, and tiotropium for people with persistent asthma. Data Sources To identify published studies, we searched MEDLINE, The Cochrane Library, Embase, International Pharmaceutical Abstracts, and reference lists of included studies through September 2010. We also requested dossiers of information from pharmaceutical manufacturers. Review Methods Study selection, data abstraction, validity assessment, grading the strength of the evidence, and data synthesis were all carried out according to standard Drug Effectiveness Review Project methods. Results Efficacy studies provide moderate strength of evidence (SOE) that equipotent doses of ICSs administered through comparable delivery devices do not differ in their ability to control asthma symptoms, prevent exacerbations, reduce the need for additional rescue medication, or in their overall incidence of adverse events or withdrawals due to adverse events. Evidence does not support a difference between montelukast and zafirlukast in their ability to decrease rescue medicine use or improve quality of life (low SOE for ≥12 years of age, insufficient <12), between formoterol and salmeterol in their ability to control symptoms, prevent exacerbations, improve quality of life, or cause harms among patients not controlled on ICSs alone (moderate SOE), or between budesonide/formoterol and fluticasone/salmeterol for efficacy or harms when each combination is administered via a single inhaler (moderate SOE for ≥12, insufficient <12). Meta-analyses and efficacy studies provide consistent evidence favoring omalizumab over placebo for most included outcomes. Omalizumab-treated patients have an increased incidence of injection site reactions and anaphylaxis compared to placebo-treated patients.
All trials assessed response rates as defined by the American College of Rheumatology safe sildalis 120 mg erectile dysfunction in the military. In addition generic 120mg sildalis fast delivery erectile dysfunction pump rings, most studies used the disease specific Psoriatic Arthritic Response Criteria which is composed of a patient global self-assessment, a physician global assessment, a swollen joint score, and a tender joint score. Further details of this scale are presented in Appendix D. In addition, the Psoriasis Area and Severity Index was used in some studies to measure improvements in both the amount of psoriatic plaque, as well as the severity of the disease. The Short Form 36 Health Survey and Health Assessment Questionnaire were used to assess quality of life. Sponsorship All trials, except the systematic review and meta-analysis, were funded by the pharmaceutical industry. Detailed assessment: Direct evidence on the comparative effectiveness We did not find any head-to-head trials for the treatment of psoriatic arthritis. One fair-quality prospective observational registry study from the United Kingdom (the British Society for Rheumatology Biologics Register) followed 596 psoriatic arthritis patients for 6 months and showed that adalimumab, etanercept, and infliximab have similar positive effects on quality of 183 life. For example, the mean improvements in Short Form 36 Health Survey mental component scale were: adalimumab 49. There were no statistically significant differences between the groups after adjusting for baseline variables such as sex, age, and severity of disease. Detailed assessment: Indirect evidence on the comparative effectiveness Two systematic reviews provided indirect evidence on the comparative effectiveness of adalimumab, etanercept, and infliximab for adults with moderate to severe plaque psoriatic 176,177 arthritis. The reviews employed different statistical techniques for the indirect comparisons; however the same six trials and 982 patients were included in both reviews. Both methods of 176 indirect comparison, adjusted indirect comparisons as proposed by Bucher and Bayesian 177 mixed treatment comparison, suggested that the three treatments are all more efficacious than placebo but that no statistically significant differences between adalimumab, etanercept, and infliximab exist. Using Bayesian analysis one group of reviewers calculated the probability of a psoriatic arthritis response criteria response for each comparator: 59% for adalimumab (95% CI, 44 to 71), 71% for etanercept (95% CI, 57 to 83), and 80% for infliximab (95% CI, 67 to 89). The second review came to a similar conclusion using an adjusted indirect comparison approach: the relative risk of an American College of Rheumatology 20 response for adalimumab compared with etanercept was 0. Table 12 summarizes the study conducting indirect comparisons. Targeted immune modulators 60 of 195 Final Update 3 Report Drug Effectiveness Review Project Table 12. Characteristics and results of studies conducting direct and adjusted- indirect comparisons Author, year Comparisons Primary Conclusion Quality outcome Adalimumab, etanercept, Adalimumab, 183 and infliximab have similar Saad et al. Detailed