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Three trials tested a high dose of ICS (BUD 800 mcg/day) celebrex 200 mg low price, one trial failed to report the dose used proven 100 mg celebrex, and three trials used low dose BDP or equivalent discount celebrex 100mg on line. Eight trials enrolled patients who had mild asthma; 19 enrolled patients with moderate asthma; 3 trials did not report baseline FEV1. Eighteen trials contributed to the primary outcome showing a 65% increased risk of exacerbations requiring systemic steroids for any LTRA (10 trials in montelukast and 5 trials in zafirlukast) compared to any ICS dosing regimen. The pediatric trials (3) could not be pooled due to a lack of exacerbations. However, 5 trials were pooled for exacerbations requiring hospitalization and there was no significant difference. Data at 12 weeks was pooled according to outcome and found ICS significantly improved change in symptom score (6 trials, SMD 0. Similarly, ICS significantly improved asthma control days (3 trials, WMD -8 %, 95% CI: -15, -1]) and rescue-free days (2 trials, WMD -9%, 95% CI: -14, -03). LTRAs significantly increased the risk of withdrawal (19 trials, RR 1. It included 6 studies (5278 subjects); 5 retrospective cohort studies and 1 prospective trial. The analysis included trials of subjects with a diagnosis of asthma, without restriction to severe asthma patients or children. The pooling of the 6 trials showed a significantly higher annual rate of emergency department visits in the LTRA group (P < 0. The rate of hospitalizations was shown to decrease significantly with the use of ICSs compared to LTRAs (2. Fluticasone (FP) compared with Montelukast (ML) 114-117, 125-130, 133 We found 9 fair quality RCTs (10 articles) that compared ML with FP that met our inclusion criteria. Our meta-analyses of outcomes from these trials show that patients treated with FP had a greater increase in the proportion of days free from rescue medication use (SMD - 0. Controller medications for asthma 76 of 369 Final Update 1 Report Drug Effectiveness Review Project 114-117, 125-130, 133 Details of the characteristics of the 9 individual RCTs are summarized in Tables 14 and 15. Beclomethasone (BDP) compared with Montelukast (ML) 110-113, 118, 124, 134 Six fair quality RCTs meeting our inclusion criteria compared montelukast with beclomethasone (Tables 14 and 15). Most of the outcomes reported favored BDP over ML or found no difference between groups. In general, the results comparing BDP with ML appear to be consistent with the overall results comparing ICSs with LTRAs. Our meta-analyses of outcomes using sufficient data from multiple trials shows that compared to ML-treated patients, those treated with BDP had fewer exacerbations (SMD -0. Details of the individual RCTs are summarized in Tables 14 and 15. The only trial enrolling children < 12 years of age was a fair-rated multinational, multi-center RCT in children (N = 360) comparing ML 5 mg/day (N = 120) compared with medium dose BDP 400 mcg/day 124 (N = 119) compared with placebo (N = 121) for 56 weeks. The primary objective of the trial was to assess the effects of ML and BDP on linear growth, however some of our primary outcomes of interest were also reported. Fewer subjects treated with ML or BDP had asthma reported as an adverse experience compared to those treated with placebo, but the difference between groups was not statistically significant (36. There were no statistically significant differences in the percentage of patients requiring oral steroids (25% compared with 23. Budesonide (BUD) compared with Montelukast (ML) 119, 131, 132 We found three fair quality RCTs comparing BUD with ML that met our inclusion criteria (Tables 14 and 15). Too few studies reported sufficient data for meta-analysis of our 131 included outcomes. Of the three RCTs, one enrolled adult populations, one enrolled children 132 and adolescents ages 6-18, and one enrolled