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Systematic review with network meta‐analysis: comparative effectiveness and safety of strategies for preventing NSAID ‐associated gastrointestinal toxicity
Author(s) -
Yuan J. Q.,
Tsoi K. K. F.,
Yang M.,
Wang J. Y.,
Threapleton D. E.,
Yang Z. Y.,
Zou B.,
Mao C.,
Tang J. L.,
Chan F. K. L.
Publication year - 2016
Publication title -
alimentary pharmacology and therapeutics
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 3.308
H-Index - 177
eISSN - 1365-2036
pISSN - 0269-2813
DOI - 10.1111/apt.13642
Subject(s) - medicine , misoprostol , relative risk , adverse effect , gastroenterology , meta analysis , confidence interval , pregnancy , genetics , abortion , biology
Summary Background Many strategies are used to prevent nonsteroidal anti‐inflammatory drug ( NSAID )‐associated gastrointestinal toxicity, but the comparative effectiveness remains unclear. Aim To evaluate the comparative effectiveness of clinical strategies for preventing gastrointestinal toxicity induced by NSAID s. Methods MEDLINE , EMBASE and the Cochrane Library (from their inception to May 2015) were searched for randomised controlled trials comparing the risk of gastrointestinal adverse events in patients taking nonselective NSAID s, selective cyclooxygenase( COX )‐2 inhibitors or nonselective NSAID s/ COX ‐2 inhibitors plus gastroprotective agents [proton pump inhibitors ( PPI s), histamine‐2 receptor antagonists, misoprostol]. Both pairwise meta‐analysis and Bayesian network meta‐analysis were performed. Results Analyses were based on 82 trials including 125 053 participants. Network meta‐analysis demonstrated that selective COX ‐2 inhibitors + PPI s [Risk ratio ( RR ), 95% Credible Interval (CrI): ulcer complications 0.07, 0.02–0.18], selective COX ‐2 inhibitors ( RR , 95% CrI: ulcer complications 0.25, 0.15– 0.38; symptomatic ulcer 0.12, 0.04–0.30), nonselective NSAID s + PPI s ( RR , 95% CrI: ulcer complications 0.28, 0.18–0.41; symptomatic ulcer 0.11, 0.04–0.23), nonselective NSAID s + misoprostol ( RR , 95% CrI: ulcer complications 0.47, 0.24–0.81; symptomatic ulcer 0.41, 0.13–1.00) were associated with significantly lower risk of clinical gastrointestinal events compared with nonselective NSAID s. For all effectiveness endpoints, selective COX ‐2 inhibitors + PPI s was associated with the lowest absolute event probability and the highest rank, followed by selective COX ‐2 inhibitors and thirdly by nonselective NSAID s + PPI s. Conclusion The combination of selective COX ‐2 inhibitors plus PPI s provides the best gastrointestinal protection, followed by selective COX ‐2 inhibitors, and thirdly by nonselective NSAID s plus PPI s.