Nevirapine-based regimens in HIV-infected antiretroviral-naive patients : systematic review and meta-analysis of randomized controlled trials

BACKGROUND:Nevirapine belongs to the group of non-nucleoside reverse transcriptase inhibitors (NNRTIs) and is commonly administered in first-line treatment of HIV infection. OBJECTIVE:Systematic review and meta-analysis was undertaken to compare effectiveness of nevirapine-based regimens with other antiretroviral schedules used as an initial treatment of HIV-infected antiretroviral-naive subjects. METHODS:Electronic databases (PubMed, EMBASE, the Cochrane Library, Trip Database) were searched up to 28 December 2012 for randomized controlled trials (RCTs) published as a full text and regarding nevirapine-based regimens used as a initial treatment for HIV infection. Meta-analysis was performed with RevMan(®) V 5.2 software. RESULTS:Twelve RCTs were included in the systematic review and all of them were suitable for meta-analysis. Results of the meta-analysis have shown that nevirapine, efavirenz, and ritonavir-boosted protease inhibitor, added to the background regimens, were equally effective in terms of reaching undetectable plasma HIV RNA level as well as risk of disease progression or death. Compared with ritonavir-boosted protease inhibitor-based regimens, nevirapine-based regimens statistically significantly increased the risk of discontinuation of assigned treatment (RR=3.10; 95% CI: 1.14-8.41; p<0.05). CONCLUSIONS:Despite limited RCTs data available for particular comparisons, our results suggest that nevirapine-based regimens may be considered for first-line treatment of HIV-infected adults, due to their comparable efficacy to the other currently recommended initial antiretroviral therapies

Efficacy of single and repeated administration of ketamine in unipolar and bipolar depression : a meta-analysis of randomized clinical trials

Background Due to unmet clinical needs for efficient drugs with a rapid onset of antidepressant effects, we aimed to evaluate the efficacy of single-dose ketamine in different subgroups of patients with major depression and establish whether repeated ketamine administration could be a viable strategy to maintain treatment gains. Methods Electronic databases (Medline via PubMed, Embase, Cochrane Library, Trip Database) were systematically searched until February 22, 2019, for published peer-reviewed randomized controlled trials (RCTs) concerning a single and repeated administration of ketamine in patients with major depression. All relevant RCTs were selected and critically appraised, and a meta-analysis of eligible studies was performed. Results A total of 20 studies were included in the meta-analysis. The largest effect of ketamine vs. controls in reducing depressive symptoms was observed at 24 h (SMD = - 0.89; 95% CI - 1.24; - 0.53; p < 0.00001); however, a significant difference was shown for up to 7 days after a single dose. Significant differences compared with controls were observed for up to 7 days in treatment-resistant patients and when ketamine was added to ongoing antidepressant treatment, while there were no significant differences at 7 days when ketamine was used as monotherapy. In patients with major depression, initial antidepressant effects of ketamine were maintained during repeated dosing. At 2-3 weeks of repeated ketamine treatment, significant reduction of depression severity scores was observed: SMD = - 0.70; 95% CI - 1.15; - 0.25 or SMD = - 0.81; 95% CI - 1.41; - 0.20 (depending on the dosing regimen used); p ≤ 0.009 vs placebo. Conclusions Our meta-analysis revealed rapid and robust antidepressant effects of single-dose ketamine in patients with treatment-resistant depression (TRD). By pooling data from RCTs, we showed for the first time that repeated ketamine administration is effective in sustaining initial antidepressant effects observed after single dosing

Imatynib w terapii adiuwantowej pacjentów po zabiegu usunięcia nowotworów podścieliskowych przewodu pokarmowego (GIST) – przegląd systematyczny badań klinicznych i metaanaliza

Background: Adjuvant therapy is recommended for the population of patients with high risk of recurrence of gastrointestinal stromal tumour after resection. The aim of the study: Evaluation of the clinical efficacy and safety profile of imatinib used in adjuvant therapy in patients after complete resection of a gastrointestinal stromal tumour. Material and methods: A systematic review of the literature published up to 30.03.2012 was performed, and a meta-analysis of identified studies was carried out. Databases were searched: PubMed, EMBASE, The Cochrane Library and others. Results: Two randomised clinical trials regarding comparisons of: imatinib vs. placebo and 12 months of adjuvant imatinib vs. 36 months of adjuvant imatinib as well as 20 non-randomised trials fulfilled the established criteria. Adjuvant imatinib statistically significantly improves recurrence-free survival compared with placebo. Patients with high risk of recurrence benefit most from assigned treatment. Three years of adjuvant imatinib therapy improves recurrence-free state and overall survival compared with 1 year of imatinib in patients after resection of a gastrointestinal stromal tumour. The safety profile of imatinib in the analyzed population is acceptable. Conclusions: For patients with a significant risk of recurrence adjuvant therapy with imatinib should be considered for every patient, due to the clinical benefits it brings.Wstęp: Zastosowanie terapii adiuwantowej jest zalecane u pacjentów ze znaczącym ryzykiem nawrotu choroby po zabiegu usunięcia nowotworu podścieliskowego przewodu pokarmowego. Cel pracy: Ocena skuteczności klinicznej i profilu bezpieczeństwa imatynibu stosowanego w ramach terapii adiuwantowej u pacjentów po zabiegu całkowitej resekcji nowotworu podścieliskowego przewodu pokarmowego. Materiał i metody: Przeprowadzono systematyczny przegląd literatury opublikowanej do 30 marca 2012 r. oraz metaanalizę zakwalifikowanych do opracowania badań. Przeszukano następujące bazy danych: PubMed, EMBASE, The Cochrane Library oraz inne. Wyniki: Odnaleziono 2 randomizowane badania kliniczne, dotyczące porównania: imatynibu z placebo oraz imatynibu stosowanego przez 12 miesięcy z imatynibem podawanym przez 36 miesięcy, oraz 20 nierandomizowanych badań klinicznych dotyczących stosowania imatynibu w analizowanym wskazaniu. Zastosowanie imatynibu w terapii adiuwantowej prowadzi do istotnego statystycznie wydłużenia przeżycia wolnego od nawrotu choroby względem placebo. Największe korzyści z zastosowanej terapii odnoszą chorzy z wysokim ryzykiem nawrotu choroby. Przedłużenie 12-miesięcznej terapii imatynibem do 36 miesięcy zwiększa prawdopodobieństwo przeżycia wolnego od progresji choroby oraz przeżycia całkowitego pacjentów po zabiegu resekcji nowotworu podścieliskowego przewodu pokarmowego. Profil bezpieczeństwa imatynibu w analizowanej populacji okazał się korzystny. Wnioski: U pacjentów o znaczącym ryzyku nawrotu terapia adiuwantowa imatynibem powinna być rozpatrywana w przypadku każdego pacjenta ze względu na korzyści kliniczne, jakie przynosi