children ages 2-8. Most subjects in these trials had mild persistent asthma. The reported outcomes of interest were either not statistically significantly different between the two groups or 119, 131 favored BUD. For symptoms, two trials reported no statistically significant difference between groups. Two trials reporting exacerbations found more favorable results for those 119, 132 treated with BUD than those treated with ML. The single trial reporting quality of life 132 found no difference between the treatments for overall quality of life measures. Fluticasone (FP) compared with Zafirlukast 120-123 We found four fair quality RCTs comparing FP with zafirlukast that met our inclusion criteria. All four trials show similar results favoring FP over zafirlukast for symptoms, rescue medicine use, and quality of life. Our meta-analyses again show that subjects treated with FP had a greater increase in days free from rescue medication use (SMD -0. Controller medications for asthma 78 of 369 Final Update 1 Report Drug Effectiveness Review Project Table 14. Characteristics of head-to-head studies comparing ICSs with LTRAs in children and adults Study design Country N Study population Comparison Quality Study Duration Setting (total daily dose) rating Inhaled corticosteroids (ICSs) compared with Leukotriene receptor antagonists (LTRAs) Castro-Rodriguez et al. ICS Good 109 Systematic review with 2010 Children < 18 yrs, diagnosed > 6 months before study entry vs. ICS Good Systematic review with 3 trials in children, 24 trials in adults (3 trials tested a higher dose; 3 meta-analysis trials tested a lower dose; 27 studies (91,00 subjects) remaining tested equal to baseline daily doses of ICS) 108 Halpern et al. LTRA Fair Meta-analysis 6 studies (5278 subjects) 5 retrospective cohort, 1 prospective trial Fluticasone (FP) compared with Montelukast (ML) 114 Busse et al. Fair RCT America) ML (5 mg) MOSAIC Study 994 Children age 6 – 14, mild persistent asthma, smoking status Medium to Low (12-14 years of 52 weeks NR age) dose ICS Multicenter (104) Primary care Controller medications for asthma 79 of 369 Final Update 1 Report Drug Effectiveness Review Project Table 14.

What was the funding source and role of funder in the study? NCS Page 64 of 71 Final Report Update 1 Drug Effectiveness Review Project Appendix C purchase 200mg celebrex with visa. Results of literature search Total number of citations identified through searches: 1688 (284)* Citations excluded at the title/abstract-level: 1121 (206) Full-text articles retrieved for more detailed evaluation: 567 (78) Articles excluded at full-text level: 452 (47) Reasons for exclusion include: not English language buy 100mg celebrex visa, wrong outcome 100mg celebrex mastercard, drug not included, population not included, wrong publication type, wrong study design, insufficient duration Included studies: 115 (31) Head-to-Head trials: 54 (1) Active-controlled trials: 1 (1) Placebo-controlled trials: 42 (15) Observational studies: 8 (4) Systematic Reviews: 4 (4) Other: 6 (6) * Totals in parenthesis reflect results of literature search specific to update 1 NCS Page 65 of 71 Final Report Update 1 Drug Effectiveness Review Project Appendix D. Listing of excluded studies Excluded studies Reasons for exclusion Active-controlled trials Khanna P, Shah A. Assessment of sensory Outcome not included perceptions and patient reference for intranasal corticosteroid sprays in allergic rhinitis. Barnes ML, Biallosterski BT, Gray RD, Fardon TC, Study design not included Lipworth BJ. Decongestant effects of nasal xylometazoline and mometasone furoate in persistent allergic rhinitis. Study design not included Increased nasal airflow with budesonide compared with desloratadine during the allergy season. Comparison of Study design not included intranasal hypertonic dead sea saline spray and intranasal aqueous triamcinolone spray in seasonal allergic rhinitis. Comparison of Study design