assessment: Evidence on the general efficacy Because of the lack of head-to-head trials, we reviewed placebo-controlled trials. We have summarized evidence on the general efficacy of targeted immune modulators in the treatment of psoriatic arthritis. This, however, does not provide evidence on the comparative efficacy and tolerability of targeted immune modulators. Abatacept We identified one fair-quality 6-month randomized controlled trial of abatacept compared with placebo in 170 patients with chronic psoriatic arthritis and one target skin lesion greater than 2 178 cm in diameter. All patients had failed prior therapy with a disease-modifying antirheumatic drug or another targeted immune modulator. Three doses of abatacept were used: 3 mg/kg, 10 mg/kg, or 30 mg/kg for two doses, followed by 10 mg/kg. Significantly more patients in the 30- 10 mg/kg group and the 30 mg/kg group achieved the primary endpoint, an American College of Rheumatology 20 response, compared with the placebo group. American College of Rheumatology 20 response rates were 42% for the 30-10 mg/kg group, 48% for the 10 mg/kg group, 33% for the 3 mg/kg group, and 19% for the placebo group, respectively. Compared with placebo the differences for 30-10 mg/kg (P=0. Adalimumab We identified two high quality meta-analyses that demonstrate the general efficacy of 176,177 adalimumab. Altogether, the reviews included information on 413 adult patients with psoriatic arthritis from trials of adalimumab compared with placebo. Pooled results presented statistically significantly greater improvements of adalimumab than placebo-treated patients on all included outcome measures. Patients who received adalimumab were more likely to achieve the Psoriatic Arthritis Response Criteria (relative risk, 2. Similarly, the adalimumab treated patients were more likely to achieve an Targeted immune modulators 61 of 195 Final Update 3 Report Drug Effectiveness Review Project American College of Rheumatology 20 response (relative risk, 3. Alefacept 179 One fair-quality phase II trial reported on the use of alefacept in psoriatic arthritis. The study included 185 patients suffering from moderate to severe psoriatic arthritis who had an inadequate response to methotrexate therapy. Patients were randomized to 15 mg of alefacept weekly or placebo for 12 weeks. The alefacept group had statistically significantly greater response rates on American College of Rheumatology 20 than the placebo group (54% compared with 23%; P<0. There were no statistically significant differences in the other outcomes including the American College of Rheumatology 50/70, Psoriasis Area and Severity Index, and Physician Global Assessment, although there was a trend that favored alefacept. For example, American College of Rheumatology 50/70 was achieved by 17% and 7% of the alefacept group compared with 10% and 2%, respectively, of the placebo group. Similarly, the Psoriasis Area and Severity Index 50 and a Physician Global Assessment of clear or almost clear were reported in 45% and 31% of the alefacept group compared with 31% and 24% in the placebo group. Etanercept 176,177 We identified two high-quality meta-analyses on the general efficacy of etanercept. Both reviews pooled results from the same two trials of 265 adult patients with psoriatic arthritis. Pooled results presented statistically significantly greater improvements of etanercept- than placebo-treated patients on all outcome measures included. At 12 weeks the relative risk for achieving the Psoriatic Arthritis Response Criteria was 2. Similarly, the etanercept treated patients were much more likely to reach an American College of Rheumatology 50 or 70 (relative risk, 10. The original publications of the two etanercept trials provided additional data on quality 184,185 of life. In both trials patients received 25 mg of etanercept twice weekly or placebo for 12 184,185 to 24 weeks. Improvement in quality of life, as measured by the Health Assessment Questionnaire, was statistically significantly better for etanercept than placebo in both studies. Mean improvements were 83% in etanercept- compared with 3% in placebo-treated patients in the 12-week study (P<0. In the longer study, at 24 weeks the mean improvement was 54% in the etanercept group and 6% in the placebo group (P<0. Golimumab We identified one fair multi-center trial of 405 patients randomized to 50mg or 100mg of 180 golimumab at weeks 0, 4, 8, 12, 16, and 20 compared with placebo.
