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By Z. Lars. University of Montevallo.

Similarly cheap loratadine 10mg overnight delivery allergy medicine over the counter best, in the CREDO trial discount loratadine 10mg mastercard allergy symptoms in eyes, after percutaneous coronary intervention, 2116 patients received open-label clopidogrel 75 mg for 28 Newer antiplatelet agents 37 of 98 Final Update 2 Report Drug Effectiveness Review Project days and then were randomly assigned to double blind treatment with continuation of clopidogrel 64 75 mg plus aspirin 325 mg for 12 months or to aspirin 325 mg alone. When we used a fixed-effects model to pool data from the 3 trials that compared 6 months of treatment with clopidogrel plus aspirin to 1 month of treatment for the outcomes of all-cause mortality, cardiovascular mortality, revascularization, and bleeding, a significant benefit with the longer-term treatment was only found for the outcome of revascularization (relative risk, 0. No other pooled outcome reached statistical significance. Only the RACS trial reported withdrawals due to adverse events but it was a nonsignificant and imprecise finding 61 (relative risk, 2. In contrast, when we considered results for revascularization from the PCI-CURE and CREDO trials, we observed that the potential benefit of a reduced risk of revascularization became only probable at 8 months was unlikely at 12 months (Table 4, Figure 2). There was also a trend toward increased bleeding risk over time when results from the PCI-CURE and CREDO trials were considered (Table 4, Figure 3). Detailed outcome data from pooled analysis of dual antiplatelet therapy length postpercutaneous coronary intervention All-cause Cardiovascular mortality mortality Revascularization Bleeding Therapy (95% confidence (95% confidence (95% confidence (95% confidence length N interval) interval) interval) interval) 64,65 1199 0. Newer antiplatelet agents 38 of 98 Final Update 2 Report Drug Effectiveness Review Project Figure 2. Revascularization risk at 6 months, 8 months, and 12 months 6 months vs 1 month (Akbulut 2004, Pekdemir 2003, 0. Major bleeding risk at 6 months, 8 months, and 12 months 6 months vs 1 month (Pekdemir 2003, Bernardi 2007) 1. The component outcomes of all-cause mortality and revascularization did not reach statistical significance because the study was not powered to detect a difference. All-cause mortality relative risk of clopidogrel long-term compared with short-term was 0. The revascularization relative risk of clopidogrel long-term compared with short-term was 1. In contrast, a nonsignificant increase in the risk of major bleeding at 1 year occurred (relative risk, 1. This study was limited by > 40% of the patients not completing the study drug treatment for 1 year with either the active medication or placebo. Reasons why patients (n=94) discontinued study medications prior to percutaneous coronary intervention were not provided. Following the percutaneous coronary intervention procedure, approximately 46% of the patients in both groups permanently discontinued treatment. The occurrence of an adverse event was the reason for permanently discontinuing the study medication in 34. As a secondary objective, CREDO evaluated a pretreatment loading dose of clopidogrel 300 mg ≥ 6 hours prior to percutaneous coronary intervention which reduced the relative risk reduction of 38. This study examined the role of clopidogrel prior to (mean of 6 days before intervention) and after percutaneous 63 coronary intervention. PCI-CURE trial found that with long-term (8 months on average) administration of clopidogrel and aspirin after percutaneous coronary intervention, the rates of the primary composite outcome of cardiovascular death, myocardial infarction, or any revascularization were lower (relative risk, 0. The component outcomes of cardiovascular death or revascularization did not reach statistical significance because the study was not powered to do so. There was not a difference in cardiovascular deaths with clopidogrel at ~8 months of treatment compared with 1 month of treatment (relative risk, 1. There was a trend towards lower risk of revascularization for clopidogrel patients (relative risk, 0. At the end of follow-up in the PCI-CURE trial (average 8 months), the only statistical significant difference in bleeding for clopidogrel compared with aspirin was minor bleeding episodes. Banerjee 2008 was a retrospective cohort study that evaluated the outcomes of 530 consecutive patients who underwent percutaneous coronary intervention from January 2004 to July 2006, were free of cardiovascular events for 6 months after percutaneous coronary intervention, and had follow-up available for 65 more than 12 months. The outcomes of patients who received clopidogrel for more than 1 year were compared with those of patients who received it for less than 1 year. The incidence of major bleeding for greater than 1 year compared with less than 1 year was 5% compared with 3. Peterson 2010 was a retrospective cohort study of 9256 66 patients receiving drug-eluting stents between January 2003 and August 2006.

