Prescrire international
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Prescrire international · May 2013
ReviewDeep venous thrombosis and pulmonary embolism. Part 2--Prevention of recurrences: warfarin or low-molecular-weight heparin for at least 3 months.
In patients with deep venous thrombosis or pulmonary embolism, initial treatment with low-molecular-weight heparin (LMWH) is primarily aimed at preventing thrombus extension. After this initial phase, the goal of treatment is to prevent recurrences, which can be fatal. Is it better to continue treatment of deep venous thrombosis or pulmonary embolism with LMWH or switch to an oral anticoagulant? What is the optimal duration of treatment? To answer these questions, we conducted a review of the literature using the standard Prescrire methodology. ⋯ Various clinical practice guidelines published since 2006 recommend first-line treatment with a vitamin K antagonist for at least 3 months in patients without cancer, and continuation of LMWH therapy in patients with cancer. Overall, LMWH and warfarin have similar harm-benefit balances. In practice, it is best to choose between these drugs on a case-by-case basis, taking into account patient preferences, monitoring constraints, difficulty controlling the INR, the risk of bleeding and interactions, and the cost of treatment.
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Idiopathic pulmonary fibrosis is a rare disorder due to progressive, widespread fibrotic damage of the lung parenchyma. It usually occurs after the age of 50, and its cause is unknown. Symptoms include progressive shortness of breath and nonproductive cough. ⋯ In practice, there is no evidence that pirfenidone improves quality of life in patients with mild to moderate idiopathic pulmonary fibrosis, or that it slows the progression of pulmonary fibrosis. The adverse effect profile is already burdensome. Pending real therapeutic advance, it is best to avoid pirfenidone altogether and to focus on symptomatic treatment.
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Prescrire international · May 2013
Anaphylactic reactions during anaesthesia: neuromuscular blocking agents, latex and antibiotics.
A French team investigated hypersensitivity reactions that occurred during locoregional or general anaesthesia over an 8-year period. They estimated that the incidence of anaphylactic reactions was about 1 per 10 000 anaesthetic procedures. Among the 1816 reports of anaphylactic reactions, the most commonly implicated drugs were neuromuscular blocking agents (1067 cases), latex (361 cases), and antibiotics (236 cases). ⋯ Most reactions in children were due to latex, followed by neuromuscular blocking agents and antibiotics. In practice, exposure to latex devices should be minimised, or simply avoided when possible. A history of sensitization to substances sharing allergenic sites with neuromuscular blocking agents should be investigated, and measures should be taken to protect patients.