The need for joint change may cause signiﬁcant constraint on amino acid substitutions in receptor binding factors order sildalis 120 mg with amex erectile dysfunction age 32. In an experimen- tal setting 120mg sildalis free shipping impotence 19 year old, one begins with a particular, deﬁned genotype as the genetic back- ground for further analysis. One then obtains single amino acid substitutions or small numbers of substitutions derived from the original background ge- notype. Substitutions may be obtained by imposing selective pressures such as antibodies in an experimental evolution regime or by imposing site-directed or random mutagenesis. Substitutions aﬀect various components of ﬁtness as described in the text. Each of these processes relates ﬁtness to diﬀerent kinetic aspects of surface binding. First, changes in cell binding and entry aﬀect the performance of in- tracellular pathogens. The relationship between binding kinetics and ﬁtness may be rather complex. In that ﬁgure, the substitutions 190 E→A, 225 G→R, and 228 S→Gallhavestronger binding aﬃnity than the common wild type. HA has a relatively low aﬃnity for its host-cell receptors (Skehel and Wiley 2000). The fact that some substitutions raise aﬃnity suggests that binding has been adjusted by selection to an intermediate rate. It may be possible to test this idea in various experimental systems by competing viruses with diﬀerent cell binding kinetics. Robertson (1993, 1999) reviews experimental evolution work on the adaptation of inﬂuenza to culture conditions in chicken eggs and Madin- Darby canine kidney (MDCK) cells. Those in vitro systems allow study of competition between diﬀerent viral genotypes (Robertson et al. EXPERIMENTAL EVOLUTION: INFLUENZA 219 Simple in vitro culture conditions may select for higher binding aﬃn- itybetween pathogen and host cells (Robertson et al. It would be interesting to compare the ﬁtnesses in vivo between wild type and mutants selected for higher binding aﬃnity in vitro. The second role of substitutions arises from binding that interferes with viral ﬁtness. Too high aﬃnity of HA for the primary host-cell re- ceptor may impair release of progeny viruses. High aﬃnity may also ag- gregate viruses in localized regions, interfering with infectious spread. Again, it would be interesting to compete variants with diﬀerent aﬃni- ties under various in vitro and in vivo conditions. Receptor binding sites may also be strongly selected to avoid binding molecules similar to the host-cell receptor. For example, the nonim- mune component of horse serum attracts inﬂuenza particles that bind the α(2, 6) linkage of sialic acid (Matrosovich et al. Selection fa- vors equine inﬂuenza strains that both bind α(2, 3) linkages and avoid α(2, 6) linkages. By contrast, mucins of human lungs contain α(2, 3)- linked sialic acid, favoring human lineages that avoid the α(2, 3) linkage (Couceiro et al. Thus, host ﬂuids or host tissues diﬀerent from the primary infection target can cull viruses from circulation. The ki- netics of such ﬁtness losses must be balanced against kinetic gains in receptor binding and avoidance of antibodies. The third ﬁtness eﬀect of surface substitutions arises from changes in antibody binding. A few studies have related diﬀerent aspects of antibody-virus binding kinetics to the neutralization (killing) of viruses (Schoﬁeld et al. This topic stands as a preliminary model for analyzing the relations between bind- ingkinetics and ﬁtness (Dimmock 1993; McLain and Dimmock 1994; Dimmock 1995). No work has clearly established the roles of various amino acid sub- stitutions in antibody neutralization kinetics. I highlight a few general issues and some particular studies on inﬂuenza. I suspect that exper- imental evolution will be an important tool in understanding the links between ﬁtness, amino acid substitutions, the kinetics of binding to host cells, and the kinetics of antibody neutralization. Consider the simple chemical re- action [A] + [V] [AV],wherebracketsdenote concentration (mol/l) for antibodies, A, viruses, V, and bound antibody-virus complexes, AV. Binding occurs at the on-rate, or rate of association, ka (l/mol·s), and the breakup of bound complexes occurs at the oﬀ-rate, or rate ofdisso- ciation, kd (1/s). The equilibrium binding aﬃnity is ka [AV] Ka = = kd [A][V] with units l/mol. At equilibrium, the binding aﬃnities can also be given by the dissociation constant, Kd = 1/Ka. Most studies of antibody-parasite binding report equilibrium aﬃnity. This may capture an important aspect of neutralization, but other pro- cesses may also be important. For example, equilibrium binding aﬃnity provides no sense of the time course of association because it describes the ratio between on-rate and oﬀ-rate. In vivo, the race occurs between the rate of antibody binding and neutralization versus the rate of patho- gen attachment and entry into host cells (Dimmock 1993; McLain and Dimmock 1994). Experimental evolution studies could be devised to measure under what conditions selection favors particular changes in rate processes or only an overall change in equilibrium aﬃnity. NEUTRALIZATION MECHANISMS AND KINETICS Inow turn to afew particular studies. They measured neutralization by the rate at which amixtureofantibody and virus loses infectivity when presented with a layer of cultured host cells. For theﬁveMAbs,the rank order of binding aﬃnity approximately matched the rank order of neutralization rate. Thus, binding