Transcript TREATMENT

TREATMENT
Reporter: Krystel Babaran
Members:
Asuncion, Gewelene
Austria, Mary Martha
Azurin, Edelyn
Clinical Scenario or Question
• What treatment could be given to improve the
renal function among patients with gouty
nephropathy?
Search: Finding the Evidence
4.
listwords
of journals
narrowed for
down
and
limited,
the that
2. With
Usedthe
key
in searching
the
right
journal
1.right
Visited
http://www.ncbi.nlm.nih.gov/pubmed/
journal
was eventually
found.
would answer
the clinical
question.
• Mesh Terms: Gouty Nephropathy, Treatment, Renal
Function
3. Narrowed our search by
limiting out topics,
languages and journal
groups
• Limits: Links to full text,
humans, English
CATMAKER
Your
Question
The
Study
Evidence
The
Study
Patients
The Bottomline
Allopurinol treatment and its effect on renal
function in gout: a controlled study
Gibson T, Rodgers V, Potter C, Simmonds HA.
Annals of the Rheumatic Diseases, 1982, 41, 59-65
CRITICAL APPRAISAL
Relevance
• Population
Is the objective of the article comparing therapeutic
– Patients with similar
gout whotohad
experienced
at least 1 attack
interventions
your
clinical dilemma?
– of
Yesacute arthritis associated with a raised blood uric acid
unrelated to drugs or other diseases
– Appropriate treatment to improve the Renal
• Intervention
Function of our patient with: Gout, Azotemia
– Allopurinol 200 mg tab for 2 years
(decreased GFR) and Recurrent gouty attacks
• Outcome
– With similar objective
– Improvement in renal function over 2 years based on the
GFR
Validity Guidelines
•• Best
case
– Worst
case
Analysis
Was
of entered
patients
to treatment
Werethe
allassignment
patients
who
the
trial properly
randomized?
accounted for andControl
attributed at
its conclusion?
Treatment
Total
0 year
33
26
59
– Yes.
No.
-1 dropout
– Randomly
allocated
to 2study.
treatment
groups 58
• 59 patients
entered
the
1 year
33
25
• Stratified
1 patient dropped
outthe
during
the 1storyear
for- age
and
presence
absence
of
4 dropouts
- 3 crossovers
to
+3 crossovers
• hypertension
4 patients dropped
out duringcolchicine
the 2nd year
from allopurinol
– One group was treated with colchicine 0.5mg bid
2 years
32
22
54
The
5back
patients
who dropped
out200
corresponds to an
– Other
allopurinol
Bring
3group with- 3
+3 mg daily in
8.5% drop-out rate
crossovers
to original
addition
to colchicine.
group
29
25
54
Validity Guidelines
Was follow-up
of
patients
long
• Were
Were
patients
the groups
, their
treated
similar
clinicians,
at
equally,
the
andstart
study
apart
ofand
the
from
patients
analyzed
in sufficiently
the
groups
to
which
they
complete?
personnel
“blind” totherapy?
treatment?
were
randomized?
the experimental
trial?
–
–
–
–
–
–
–
The
patients
and were
the clinicians
not
blinded
to the they
treatment.
1st year:
patients
analyzedwere
in the
groups
to which
were
Yes.
Yes
randomized,
thus
“intention-to-treat”
was present
Inferred
thereanisintervals
single-blinding
sinceanalysis
on thereviewed
reading
of the
Atnd 2- orthat
3-month
patients
were
results,
neither
the
technicians
nor
the 1
machines
were
aware
2 year,
3 experienced
patients
failed
to take
allopurinol
regularly
wereof the
Both
All
had
groups
received
atcolchicine
least
attack
0.5mg
ofand
acute
– 58
patients
followed
up for group
at least
year;
subjects’
characteristics
and conditions.
reallocated
to were
the colchicine
treatment
for 1the
purposes of
arthritis
associated
with
a
raised
blood
uric
acid
– 54
No
other
co-interventions
were
given
analysis.
were assessed over 2 years
drugs from
or other
diseases
– unrelated
Assumed the 3to
crossovers
allopurinol
to have the bad outcomes
and we brought them back to their original group
– The number of crossover would not threaten the validity of the study
because the conclusions would still favor allopurinol
Is the study VALID?
• Yes
–
–
–
–
–
–
The majority of the validity guidelines were met
The subjects were randomly allocated into treatment groups
The baseline characteristics of both groups were similar
Single-blinding was utilized.
The follow-ups were sufficiently long however incomplete
There was surely an “intention-to-treat” analysis on the 1st
year of investigation
Can the results help me in caring for my patients?
Results
• How precise was the estimate of the
• treatment
How large effect?
was the treatment effect?
• Can the results be applied
to
my
patient?
RESULTS
– 95% CI was not reported
– YesRisk in Control
0.364
– CATMAKER:
– OurRisk
patient
met all the inclusion
criteria and has
0.077
in Treatment
95%study.
CI
none of the exclusion criteria of this
Relative
RRR
79% 0.212 26-100%
Risk
ARR
0.287
0.093 to 0.481
0.79 (79%)
Relative Risk
NNT
3
2 to 11
Reduction
Absolute Risk
Reduction
0.287
– The p-value was less than 0.10 (p<0.025)
3
Number Needed to
– Thetreat
treatment effect was precise and acceptable
Can the results help me in caring for my patients?
• Were all clinically important outcomes considered?
How
isare
your
patient
similar
to the
study
population?
• Is
available
and
affordable
your
What
your
patient’s
different?
potential
Willbenefits
thetodifferences
andpatient?
harms
affect
from
thethe
–treatment
Yes.
applicability
therapy?
of parameters
the is
study’s
results
toavailable
your patient?
– Yes. Allopurinol
affordable
and
locally.Patient
other
measured:
Study
of gouty attacks
• The-#Generics
Pharmacy49– +100mg
tab, P1.60
Age
12
50
-mean body weights
Gender
Both
• USTH
– 100 mg
tab,
P 11.00
Based
on the
journal presented,
our
patient
will benefit fromMale
allopurinol
-BPPharmacy
-some
the
participants
inlipids
thethe
study
were
Duration
of of
Gout
(in
years)
Control:
5.4 +hypertensive
5.9 of renal function
10 among
because
of-fasting
its
ability
to retard
deterioration
serum
• Terramedic:
Allurase
– 100mg x 100s = P512.20
Control:
6
(18%)
Treatment:
+ 6.0
patients with
acute
gouty
arthritis
and 6.4
hyperuricemia
unrelated to drugs.
-BUN
7 (27%)
• GlaxoSmithKline:
– 100mg
x 100s = Recurrent
P697
Gouty attacks
At least
1
-blood Treatment:
creatinineZyloprim
Patient’s BP-urine
=120/70
(pre-hypertensive)
concentrating
ability
Hyperuricemia unrelated
to


-no. with>0.1g/24 h proteinuria and quantity with proteinuria
drugs-NO.
or other diseases
-daily minimum-maximum
treatment
Presence
of
Tophi
Some

-Treated throughout
with
non-diuretic
hypotensive
agents
-pH 24 h urine
Control:
7 (21%)
-majority of -ammonium
the study population
excretion(78%) do not have hypertension
Treatment: 3 (11%)
-titratable acid excretion
Azotemia


-net acid excretion
Poorly compliant-plasma
to


uric acid
-uric acid excretion
medications
-urate clearanceand Cur/ GFR x 100%.
Recommendation
• Based on this evidence, what would you
recommend?
– Our group therefore recommends the intake of
allopurinol 200mg daily to further delay the
progression of renal insufficiency causing
azotemia in our patient with chronic gouty
arthritis.