Prescrire international
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Prescrire international · May 2017
ReviewThrombophilia: Testing rarely useful after a venous thromboembolic event.
Some people have coagulation abnormalities, collectively referred to as thrombophilia, which increase the risk of thrombosis. What are the most frequently detected thrombophilia? Does throm- bophilia testing after a venous thromboembolic event enable effective adjustment of the treatment strategy?To answer these questions, we reviewed the available evidence using the standard Prescrire methodology. The best known inherited thrombophilia includes the factorV Leiden mutation and the prothrombin G20210A mutation. ⋯ Clinical guidelines only suggest performing thrombophilia testing after a venous thromboem- bolic event in certain situations, for patients with no identified risk factors for recurrence, when the result might influence the decision to continue or stop anticoagulation: testing for inherited thrombophilia if a close relative had unexplained venous thrombosis at a young age, and antiphospholipid antibody testing. The identification of a thrombophilia can lead to overestimating the risk of thrombosis, and underestimating the risk of bleeding in patients receiving anticoagulation. In practice, thrombophilia testing is rarely useful following venous thromboembolism, except perhaps to clarify the risk of recurrence in some patients in whom the thromboembolic event was unexplained, when deciding whether to discon- tinue anticoagulation.
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To help healthcare professionals and patients choose high-quality treatments that minimise the risk of adverse effects, in early 2017 we updated the list of drugs that Prescrire advises health pro- fessionals and patients to avoid. Prescire's assessments of the harm-benefit balance of new drugs and indications are based on a rigorous procedure that includes a systematic and reproducible literature search, identification of patient-relevant outcomes, prioritisation of the supporting data based on the strength of evidence, comparison with standard treatments, and an analysis of both known and potential adverse effects. This fifth annual review of drugs to avoid has been extended to cover all drugs examined by Prescrire between 2010 and 2016 and authorised in the European Union, whereas previous reviews only considered drugs marketed in France. ⋯ Even in serious situations, when no effective treatment exists, there is no justification for prescribing a drug with no proven efficacy that provokes severe adverse effects. It may be acceptable to test these drugs in clinical trials, but patients must be informed of the uncertainty over their harm-benefit balance, and the trial design must be relevant. Tailored supportive care is the best option when there are no available treatments capable of improving prognosis or quality of life, beyond their placebo effect.
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Prescrire international · Dec 2016
Prescrire's Médicaments en Questions: First results of a practice improvement programme.
In 2014, Prescrire launched a new distance-learning practice improve- ment programme for subscribers to our French edition, called M6dicaments en Questions (Medicines in Question). The aim of this programme is to help healthcare professionals take greater account of the harmful effects of drug treatments in their daily practice, manage adverse effects better, and help to reduce their inci- dence and severity. This programme is based on a reflexive approach: participants describe, analyse and compare their practices; update and improve their knowledge base; exchange ideas with other health professionals; and devel- op strategies for improvement. The results of the first session (2014-2015) have been encouraging: participants took greater account of adverse effects, exposed fewer patients to the harms of drugs that have an unfavourable harm-benefit balance, communicated better with other healthcare professionals, found it easier to discuss adverse effects with patients, and were encouraged to report adverse effects to the public pharmacovigilance system.
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Prescrire international · Nov 2016
ReviewChronic obstructive pulmonary disease: Useful medications for patients with recurrent symptoms.
Chronic obstructive pulmonary disease (COPD) is a respiratory disorder characterised by largely irreversible changes in air flow due to irritants such as tobacco smoke. Patients with COPD experience acute exacerbations. Severe disease may progress to chronic respiratory failure. ⋯ Drugs used in COPD have only modest, mainly symptomatic efficacy. Treatment should be adapted to symptoms and the frequency of exacerbations: a short-acting beta-2 agonist should be tried first, then replaced by an inhaled long-acting bronchodilator, or possibly tiotropium, when its effect is too short-lived. An inhaled corticosteroid can be added if symptoms persist or exacerbations are frequent.