aﬃnity explains some of the variation in neutralization rate. However, the ratio of aﬃnity to neutralization rate varied by a factor of 125. Edwards and Dimmock (2000) studied several aspects by which IgG MAbs H36 and H37 neutralize inﬂuenza. H36 binds to site B and H37 to site A on the HA molecule (see ﬁg. Antibodies in cell culture may neutralize by blocking viral attachment, by preventing fusion of the EXPERIMENTAL EVOLUTION: INFLUENZA 221 virus with the host cell membrane, by inhibiting internalization of the virus, or by interfering with viral replication. Edwards and Dimmock (2000) found that, when antibodies inhibited infectivity by 50% of viruses, attachment was blocked for only 5 to 20% of viruses. Thus, other neutralizing mechanisms must play an important role. Further studies demonstrated that antibody inhibition of viral fu- sion increased in proportion to neutralization.
In the sections below cheapest sildalis erectile dysfunction causes alcohol, we include the active-control good- and fair-quality TZD studies included in the 2008 Drug Effectiveness Review Project drug class review on TZDs (searches through Nov 2007) buy sildalis paypal erectile dysfunction doctor london, as well as new good- and fair-quality studies identified since that time (searches through July 28, 2010). Pioglitazone compared with an active control Characteristics of studies 125-140 We included 16 trials comparing pioglitazone with an active control (Tables 28 and 29). Seven monotherapy trials 126, 130, 133, 135 135, 137, 139, 140 compared pioglitazone to a sulfonylurea or to metformin. Trials examining combination therapy compared pioglitazone to a sulfonylurea with both groups 125, 127-129, 131 134 receiving various oral hypoglycemic agents or insulin or metformin. Pioglitazone 132, 136, 138 was compared to metformin as add-on to other diabetic therapy in 3 trials. Drug dosing across studies was fairly consistent, with most study populations 50-60 years of age. Studies 127, 128, 130, 135, 137 ranged between 3 and 18 months; 5 trials had follow-up of greater than 6 months. Characteristics of pioglitazone active-control trials with sulfonylureas in adults with type 2 diabetes a Age (years) (SD) a % Female a Sample size % White a (N) % Hispanic Author, year Follow-up Other population Combination Quality (weeks) characteristics Intervention therapy 67 (8. Characteristics of pioglitazone active-control trials with metformin in adults with type 2 diabetes a Age (years) (SD) a % Female a Sample % White a size (N) % Hispanic Author, year Follow-up Other population Combination Quality (weeks) characteristics Intervention therapy 51. Efficacy results HbA1c results for active-control trials of pioglitazone are presented in Tables 30 and 31. Effects on HbA1c were similar between treatment groups, with no statistically significant difference noted between groups in 13 of the 16 trials. The 3 trials reporting a statistically significant difference compared pioglitazone to a sulfonylurea and reported small between-group 127, 128, 133 differences in HbA1c (0. None of the trials comparing pioglitazone to metformin reported a statistically significant difference. In a small (N=92), monotherapy study in 133 Japan, HbA1c decreased more with glibenclamide (change in HbA1c −1. In an 18-month trial of glibenclamide compared with pioglitazone in newly-diagnosed diabetic 127 subjects taking a variety of concurrent hypoglycemic agents including insulin, HbA1c improved in both groups to a similar degree to week 32, then the improvement was maintained with pioglitazone but not with glimepiride. At the final follow-up (week 72), the between-group difference (in favor of pioglitazone) was −0. In the PERISCOPE trial (N=543), greater improvement in HbA1c was reported for subjects treated with pioglitazone (−0. Change in HbA1c for pioglitazone compared with sulfonylureas in adults with type 2 diabetes HbA1c (%) HbA1c (%) change from P value change from baseline of baseline (mean, SD) between- Author, year (mean, SD) for for active group Quality Intervention pioglitazone control difference Glipizide: start 5 mg daily; mean 125 Agarwal 2005 maximal dosage 41 mg daily −0. Change in HbA1c for pioglitazone compared with metformin in adults with type 2 diabetes HbA1c (%) change from HbA1c change P value of baseline (mean, from baseline between- Author, year SD) for (mean, SD) for group Quality Intervention pioglitazone active control difference 140 Pio 15 mg daily Kato 2009 -1. Rosiglitazone compared with an active control Characteristics of studies We included 14 active-control trials comparing rosiglitazone with an active control (Tables 32 141-154 144, 148, 149, 152-154 and 33). Six of these are new to this section in this report. There were 4 147, 148 monotherapy trials comparing rosiglitazone to metformin or rosiglitazone to a 145, 147, 149 sulfonylurea. The combined therapy trials compared rosiglitazone to a sulfonylurea 141-144, 152, 154 with