Prescrire international
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Prescrire international · Nov 2010
ReviewAspirin and primary cardiovascular prevention. Uncertain balance between benefits and risks.
Most individuals with no pre-existing cardiovascular disease have a low risk of experiencing arterial thrombosis. Using the standard Prescrire methodology, we reviewed the literature on the risk-benefit balance of aspirin in the primary prevention of cardiovascular events. In the general population, a meta-analysis in 95 456 persons suggests that aspirin has no effect on either total or cardiovascular mortality. ⋯ When the cardiovascular risk is higher than in the general population, for example in patients with risk factors, the weak preventive effects of aspirin on myocardial infarction and ischaemic stroke may outweigh the small extra risk of bleeding. The possible value of aspirin for cardiovascular prevention should be discussed with each individual patient. In general, it is preferable to recommend measures with a proven impact on mortality, such as dietary changes, smoking cessation, or drug therapy for patients with risk factors.
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Prescrire international · Nov 2010
ReviewIcatibant. Attacks of hereditary angioedema: continue to use C1 esterase inhibitor.
Hereditary angioedema is a severe genetic disorder due to C1 esterase inhibitor deficiency, which leads to an excess of bradykinin. It is characterised by attacks of subcutaneous or mucosal oedema, which can carry a risk of asphyxiation if the larynx is involved. The first-choice symptomatic treatment for attacks is intravenous C1 esterase inhibitor administration. ⋯ In practice, in the absence of head-to-head comparisons, it remains to be shown whether or not icatibant has a better risk-benefit balance than C1 esterase inhibitor. Due to inconsistencies between the results and numerous biases in the two main clinical trials, the evidence supporting the efficacy of icatibant is weak. C1 esterase inhibitor remains the first-choice treatment for patients with acute attacks of hereditary angioedema.
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There is no firm evidence that intranasal fentanyl is more effective than buccal fentanyl. The packaging is not entirely safe, thus exposing patients and others to major risks.
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Without treatment, patients with inoperable or metastatic colorectal cancer have a median life expectancy of about 8 months. The following article is an update of our 2005 review of chemotherapy regimens used in metastatic colorectal cancer, based on the standard Prescrire methodology. In 2005, the de Gramont protocol, based on fluorouracil (always combined with folinic acid) plus either oxaliplatin (Folfox protocol) or irinotecan (Folfiri protocol), was the standard first-line chemotherapy in this setting. ⋯ When the metastases are inoperable and are unlikely to become operable after chemotherapy, it seems best to begin treatment with single-agent fluorouracil (+ folinic acid) or capecitabine. The use of monoclonal antibodies in first-line treatment of patients with colorectal cancer is not justified. Further trials of these drugs are warranted as second-line treatment for patients with KRAS wild-type tumours.