not included the efficacy of inhaled budesonide and oral choline in patients with allergic rhinitis. Zieglmayer UP, Horak F, Toth J, Marks B, Berger Study design not included UE, Burtin B. Efficacy and safety of an oral formulation of cetirizine and prolonged-release pseudoephedrine versus budesonide nasal spray in the management of nasal congestion in allergic rhinitis. Effects of intranasal corticosteroid on nasal adenosine monophosphate challenge in persistent allergic rhinitis. Short-term lower-leg growth Intervention not included rate and urine cortisol excretion in children treated with ciclesonide. A 2-week, Population not included crossover study to investigate the effect of fluticasone furoate nasal spray on short-term growth in children with allergic rhinitis. Nave R, Wingertzahn MA, Brookman S, Kaida S, Population not included Matsunaga T. Safety, tolerability, and exposure of ciclesonide nasal spray in healthy and asymptomatic subjects with seasonal allergic rhinitis. NCS Page 66 of 71 Final Report Update 1 Drug Effectiveness Review Project Excluded studies Reasons for exclusion Rowe-Jones JM, Medcalf M, Durham SR, Richards Population not included DH, Mackay IS. Functional endoscopic sinus surgery: 5 year follow up and results of a prospective, randomised, stratified, double-blind, placebo controlled study of postoperative fluticasone propionate aqueous nasal spray. Observational studies Bousquet J, Neukirch F, Bousquet PJ, et al. Severity Outcome not included and impairment of allergic rhinitis in patients consulting in primary care. Development Outcome not included of questionnaires to measure patient preferences for intranasal corticosteroids in patients with allergic rhinitis. Otolaryngology--head and neck surgery: Official journal of American Academy of Otolaryngology-Head and Neck Surgery. Influence of Population not included allergy on the symptoms and treatment of nasal polyposis. Population not included Intranasal corticosteroid use is associated with lower rates of bacterial recovery in chronic rhinosinusitis. Evaluation of Population not included efficacy of topical corticosteroid for the clinical treatment of nasal polyposis: searching for clinical events that may predict response to treatment. NCS Page 67 of 71 Final Report Update 1 Drug Effectiveness Review Project Appendix E. Adverseeffectsinhead-to-headtrials Age Withdrawals Study % female Treatments dueto Samplesize Rhinitis (totaldaily adverse Throat Trialduration type doseinmcg) events Headache soreness Epistaxis Nasarritation Al-Moh aimeid 30y ears BU D400ȝg 5. N=136 62% BEC336 NS NS 2%;NS 2wks SAR Ra tner1996 44yrs New vs. FLUT 200 NS NS 3wks SAR Stern1997 Age NR BUD128/256 0. Reports are not usage guidelines, nor should they be read as an endorsement of, or recommendation for, any particular drug, use or approach. Oregon Health & Science University does not recommend or endorse any guideline or recommendation developed by users of these reports. Dana Selover, MD Tracy Dana, MLS Colleen Smith, PharmD Kim Peterson, MS Oregon Evidence-based Practice Center Oregon Health & Science University Mark Helfand, MD, MPH, Director Marian McDonagh, PharmD, Principal Investigator, Drug Effectiveness Review Project Copyright © 2008 by Oregon Health & Science University Portland, Oregon 97239. Final Report Update 1 Drug Effectiveness Review Project TABLE OF CONTENTS Evidence Table 1. Head-to-head trials in patients with SAR………………………………………….. Placebo-controlled trials in patients with SAR………………………………………..... Quality assessment of head-to-head trials in patients with SAR…………………..... Quality assessment of placebo-controlled trials in patients with SAR……………... Placebo-controlled trials in children with SAR………………………………………... Quality assessment of placebo-controlled trials in children with SAR……………... Head-to-head trials in patients with PAR………………………………………………145 Evidence Table 5a. Placebo-controlled trials in patients with PAR……………………………….