both groups receiving metformin or insulin or compared rosiglitazone to 151 146 metformin with both groups receiving sulfonylureas or various hypoglycemic agents. Kadoglou and colleagues compared the addition of rosiglitazone with increasing the dose of metformin for people with inadequately controlled diabetes while taking metformin 850mg daily. Across active-control studies, rosiglitazone dosing was either 4 or 8 mg daily. Follow-up 147 142, intervals ranged from 24 weeks to 4 years, with 7 trials having follow-up of 1 year or more. Characteristics of rosiglitazone active-control trials with sulfonylurea in adults with type 2 diabetes a Age (years) (SD) a % Female a % White a Author, Sample size (N) % Hispanic year Follow-up Other population Combination Quality (weeks) characteristics Intervention therapy 58. Data shown are mean (SD) unless otherwise indicated. Characteristics of rosiglitazone active-control trials with metformin or other in adults with type 2 diabetes a Age (years) (SD) a % Female a % White a Sample size (N) % Hispanic Author, year Follow-up Other population Combination Quality (weeks) characteristics Intervention therapy 146b 58. Data shown are mean (SD) unless otherwise indicated. Efficacy results HbA1c results for active-control trials of rosiglitazone are presented in Tables 34 and 35. One of 147 the 14 trials, A Diabetes Outcomes Progression Trial (ADOPT), reported a statistically significantly greater improvement in HbA1c for subjects treated with rosiglitazone than those 143 treated with active controls and one reported greater improvement for the active control than for rosiglitazone. The other 12 trials reported no statistically significant difference between groups. ADOPT was a large (N=4360), multicenter, double-blind, randomized controlled trial designed to evaluate monotherapy with rosiglitazone, metformin, or glyburide. The trial reported greater improvement in HbA1c at 4 years for subjects treated with rosiglitazone than for those treated with metformin (treatment difference −0. Garber and colleagues reported greater improvement in glycemic control for subjects treated with a combination of glibenclamide 5 mg/metformin 1000 mg (once or twice daily) than for those treated with rosiglitazone 4-8 mg daily combined with metformin 1500-2000 mg daily (between-group 143 difference in HbA1c 0. Among the monotherapy trials, ADOPT (N=4360) was designed to evaluate monotherapy with rosiglitazone, metformin, or glyburide among subjects recently diagnosed (within 3 years) with type 2 diabetes and who had failed lifestyle therapy but had not started on 147 oral hypoglycemic agents. The primary outcome was monotherapy failure defined as fasting plasma glucose level of >180 mg/dL. Median duration of treatment with rosiglitazone was 4 years. The cumulative incidence of monotherapy failure at 5 years was 15% with rosiglitazone, 21% with metformin, and 34% with glyburide (P<0. The results of 2 smaller rosiglitazone monotherapy trials were similar to the results from ADOPT when the appropriate follow-up intervals were compared. Hanefeld and colleagues 145 found no significant difference between glibenclamide and rosiglitazone at 52-week follow-up and Pop-Busui and colleagues found no significant difference between glyburide and 149 rosiglitazone at 26 weeks. Likewise, Kiyici and colleagues reported similar changes from 148 baseline in HbA1c for subjects treated with rosiglitazone and those treated with metformin. Among the combination therapy trials where rosiglitazone was added to ongoing metformin therapy compared with adding various sulfonylureas to ongoing metformin, 4 trials 141, 142, 144, 152 did not show significant differences between rosiglitazone and active comparators. Combination therapy studies comparing rosiglitazone to metformin with both groups 146, 151 receiving other oral agents did not show significant differences between treatment groups. Rosiglitazone was superior to repaglinide (each as monotherapy; no statistics provided). Subjects taking metformin at study entry were randomized to add-on sulfonylurea. Change in HbA1c in rosiglitazone active-control trials with sulfonylurea in adults with type 2 diabetes HbA1c (%) HbA1c (%) change change from from baseline baseline (mean, P value of Author, year (mean, SD) for SD) for active between-group Quality Intervention rosiglitazone control difference Rosi: start 4 mg daily 141 Bakris 2006 −0. Change in HbA1c in rosiglitazone active-control trials with metformin or other in adults with type 2 diabetes HbA1c (%) HbA1c (%) change change from from baseline baseline (mean, P value of (mean, SD) for Author, year SD) for active between-group rosiglitazone Quality Intervention control difference SU (background Rosi + metformin: metformin) vs. TZDs compared with newer diabetes drugs Characteristics of studies We found 4 trials comparing rosiglitazone with a newer diabetes drug of primary interest to this 36, 40, 67, 84 report (Table 36).