Efavirenz-Based Regimens in Antiretroviral-Naive HIV-Infected Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

<div><p>Efavirenz, a non-nucleoside reverse-transcriptase inhibitor (NNRTI) is one of the most commonly prescribed antiretroviral drugs. The present article provides a systematic overview and meta-analysis of clinical trials comparing efavirenz and other active drugs currently recommended for treatment of HIV-infected, antiretroviral-naive patients. Electronic databases (Pubmed, Embase, the Cochrane Library, Trip Database) were searched up till 23 December 2013 for randomized controlled clinical trials published as a peer-reviewed papers, and concerning efavirenz-based regimens used as initial treatment for HIV infection. Thirty-four studies were included in the systematic review, while twenty-six trials were suitable for the meta-analysis. Efavirenz was compared with drugs from four different classes: NNRTIs other than efavirenz (nevirapine or rilpivirine), integrase strand transfer inhibitors (InSTIs), ritonavir-boosted protease inhibitors (bPI) and chemokine (C-C motif) receptor 5 (CCR5) antagonists (maraviroc), all of them were added to the background regimen. Results of the current meta-analysis showed that efavirenz-based regimens were equally effective as other recommended regimens based on NNRTI, ritonavir-boosted PI or CCR5 antagonist in terms of efficacy outcomes (disease progression and/or death, plasma viral HIV RNA <50 copies/ml) while statistically significant more patients treated with InSTI achieved plasma viral load <50 copies/ml at week 48. In comparison with both InSTI-based and CCR5-based therapy, efavirenz-based treatment was associated with a higher risk of therapy discontinuation due to adverse events. However, comparisons of efevirenz-based treatment with InSTI-based and CCR5-based therapy were based on a limited number of trials, therefore, conclusions from these two comparisons must be confirmed in further reliable randomized controlled studies. Results of our meta-analysis support the present clinical guidelines for antiretroviral-naive, HIV-infected patients, in which efavirenz is one of the most preferred regimens in the analyzed population. Beneficial safety profile of InSTI-based and CCR5-based therapy over efavirenz-based treatment needs further studies.</p></div

MeSH subject headings and EMTREE keywords used in search strategy construction (last updated: 23.12.2013).

<p>MeSH subject headings and EMTREE keywords used in search strategy construction (last updated: 23.12.2013).</p

PRISMA flow diagram for selection of studies identified in the systematic review.

<p>PRISMA flow diagram for selection of studies identified in the systematic review.</p

Characteristics of the randomized controlled trials for efavirenz compared to different regimens used to treat antiretroviral–naive HIV-infected adult patients.

<p>3TC—lamivudine, ABC—abacavir, APL—aplaviroc, APV—amprenavir, ART—antiretroviral therapy, ATV—atazanavir, AZT—zidovudine, bid—twice a day, bPI—ritonavir-boosted protease inhibitor, CCR5—CC chemokine receptor type 5, COBI—cobicistat, d4T - stavudine, ddC—zalcitabine, ddI—didanosine, DTG—dolutegravir, EFV—efavirenz, ETV—etravirine, EVG—elvitegravir, FPV—fosamprenavir, FTC—emtricitabine, IDV—indinavir, MVC—maraviroc, LPV—lopinavir, LRV—lersivirine, NFV—nelfinavir, NNRTI—non-nucleoside reverse transcriptase inhibitor, NRTI—nucleoside reverse transcriptase inhibitor, NVP—nevirapine, PI—protease inhibitor, r—ritonavir, RAL—raltegravir, RCT—randomized controlled trial, RPV—rilpivirine, SQV—saquinavir, TDF—tenofovir, pVL—plasma HIV RNA, VCV—vicriviroc.</p><p>* interventions included in meta-analysis only.</p><p>**raltegravir monotherapy did not influenced the efficacy results, so both groups (pretreated and not pretreated with raltegravir were combined).</p><p>***results for groups assigned EFV + different NRTIs and separately ATV/r + different NRTIs were combined.</p><p>#enrolment in the TDF + ddI + EFV arm was stopped as soon as the high rate of virological failure was recognized.</p><p>##once-daily MVC arm was discontinued prematurely and not analyzed.</p><p>###stopped prematurely due to unexpected hepatotoxicity.</p><p>Characteristics of the randomized controlled trials for efavirenz compared to different regimens used to treat antiretroviral–naive HIV-infected adult patients.</p

Forest plot of comparison: efavirenz vs InSTI added to the background regimen.

<p>Forest plot of comparison: efavirenz vs InSTI added to the background regimen.</p