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McNally purchase celebrex 100mg otc, MPH MA Sujata Thakurta generic celebrex 100 mg mastercard, MPA:HA Original report: Susan L cheap celebrex 200 mg on-line. Burda Oregon Evidence-based Practice Center Oregon Health & Science University Mark Helfand, MD, MPH, Director Copyright © 2008 by Oregon Health & Science University, Portland, Oregon 97239. Final Report Update 1 Drug Effectiveness Review Project TABLE OF CONTENTS Evidence Table 1. Quality assessment of controlled trials for quick relief medications for asthma………………………………………………………………………………………………. Included studies Berger, 2006 Quality rating: Poor Design: Study design RCT DB RunͲin: 1Ͳweek SB Setting: Clinic Country: USA Sample: # Screened / Eligible / Enrolled # Withdrawn / Lost to followͲup / Analyzed NR / 173/ 150 16/ NR/134 Inclusion criteria: Children aged 4Ͳ11 years; stable asthma for at least 6 months before screening; FEV between 45% and 80% predicted with> 12% reversibility to 2. Included studies Chakraborti, 2006 Quality rating : Fair Design: Study design RCT DB RunͲin: NR Setting: Hospital clinic Country: India Sample: # Screened / Eligible / Enrolled # Withdrawn / Lost to followͲup / Analyzed NR / NR/ 60 NR/ NR/ 60 Inclusion criteria: Children between 5Ͳ15 years of age; mild to moderate acute exacerbation of asthma who were able to perform spirometry Exclusion criteria: Severe acute exacerbation; coexisting cardiac or renal disease; known intolerance to salbutamol; or ipratropium bromide; glaucoma, urinary retention and children who had used oral bronchodilator in the last 12 hours or inhaled bronchodilator in the last 6 hours Comments Patients could be enrolled twice in study if events were more than one month apart Intervention: Duration: 30 minutes Dosage N Mean age Gender Drug name 100 ʅg /actuation of salbutamol; Salbutamol with 20ʅg ipratropium 30 106 months 63% males ipratroprium bromide* Salbutamol* 100 ʅg /actuation 30 118 months 57% males *All patients were administered 4 actuations of salbutamol through similar looking MDI and spacer. Then 4 actuations of either ipratropium or placebo were administered Outcomes: Effectiveness Outcomes: Symptoms Comparison of salbutamol with ipratropium bromide and salbutalmol after treatment Salbutamol with ipratropium Salbutamol pͲvalue Heart rate/min 119. Included studies Hamilos, 2007 Quality rating: Poor Design: Study design RCT Open RunͲin: 1Ͳweek SB Setting: NR Country: USA Sample: # Screened / Eligible / Enrolled # Withdrawn / Lost to followͲup / Analyzed NR / 932 / 746 330/ 40 /746 Inclusion criteria: > 12 years; had stable asthma for at least 6 months; an FEVІ of 50% or higher and 80% or lower of predicted, 12% or higher of reversibility of airflow obstruction within 13 to 30 minutes after administration of 180ʅg of racemic albuterol MDI; used a ɴЇ Ͳ adrenergic agonist, antiasthma anitͲinflammatory medication, or overͲtheͲcounter asthma medication for at least 6 months before screening Exclusion criteria: History of lifeͲthreatening asthma within 3 months of screening or if they were hospitalized for acute asthma within 45 days of screening; greater than 10ͲpackͲyear history of cigarette smoking within 6 months of screening Comments * The study protocols were amended to reduce the study period to 6 mos for newlyͲenrolled patients. Pediatric AQLQ was greater for levalbuterol than racemic albuterol: levalbuterol 0. Included studies Nowak, 2006 Quality rating: Fair Design: Study design RCT DB RunͲin: NR Setting: Hospital ED/clinic Country: USA Sample: # Screened / Eligible / Enrolled # Withdrawn / Lost to followͲup / Analyzed NR /NR/627 1/0/626 Inclusion criteria: > 18 years; presented to ED/clinic with acute exacerbation of asthma; an FEVІ value of 20Ͳ55% predicted; at least a 6Ͳmonth history of physician diagnosed asthma; an oxygen saturation of at least 90% with no more than 6L/min supplemental oxygen; nonͲpregnant; no other known (nonͲasthma) cause of wheezing or shortness of breath Exclusion