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Diabetes Page 24 of 99 Final Report Drug Effectiveness Review Project Table6 generic loratadine 10mg with amex allergy symptoms zoloft. Characteristics of pram lintideplacebo-controlledtrials inadults with type2diabetes Baseline a a A1c (%)(SD) Age(years)(SD) a a W eight(kg) % M ale 2 a Sam ple a BM I (kg/m ) Author purchase loratadine 10mg on-line allergy symptoms early pregnancy, size(N ) % W hite Totaldailyinsulin a year F ollow- % Hispanic dose(units) Country up Diabetes duration Glycem ic goals Intervention Com bination a Q uality (weeks) (years) prespecified? Dosages therapy Pram :30m cg 75m cg,150m cg TID, Stabledoses 9. Abbreviations:Pram ,pram lintide;N R ,notreported;O HA,oralhypoglycem ic agents;SU ,sulfonylureas;M E T, m etform in;TZD,thiaz olidinediones;BID,twicedaily;TID,threetim esdaily. Diabetes Page 25 of 99 Final Report Drug Effectiveness Review Project Table7. E ffectof pram lintideintype2diabetes Author, ChangeinPPG from Changeinweight Changeintotaldaily Percentachieving year ChangeinA1c from baselineat(%) baselineat(m g/dL ) from baselineat(kg) insulindosefrom baseline A1c goal<7% 16weeks 16weeks 16weeks 16weeks 16weeks 60/120 60/120 60/120 60/120 60/120 R iddle, PBO PBO PBO PBO PBO 18 BID-TID BID-TID BID-TID BID-TID BID-TID 2007 -0. Diabetes Page 26 of 99 Final Report Drug Effectiveness Review Project Table8. Adverseeffects reportedwith pram lintide 17 16 18 R atner2002 Hollander2003 R iddle2007 60/120 a 75TID 150TID Placebo 90BID 120BID Placebo BID-TID Placebo b M eannum berof severehypoglycem iaevents perpatient-year(SD) W eeks0-4 --- --- --- 0. Diabetes Page 27 of 99 Final Report Drug Effectiveness Review Project Harms Pramlintide-plus-insulin and placebo-plus-insulin groups had similar rates of withdrawal due to all causes and withdrawal due to adverse events (see Evidence Table 3). There was no evidence of cardiac, hepatic, renal, or drug-related idiosyncratic adverse events in patients in any treatment arm of the three randomized controlled trials identified for this review and no deaths were reported. Hypoglycemia Pramlintide-plus-insulin and placebo-plus-insulin groups experienced similar rates of mild-to- 17, 18 moderate hypoglycemia, but pramlintide-treated patients experienced more episodes of severe hypoglycemia. Severe hypoglycemia occurred most with pramlintide 120 mcg during the first 4 weeks of therapy (0. The incidence of severe symptoms declined with continued use of pramlintide, and 16 rates were similar to placebo for weeks 4-26 and 26-52. All 3 trials predefined the term “severe hypoglycemia” to mean: those requiring either assistance of another person, the administration of glucagon, or the administration of intravenous glucose. Nausea The incidence of mild-to-moderate and severe nausea was significantly higher with pramlintide 75, 90, 120, and 150 mcg than with placebo plus insulin. Only 1 trial reported data showing that 16 most events occurred within the first 4 weeks of treatment. When metformin use was stratified in one trial, its addition to pramlintide plus insulin appeared to have no significant effect on 16 nausea compared with the larger study population. Headache Higher rates of headache were reported with pramlintide (15% and 17%) than with placebo 16 17 (8%). In another trial rate of headache was similar among treatment groups, ranging from 13. None of the studies provided enough information to determine whether there were any correlations between the incidence of headaches and hypoglycemic events. Other adverse events No trials reported any treatment-emergent adverse events occurring with a frequency of more than 2%-5%. Overall adverse events occurring with a frequency of ≥10% with a minimum 5 percentage point difference between pramlintide- and placebo-treated patients comprised 16, 17 sinusitis, retinal disorder, inflicted injury, and injection site reactions (Table 8). Higher incidence of retinal disorder was reported with pramlintide 150 mcg than with 17 lower pramlintide doses and placebo. The authors performed detailed medical reviews of these patients with reported retinal disorder and concluded that the increased incidence was likely attributable to preexisting conditions that were not documented at the time of screening. Diabetes Page 28 of 99 Final Report Drug Effectiveness Review Project Key Question 3. Are there subgroups of patients with type 2 diabetes for which pramlintide is more or less suitable than other hypoglycemic agents? Age, sex, total daily insulin dose, and prior use of oral hypoglycemic agents None of the randomized controlled trials conducted subgroup analyses evaluating whether pramlintide had differential effects in these populations. Race and ethnicity 23 16, 17 A post hoc analysis of two 52-week trials pooled subjects of various ethnic groups. Black and Hispanic patients tended to have higher baseline A1c (9. Pramlintide produced larger reductions in A1c and weight from baseline in black patients (0. Changes in total daily insulin requirement and baseline oral hyperglycemic use were not different among the different races and ethnicities. Nausea and weight loss and effects of weight on A1c Weight loss experienced with pramlintide 90 or 120 mcg appeared to be independent of nausea, as weight loss was similar in patients never experiencing nausea (90 or 150 mcg, -1.

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