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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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 · Apr 2013
Review Comparative StudyDeep venous thrombosis and pulmonary embolism. Part 1. Initial treatment: usually a low-molecular-weight heparin.
Patients with deep venous thrombosis are at a short-term risk of symptomatic or even life-threatening pulmonary embolism, and a long-term risk of post-thrombotic syndrome, characterised by lower-limb pain, varicose veins, oedema, and sometimes skin ulcers. What is the best choice of initial antithrombotic therapy following deep venous thrombosis or pulmonary embolism, in terms of mortality and short-term and long-term complications? How do the harm-benefit balances of the different options compare? To answer these questions, we reviewed the available literature using the standard Prescrire methodology. Unfractionated heparin has documented efficacy in reducing mortality and recurrent thromboembolic events in patients with pulmonary embolism or symptomatic proximal (above-knee) deep venous thrombosis. ⋯ In practice, initial treatment of deep venous thrombosis and pulmonary embolism should be based on LMWH in patients without renal failure. Thrombolytic agents may be useful in case of massive pulmonary embolism, but more evaluation is needed. Bleeding and heparin thrombocytopenia are the main adverse effects of these treatments.
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Prescrire international · Dec 2002
Review Comparative StudyTreatment of postherpetic neuralgia: tricyclic antidepressants still the reference.
(1) Pain generally disappears when herpes zoster lesions have healed, but the risk of postherpetic neuralgia, though it is low, increases with age. (2) Antivirals prescribed during the acute phase do not reduce the risk of postherpetic neuralgia, but they do reduce its duration. (3) Common non specific analgesics such as paracetamol seem inadequate against postherpetic neuralgia. Amitriptyline and desipramine, despite their limited efficacy, are the reference. Gabapentin, although somewhat less effective, is a possible second line option. It is unclear how long treatment should last.