criteria: Respiratory distress of sufficient severity to preclude enroolment in the trial were excluded to avoid delayed treatment; patients administered therapy other than oxygen after ED/clinic arrival; history of severe asthma within previous 12 months; undergone treatemnt of acute asthma within 2 weeks; or hospitalization within 1 month of presentation;> 10Ͳpack year smoking history Comments Intervention: Duration: Dosage N Mean age Gender Drug name Levalbuterol 1. Outcomes: Effectiveness Outcomes: Symptoms: NR Change in treatment regimen for the exacerbation: NR Healthcare utilization: Levalbuterol Racemic albuterol Time to discharge (min) 76 78. Included studies Ralston, 2005 Quality rating: Fair Design: Study design RCT DB RunͲin: NA Setting: Hospital Country: USA Sample: # Screened / Eligible / Enrolled # Withdrawn / Lost to followͲup / Analyzed 833 / 306/ 154 14/ 0/ 140 Inclusion criteria: Patients 6Ͳ18 years; history of asthma of any severity; demonstrated ability to use a peak flow meter and with a PEF of <80% on presentation to ED Exclusion criteria: Known sensitivity to study meds; previous study enrollment; impending or actual respiratory arrest or treatment or treatment with Levalbuterol or Ipratropium bromide within the 6 h of study enrollment Comments Intervention: Duration: 1 treatment Dosage N Mean age (years) Gender Drug name Racemic 76 11. Included studies Salo, 2006 Quality rating: Good Design: Study design RCT DB RunͲin: NR Setting: Hospital ED Country: USA Sample: # Screened / Eligible / Enrolled # Withdrawn / Lost to followͲup / Analyzed 375 / 166/63 1/ NR/ 62 Inclusion criteria: >18 years; PEFR<70% predicted; prior history of asthma; wheezing; or wheezing for the first time and meeting ATS definition of asthma including patients who had a history of asthma diagnosed by a physician or who had episodes of wheezing that improved withɴͲ2 agonist inhalers Exclusion criteria: Refusal to give informed consent; use of ipratroprium bromide in the past 48 hours; previous enrollment in this study; greater than 20 pack year history of smoking ; symptomatic angina pectoris; known symptomatic atherosclerotic heart disease;; patients who can perform a PEFR; pregnant women; HR >150 beats per minute; BP> 180/100 mm Hg; cystic fibrosis; tuberculosis or pulmonary malignancies; any infection controlled with antibiotics; pneumonia; active in any study at enrollment or 4 weeks prior; taking any oral steroids; known allergies to study medications; current alcohol or drug use Comments Intervention: Duration: 120 minutes Dosage N Median age Gender Drug name Albuterol and 7. Included studies Sharma, 2004 Quality rating: Poor Design: Study design RCT NB RunͲin: NR Setting: Hospital ED Country: India Sample: # Screened / Eligible / Enrolled # Withdrawn / Lost to followͲup / Analyzed NR/ NR/ 50 NR/ NR /50 Inclusion criteria: 6Ͳ14 years; reported to ED with acute exacerbation of bronchial asthma Exclusion criteria: Life threatening or severe attack characterized by cyanosis, silent chest or poor air entry maked by dyspnoea so that a child was unable to speak 3Ͳ4 words; PEFR <30% for height; received bronchodilator 6 hours prior to admission; history of previous admission to ICU Comments Listed refernce did not provide specific wheeze or dypnea score Intervention: Duration: 240 minutes Dosage N Mean age Gender Drug name Salbutamol (via nebulizer) 150ug/kg/dose 25 10. Included studies vanderMerweL,2006 Qualityrating: Design: Studydesign: CaseͲcontrol RunͲin: N/A Setting: Hospitalandrespiratoryclinic Country: SouthAfrica Sample: Severelifethreateningasthma(SLTA):30 Control:60 Inclusioncriteria: 13Ͳ45years SLTA:meetadmissioncriteriaforSLTA Exclusioncriteria: <13years; >45years Control:historyofanasthmarelatedadmissiontoanICU Comments:TheSLTAgroupweredrawn frompatientsadmittedtotheemergencyroomwhilethecontrolgroupwasdrawnfromanoutpatientrespiratoryclinic Population: Meanage(SE): SLTA31 (1. Included studies Watanasomsiri, 2006 Quality rating: Fair Design: Study design: