The Cochrane Abstract below is a su...

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by dint of an interpretation that will help clinicians lay evidence into practice. Michael Schooff MD and Jason Wickersham, MD at hand a clinical scenario and question based forward the Cochrane Abstract, along with the evidence-based answer and a replete critique of the abstract.

This clinical appease conforms to AAFP criteria for evidence-based continuing medical education (EB CME) EB CME is clinical appease presented with practice recommendations supported according to evidence that has been systematically reviewed by means of an AAFP-approved source. The practice recommendations in this activity are available at www.update-software.com/abstracts/ ab002047.htm.

diocese page 785 for definitions of strength-of-evidence levels

Clinical Scenario

A 43-year-old woman is newly diagnosed with rheumatoid arthritis. You want to elect a disease-modifying anti-rheumatic drug (DMARD) to help intercept disease progression.

Clinical Question

Is leflunomide as safe and effective in the treatment of rheumatoid arthritis as other DMARDs?

Evidence-Based Answer

Compared with placebo, leflunomide improves clinical issues and delays radiologic progression of rheumatoid arthritis. After sum of two units years of treatment, leflunomide is as safe as sulfasalazine and more effective. Leflunomide's efficacy and adverse affairs are similar to those of methotrexate. Leflunomide sumptuousnesss significantly more than sulfasalazine and methotrexate. [Evidence of the same height A, systematic review of randomized controll trials]

Cochrane Critique

Did the authors address a focused clinical question? Yes

Were the criteria used to single out articles for inclusion appropriate? Yes

Is it likely that important and relevant articles were missed? No.

Was the validity of the individual articles appraised? Yes

Were the assessments of studies reproducible? Yes

Were the outcomes similar from study to study? No. Five of the six trials had similar rises (treatment with leflunomide and methotrexate were equally effective). In undivided study that compared leflunomide with methotrexate at 12 month and sum of two units years, improvements with methotrexate were significantly greater than those with leflunomide. Therefore, the comparison of issues between leflunomide and methotrexate was based onward random effects models.

Can the be deriveds be applied to patient care? Yes

Do the conclusions make biologic and clinical sense? Yes

Are the benefits worth the harms and cost? No.

Practice Pointers

Leflunomide is a strange drug with a different mechanism of action than other DMARDs like as methotrexate, antimalarial drugs (chloroquine and hydroxychloroquine), sulfasalazine, gold azathioprine, d-penicillamine, and cyclosporin A. Leflunomide is given in a dosage of 100 mg by day for the first single to three days and 20 to 25 mg by means of day thereafter.

Studies were raise that compared leflunomide with sulfasalazine and methotrexate. Adverse marked occurrences were 10 percent greater in the leflunomide-treated assign places to compared with placebo. However, the total withdrawal rate was higher in the placebo dispose because of lack of treatment efficacy.

The efficacy of leflunomide was not significantly different from that of sulfasalazine at six and 12 month At 24 month however, leflunomide was significantly better than sulfasalazine in principally of the clinical outcomes measured. There were no differences in adverse ends or discontinuation rates between leflunomide and sulfasalazine.

Compared with methotrexate, leflunomide was not significantly more effective upon most outcome measures. There was no difference in the number of weak or swollen joints, pain scores, or work productivity. Patients who took leflunomide were more likely than those who took methotrexate to discontinue treatment unless not because of adverse adventures There was no significant difference between the leflunomide and methotrexate clumps in the likelihood of elevated hepatic transaminase of the same heights or weight loss. Patients in the leflunomide assign places to were more likely to experience gastrointestinal symptoms, allergic reactions, infections, alopecia, and hypertension.

Safety profiles were similar for the three medications studied. However, leflunomide has not been studied for longer than pair years. Leflunomide is much more expensive than sulfasalazine or methotrexate. undivided month of therapy with leflunomide expenses $375 compared with $15 to $31 for sulfasalazine and $36 to $47 for methotrexate (figures based upon average wholesale prices in R work Montvale, N.J.: Medical Economics Data, 2003) Based onward the evidence in this review, leflunomide was plenteous more effective than placebo after pair years of therapy, somewhat more effective than sulfasalazine, and equally as effective as methotrexate, although at a greatly higher cost.

REFERENCE

(1) Osiri M Shea B Robinson B Suarez-Almazor M Strand V Tugwell P et al. Leflunomide for treating rheumatoid arthritis. Cochrane Database Syst Rev 2003:CD002047