RCT DB RunͲin: NR Setting: Hospital Country: Thailand Sample: # Screened / Eligible / Enrolled # Withdrawn / Lost to followͲup / Analyzed NR / NR/ 74 3/ 0 / 71 Inclusion criteria: A clinical diagnosis of asthma. Patients < 5 years had to have> 3 episodes of wheezing before the presenting illness and a history of physician diagnosed wheezing. Exclusion criteria: Patients excluded if they presented with a firstͲtime wheezing episode and if they had 1 or more of the following conditions: coexistent cardiac, renal, or other chronic pulmonary diseases; bronchopulmonary dysplasia;intolerance to salbutamol or ipratroprium bromide; glaucoma; or urinary retention. Patients who had used ipratroprium bromide within 24 hours, used oral corticosteroids within 3 days, and required immediate resuscitation or airway intervention were also excluded from the study Comments Population: Intervention: Duration: Every 20 minutes for 120 minutes and additional doses of salbutamol every 30 minutes PRN Dosage N Mean age Gender Drug name: Salbutamol mixed NR 38 7. Subgroup analysis by age and severity showed no statistically significant differences between the 2 groups at any time point. No baseline or followͲup data reported for clinical scores. Change in treatment regimen for the exacerbation: NR Healthcare utilization ( %): Treatment 5 (2/38); Control 9 (3/33) were hospitalized Mortality: NR Other Effectiveness Outcomes and Comments: Adverse Events and Comments: Headache (%) Treatment: 3 (1/38) Control: 0 Nausea (%) Treatment: 3 (1/38) Control: 3(1/33) Quick-relief medications for asthma 13 of 16 Final Report Update 1 Drug Effectiveness Review Project Evidence Table 1. Included studies Wraight, 2004 Quality rating: FairͲpoor Design: Study design RCT NR Parallel RunͲin: 2 weeks Setting: Country: New Zealand Sample: # Screened / Eligible / Enrolled # Withdrawn / Lost to followͲup / Analyzed 47 / 40/ 40 9/ NR / 31 Inclusion criteria: 18Ͳ70 years, taking a minimum of 200 ʅ/day of inhaled beclomethasone or equivalent; methacoline PD < 8 ʅmol; and nonͲsmokers or exͲsmokers (< 5 packͲyears). Exclusion criteria: History of lifeͲthreatening asthma; a requirement for oral prednisone within the previous 3 months; inability to withdraw short or longͲacting beta agonists; and any other significant medical conditions. Comments The 2Ͳweek runͲin period withdrew all betaͲagonist treatment from patients and substituted ipratropium bromide as the sole reliever medication. Intervention: Duration: Phase 1: 2 weeks; Phase 2: continued until a deterioration in asthma control (LOC) occurred after inhaled corticosteroid therapy (ICS) withdrawal. Dosage N Mean age Gender Drug name Salbutamol/ 100 ʅg/20 ʅg, 18 41. Qualityassessment ofcontrolledtrialsforquickreliefmedicationsforasthma Internalvalidity Didthearticle Wasthe Wasthe Werethegroups Wereoutcome includeanITT Didthestudy Author assignment tothe treatment similarat baselinein assessorsblindedto Wasthepatient kept analysis,orprovidemaintain Date treatment groups allocation termsofprognostic Weretheeligibility thetreatment Wasthecareproviderunawareofthe thedataneededto comparable Country reallyrandom? Berger,W U nclear,m ethods U nclear, Yes Yes U nclear;reportedas U nclear;reportedas DBYes Yes (5/150patients Yes 2006 NR m ethods NR DB excluded) USA Chakraborti,A Yes Yes (3rdparty Yes (salbutaom ol g roup Yes Yes Yes Yes U nclear;attriton NR U nclear 2006 adm inistration 12m older,p=0. Quick-relief medications for asthma 15 of 16 Final Report Update 1 Drug Effectiveness Review Project EvidenceTable2. Quality assessmentofcontrolledtrialsforquickreliefmedicationsforasthma Externalvalidity Howsimilaristhe p op ulationtothe Whatwerethe Didthearticle Wasthereimp ortant p op ulationto ex clusioncriteria Whatwasthe Whatwasthe rep ortattrition, differentiallosstofollow- whomthe forrecruitment? Reports are not usage guidelines, nor should they be read as an endorsement of or recommendation for any particular drug, use, or approach. Oregon Health & Science University does not recommend or endorse any guideline or recommendation developed by users of these reports. Original Report: January 2005 Update 1: April 2006 Update 2: May 2008 Marian S. McDonagh, PharmD Kim Peterson, MS Susan Carson, MPH Rochelle Fu, PhD Sujata Thakurta, MPA:HA Drug Effectiveness Review Project Marian McDonagh, PharmD, Principal Investigator Oregon Evidence-based Practice Center Mark Helfand, MD, MPH, Director Copyright © 2010 by Oregon Health & Science University Portland, Oregon 97239. Final Report Update 3 Drug Effectiveness Review Project The medical literature relating to this topic is scanned periodically. Prior versions of this report can be accessed at the DERP website. Atypical antipsychotic drugs Page 2 of 230 Final Report Update 3 Drug Effectiveness Review Project STRUCTURED ABSTRACT Purpose Atypical antipsychotic agents are used to treat the symptoms of schizophrenia and bipolar disorder. The purpose of this review is to help policy makers and clinicians make informed choices about their use.

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As with the first ASH Choosing Wisely campaign buy generic celebrex 200 mg on line, harm avoidance was established nonmalignant focus and 34 with a malignant focus cheap celebrex 100 mg with visa. Among the 10 as the campaign’s preeminent guiding principle celebrex 200 mg free shipping. For the second semifinalist items selected for systematic review, 7 had a nonmalig- ASH Choosing Wisely campaign, a sixth overarching principle nant focus and 3 had a malignant focus. One of the 10 semifinalist was adopted: impact (Table 1). Items that were felt to have a greater items was ultimately excluded because the systematic review probability of triggering positive changes in practice were priori- proved to be infeasible in the prescribed time frame due to a very tized over items felt to have lower potential impact. Items that high number of potentially eligible citations. This item involved overlapped substantially with published Choosing Wisely recom- thrombophilia testing for arterial disease. Table 2 summarizes the 5 mendations from other medical societies received lower priority. Suggestions for the second ASH Choosing Wisely list were solicited from members of the ASH Committee on Practice, the Discussion ASH Committee on Quality, the ASH Choosing Wisely Task The first recommendation of ASH’s second Choosing Wisely Force, ASH Consult-a-Colleague volunteers, and members of the campaign is not to anticoagulate patients with a first VTE provoked ASH Practice Partnership. Guided by the 6 principles outlined by a major, transient VTE risk factor such as surgery, trauma, or an above (Table 1), the ASH Choosing Wisely Task Force scored all 4-9 intravascular catheter for more than 3 months. Randomized suggestions for inclusion in ASH’s second Choosing Wisely list. These recommendations are driven largely by a low the 10 semifinalist items using the same methods described previ- 2 risk of VTE recurrence after 3 months in the setting of a provoked ously. The search strategies for each of the Anticoagulation for VTE continued beyond 3 months is associated 10 semifinalist items are outlined in the supplemental Appendix to with a major bleeding risk of 2. These estimates come from prospective hierarchical search strategies were used such that if recent (subse- clinical trials of warfarin; it is likely that bleeding risks are higher in quent to 2008) evidence-based guidelines were found, the literature clinical practice, where patients tend to be older and have more search was curtailed. Bleeding risks may be lower with new oral anticoagulants. However, in addition to potential harms from Guided by the 6 core principles outlined in Table 1 and by our anticoagulation, anticoagulation with new oral anticoagulants is systematic reviews of the evidence, the ASH Choosing Wisely expensive. Task Force selected 5 recommendations for inclusion in ASH’s second Choosing Wisely campaign. Each item was reviewed and Importantly, the ASH Choosing Wisely recommendation is not revised for accuracy and clarity by 2-4 external content experts per intended to apply to patients with non-major, transient VTE risk item. The final list was reviewed and approved by the ASH factors such as travel-associated immobility, pregnancy, or hormone executive officers and by the ABIM Foundation. Guidelines suggest that women who experience a first VTE in the setting of pregnancy should receive anticoagulation until at least Results 6 weeks postpartum for a minimum total duration of 3 months or A total of 210 ASH members were solicited for suggestions for longer. After removing therapy/oral contraception is not resumed; 3 months of anticoagula- redundant items, there were 73 unique suggestions; 39 with a tion may be appropriate in some cases. Less is known about HIT in the duration of anticoagulation should be determined on a case-by-case pediatric population, although emerging evidence suggests that HIT basis. Most cated pain crises in patients with sickle cell disease (SCD). Starting an alterna- Patients with SCD are uniquely vulnerable to harm from RBC tive anticoagulant in a thrombocytopenic patient incorrectly diag- transfusion. African Americans are underrepresented among the nosed as having HIT exposes that patient to a risk of bleeding. This Patients with cardiovascular disease, particularly those undergoing phenomenon, combined with recurrent exposure to blood, markedly bypass surgery, have an increased incidence of both thrombocytope- increases the risk of alloimmunization to minor blood group nia and of positive EIA HIT results. Finally, HIT testing increases both direct and indirect costs of care. Patients with SCD are also at high risk of secondary iron overload Many hospitals use nonautomated HIT tests that require substantial from repeated transfusions. Iron overload is an important cause of technician time and thus are relatively costly laboratory tests. In addition, alternative anticoagulants such as decreases in hemoglobin (often due to hemodilution after adminis- argatroban are much more expensive than unfractionated heparin tration of intravenous fluids) without developing symptoms of and in some cases are associated with higher risks of bleeding. There is also little evidence that episodic RBC transfusion 16 result of these and other factors, it has been reported that testing for reduces pain during acute vasoocclusive crises. Evidence-based HIT is only cost-effective when the pretest probability of HIT is guidelines on the management of SCD have recently been com- 8%, a number that corresponds to an intermediate or high 4 Ts pleted and clinicians are encouraged to refer to them for appropriate 33 15 score. ASH’s final 2014 Choosing Wisely item recommends against The third recommendation of ASH’s 2014 Choosing Wisely treating immune thrombocytopenic purpura (ITP) in the absence of campaign advises against baseline or surveillance CT scans in 34 bleeding or a very low platelet count. In children, ITP is often a patients with asymptomatic, early-stage chronic lymphocytic leuke- 19,20 temporary condition that resolves without treatment. Unlike in other lymphoproliferative diseases, CT lines recommend not treating childhood ITP unless there is bleeding scans are not necessary to fully stage patients with CLL. Both the 34 or there are factors felt to increase the risk of bleeding. In adults, Rai and Binet staging systems are based on physical examination 21,22 ITP is usually a chronic disease with a relapsing and remitting findings and complete blood counts. Prognosis can be further course over a patient’s lifetime. Many patients are able to maintain refined with molecular tests for mutations of established prognostic significance. Current guidelines scans improve survival in patients with asymptomatic, early-stage suggest that a patient with a platelet count of 30 000/ L and no 19,20 bleeding can usually be safely managed with observation alone.

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